24991APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOuR.ImvT-L'LET;TRTCnI.
APPLICATION/PERMIT PLUMBING,-FIRCHnNICn 1,
BUILDING DIVISION BUILDING PRO3ECf IDENTIFICATION
PERMITNO,
n A A (] �1
L 4 J J 1
BUILDINGADDRESS
SANITARY NO,
SANITARY
APPLICAT ION SUBMITTAL. DAT Ii
—/ �t%�-Jx-� e:� C G C /�
UNITN LOT%
'RS E: . PHONE:
RAC70W AMC:
N/C CONTROL#
❑
_ BUILDING PERMITINFO
�-�
C.C/ z- -O Zf J
tlJlell y�cy-�' !/ l Z _C
A CIII'I'E GINHER: LIC NO:
�,
�C N'I'ACL PHONE:
96-�Zr7
ADDRESS:
9d Gr% . rz
4x. t '. S .;
Q fY �t'y ,, R ELECTRIC PERMIT ;n PEI: `
1 Y
ELECT PLUMB MEC
BL II
PERMIT
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affnormat l am licensed derpervicoof Chapters)(commencing with
1 DESCRIPTION
PANELS
Section700()of Division 3.1 he Business and Professions Code, and my license is in
full rortt a t.
License Class � OLic.p - C
Lia
Data V—;1 �z—s7ns—Conlrector z
ARCHITECTS DECLARATION
I understand my plums shall be axed us public retard..
UP TO 200AMP$
201 -INN AMPS
OVER 1000 AMPS fi
SIGNS ELECTRICAL -• LZ
SPECIAL CIRCUR/MISC.
SQ. FT. FLOOR AREA
.I_ /
T
� t
$/SQ. IT.
LicemeJ Professional
OWNER -BUILDER DECLARATION
e a Contractors
I hereby affinin(Se that 1 am exempt from the Contractor's License law for @e
TEMP. METER OR POLE 1 ST.
following reason. (Section JOam
Business and Code: Any city or county
f
which requires a permit to construct, alter, improve, demolish, or repair any swcturc
DATE
Prior o its issuance, also requires the applicant for such petminnfile a signed statement
POWER DEVICES
1
46
that he is licensed pursuanuo the Provisions of the Cmdracme. License Law (Chapter
9(commencing with Section 7000) of Division 3 of the Business and Professions Code)
-�J
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt herefrom and the basis for the alleged exemption. Any violation allOUTLETS
Section 7031.3 by any upPiicant fora permit subjects the .path m to a civil penalty of
- SWITCHES - FIXTURES
t more than Gve hundred dol lots ($50fp'
n❑ 1,mownerofhepropeny,ormyemployeeswithwagesastheirsolecompnsadon.
NEW RESNENTIAL ELECTR —SQ.FU PT.
STORIES
'I YPECONSTRUCfION
will Probework. and mreisnotintendede Sec. Business
fs
ocuo's License Law dace not haply to am owner of
c:'Do, Law le not u to an
and Professions Crete: Thr
va, located,
propertywhobu Idsorireproves andwhodoessuchwmh hitoeelfor dsmugh his
intendedmoffered forsale.1L
that such impro.ld
own employeha
OCC. GROUP
RES. UNITS
witarenot
dinidea
improvement is sold within one yam orimprove for the
baweveq the ave
the bur proving p purpr,aeo
builder will have the burden of that he did not build or improve for f
purpose of
Q��+Y: PLUMBING PERMIT FEE
rale.).
❑ Las owner oldie propeny,nm exclusively contracting with licensed contractors to
Fl.(H)D ZONE
APN
cmtatruct the project (Sec. 700, Business and'Profeamr, CndC:) The Comuanor's
License Law dm not apply man owner of property who builds or improves thereon, and
PERMIT ISSUANCE
who contracts forsueh projects with aeonaracmgs) licensed purauam to the Contractor's
Law.
ALTER VENT- WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & PC for this remon
BACK FLOW PROTECT. DEVICE.
UT IDIFF.:'
SANITARY Y —N—
RECEIP a
Owner DateDRAINS-FLOOR,
ROOF,AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
'❑ Thereby affirm thmlbnvrnceritiwte nl'ttmxnua self-inxure, ecru ceniFcme of
Workers ComPensatimn hsurance ormcerified copy Nerud(Sec. 3800, Lab C.) which
PIX'I'UNPS-PER TRAP
RECF.IPI'p
PARK FEE Y_N
coven all employee's under this permit.
Policy N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT p
BUILDING DIVISION FEES
Company
❑ Certified copy is hereby famished.
GAS - EA. SYSTHM-OVEN 4(CA)
IwifJ
PLANCHECK FEE
GRPAMWINDUSTRI, WASTE IN'I'CRCEPIOR
GRADING LIE
❑ Certified copy is Glad with the city inspection divisimn.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM F.A. 200FT.
ENERGY FEE
(This section need not becompletd lithe pentyl is former, hundred dollars(SIM)
or leas.)
WATER I[EATER W/VENT/P.LECTR
I certify that in the performance of the work for which this permit is issued,I shall
can employ any person in any manner so as to become subject to the Workers '
PAID
Cotnpensationlawsof Califomia. Date
WATER SYSTEMfMEATING
Date Receipt If
Applicant
NO DCE TO APPLICANT: If, of¢r making this Certificate of Haempdon, you shmuld
become subject to the Worker's Compensation provisions of Ne Iatwr Code, you must
NEW RESIDENTIAL PINE. SQ. FT.
TO'T'AL: 3
forthwith comply with such provisions or this Permit shall be Jeemedrevoked.
BUILDING PER S
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3(19], Civ. CJ
Lender's Name
sino
ELECTRIC ILC
Leaders Address
QTY. MECI IANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read this application and state to., the above information is
correct. l agree o comply with all city and county ordinances endstatelaws relatin8to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby anthmdze representatives of this city to eri noIr a the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MCCH.-:
CONSTRUCTION TAX
(We) agree m save, indemnify and keep harmless the City of Crammer, against
liabi lines,judgments, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (10 l rood CFM)
in consequence cf the granting of this permit.
AIR HANDLING UNIT (OVER 10,000 CPM)
Signature of ApplicanVContrvcmr Date
EXHAUST' HOOD(W/DUCD
PAID
BEATING UNITU Im),000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date NceeiplN
Will the applicant or future building mcupa d store or handle ha esolous material
ns defined by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Salety
HPATING UNIT (OVER 100,000 BTU)
Code, Section 25532(0)9
❑ Yea No
Will the opplicamorfunne building reverend useequipment mrdevices whichemit
VENTILATION PAN (SINGLE RISID)
BOILER - COME (311P OR 10!1,000 BTU)
ISSUANCE DATE
BOILER -COMP (OVER 100,000 KTU)
hazardous air contaminants is defined by the Bay Area Air Quality Management
11YO4
/A {�II
{'�
NEW RESIDENTIAL MECII. SQ. FT.
1 have mud the hazaNaus dementia Tequirementx under Chapter 6.95 of the
�9
California Health & Safety Code, Sections 25505.23533 and 25534. 1 understand that
�Jp��
if the building doe nut currently haven tenant. that it is my responsibility to notify the
"/
.all an of th ents which must be met prior m is. once of crtificate of
7
caullemeW
93
agent Date
ISSUED BY:
OFFICE ry