24480 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
JOB UMBIN'G-ELECTRICAL PERMIT NO. 24480
� ^ ^ H O
APPLICATION/PERMIT PIGPROJECTIDBING- IIANICAI
FICA L4l.�
BUILDING DIVISION BUIIAING PROJEf,T IIIP:NTIN'ICA'1'[ON
❑UILDING ADDRLgS: SANITARY NO. I APPLICATION SUBMITTAL.DATE
3 yT/•N LOTH 1110♦
OWNERNA Elsa P E: CO RACTO 'SNAME: LIC NO N/C CONTROL#
73 • '{mac`/�
• ARCIIITE GINEER:
NO: AD E. : d V�
CONTACT PHONE �iBUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
RL r 13 PLUMB M
PERMIT ISSUANCE .►+
ECH
LICENSED CONTRACTOR'S ISECLARAI'ION APPLIANCES-RESIDENI IAL
ZWZ Ihereby affirm that l an licensed under provisions of Chapter 9(cammencing with JOB DESCRIPTION
FilOO Secilm9000)of Division 3 of the Business and Professions Cade,and my license is in PANELS '
full(ocean!effect. opr-till
<ZW License Claes Lic.# UPTO200AMPS
ri[—, y Date Contractor 201-IOIXI AMP'S
Z Oy01 ARCHITECTS DECLARATION OVER I ll AMPS SQ.FT.MOOR AREA $/SQ.PT.
O Z—p I understand my plans stroll be used n public rooms. I•
F'Yt+1 SIGNS ELECTRICAL 1 �!
Licensed Prol'essinnal (f
p, tx< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X Oa V I beach,min.that 1 am exempt from the Contractor's License Law far the
413 4lF following reason.(Section 7031.5.Business and Profewiom Cade:Any city mem my TEMP.METER OR POLE INST.
Lbso
tatwhich reclaims a permit to construct,alter,improve,demolish,or repair any mmctuo,
°'P2 m is issuance,alsorc irea mei applicant forsuch permit file a signedstatement POWER DEVICES
prior qto pp permLi
2p mmhansumengwimSuanupthrprovivishon3of Contradols License Line(Chimer
(LOC 9(arm heisexemit therefrom
and
Division Sof lle Business and Professions Csde) SWIMMING POOL ELECT RIC VALIIA'HON
or h7031.5 by any applica net the permit
the exemption.An t f �►
rn Any GU'L'LET$-SWITCfi135-PIXTlBEg
FZQ Section not
mthan by iv hundred
dollrs(S permit subjects the epplicammacivil penalty of (fib
may+ not more. .n ,'it pnrc)N y.orsmyem). NEW RESIDENTIALELECTR _SQ.FT.
ro ❑ I,osowneroDM1epmpeny,armycmpindrdmthwugesustheirsolccomFwnention, STORIES TYPIiCONSTRUCDON
o. will do the work,and thestmcmrc isnot maindedproffered forsale(are.I.,Business
and Ikofesoom Cedr:'1'he CammemCs License haw does not apply to as owner of
Progeny who builds or improves themon,and whi such work himself.,through his
nempinyces,pmvidcAmmstteh impmvernante aro opt inmMedm.1fcrrd forode.If. OCC.GROUP RPS.UNITS
however.the building or improvement is sold within one yearofcompletion,theowner- TOT
builder will have Its,burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownernfthe prop¢rty,vat exclusively contrntingwithlicemsdamtmmorso, QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
.nand the project(Sec.7044,Business and Professions Code)The Cnntmemr's PERMIT ISSUANCE
License Lawdoes notapply to an ownerafpropenywho builds or improves thereon,and
v)hocontracts far such projects with a contractors)licensed,onon to the Contractor's ALTER IEA) a
License law. FEL SUMMARY
❑ 1 am exempt under gee. ❑&P C for thin reason BACK ROW PROTECT.DEVICE UT IDE FF.F.S
SANITARY Y_N
Owner Dae RECEIPT#
DRAT -FI f ', R .0 NO.WORKMAN COMP17NSA'TION DECLARATION S GOT TAX Y N
❑ Thereby affirm thrtlhove acenificam n(consentmselGinsurc,oracrmfutateof RECEIPT
Wmona'Cnmpemation lnmormcnracerifed copy moons e.38IX1,lab C.)which FIXTUi L's5- ER' A PA KFEE Y N
rsallemployce's under,this parent. GAS-EA.S I �Vj L RECEI
Policy# BUILDING DIV ION FEIS
Company GAS- A.SYST'M-OVER4(EA) PL NCI FEE
O
❑ Cenifiraa,pyishemleymmiehed. 14 T-P
❑ Certified copy is filed with the city inspection division. GREA NDUSTRL WAS DING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE,
(Thissection need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM FA.200FT. 4�14RGYI cenify that in Ne perfor ance offle work for which this permit is issued,l shall WATER){EATERW/VEND13LECTRnot employ any person in any manner co as to become subject to the Workers'z CompensationlawsofCaOfOmld. Date WATER SYSTHMGRAf TINGceipt#
ApplicantZ 0— NOTICE TO APPLICANT:If,after makng this Cenifcale of Exemption,you should NEW RESIDENTIAL Pi SQ.fT. TOTAL:
DG become subject to the Workers Compensation provisions of the Labor Cade,you must
> forthwith comply with such inwieionsonhis permit shall be deemed revoked.CONS'TRUCT'ION LENDING AGENCY lI hereby affirn that them is a construction lending agency for the performance ofOthe work for which this Ixrmit is issued(gee.YaD,Civ.C.) TOTAL: Q
Lemiels Name
LL.O F Lenders Add.,, QTY, MECHANICALPERMIT FEE PLUMBING :T:
V 1 minify fast I have read in,spplication and some ohm the above infotmnion in
Fa correct Iagree to comply with all city and county ordinances and state laws reining to PERMIT ISSUANCE MECHANICAL EE �•
En building construction,and hereby authorize representatives ofthia city to colingon the purpCONSTRUCTIO TAX
O 7 abovm
e- emioned properlyction for inspeoses. ALTER OR ADD TO MECB. �+
�-t (We)agree to save,Indemnlly and kcep harmless the City of Cupertino against
liabi'ies1judgmcnb,cansand r,ai which may in anywayaceme against said City AIR HANDLING UNIT(TO 10,0011 CFM)
inIrnstlinem:9 the rnntiUmit.
t 1`0
AIR HANDLING UNIT(OVER 10,000 CPM)
Signamre of Applica /Cpntmcmr Date EXHAUST HOOD(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE IBA'fING UNIT(To I0R,m BTU) Date Receipt#
Will the applicant or future building occupant store or hurdle hazardous material
Qs ddined by the Cupenina Municipal Code,Chapter 9.12,and the Health and Safety IIRATING UNIT(OVER IW1,000 BTU) T( T
Code,Section 25532(n)P
Cl Yes Pilile VENTILATION PAN(SINGLE RESID)
BOILER-COME(3HP OR 1000X0 BTU) ISSUANC 'ATC
Will applicant erfmurebuildingoccupm a
aoseryipmcnt urdevicex whichem ,
it
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER 100,000 BTU)
District, ❑Yes ,ors NOV 12 1992
I NEW RESIDENTIAL MEC#, gQ.FT.
1 have read the hazardous m cencids requirements under Chapter 6.95 of the
Caum buialleal oma Safety Code,Sections25I It 25533 and 25534. Iundersmndohm CITYIGuren, mJ,
if the builtlingd«snot curen0 baveemnantnhm it is my responsihility to notify the /
oce of the 'quires uta LIC U IK met prior to i seance of a Certificate of
CetiT.
Owner m inim.nzcli,em Date ISSUED BY:
OFFICE