24967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY'OF CUPERTINO BUILOIN(i- .-., PERMIT Na. 24967*
APPLICATION/PERMIT PLUMBING-MRCHANICAI.
HUILUINC DIVISION I4UILUING PROJECT IIIRN'1'IIrICA'1'ION
II UILDIN/GAAjDDRESS: G •'(� /may /n� SANITARY NO. APPLICATION SSUBMII FIIAL DATE
21 l/O S7;,MA lel 6ee- GJ� UNTr# �OD I.OTN
OWNS ME: � K� PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
RCHI'I ECT/ENGINEER: LIC NO: ADDRESS: ❑
CQFrfpf*e%, � Puowi:/ �� QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
►/"j�����, Fi 17I.D0 EL�' PLUMB Iigiii
PERMIT ISSUANCE ITR(,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALJOB DESCRIPTION
Zyz Ihereby affimt that l am licensed underprmvisions of Chapter9(commencingwith /a
PJ00 Section 7000)of Division 3of the Business and Professions Cods,and my license is in PANELS y L O • vI
" rI
full force and effect. �V rT
6L� License Class Lie,is UPT0200AMPS
L,<a Date Cantmctm 201-1000 AMPS
FyZ ANCIII'1'F.CI"S DECLARATION SQ.IT.ILOORAREA 4/SQ.FT.
ZOm" lunderstmd my plans shellboused as public recardx. OVER I(oO AMPS I
0-L'G
F= _j SIGNS ELECTRICAL ��
6Y .1 LicrnsM Professional
6 OWNER-BUILDER from
the Con TION SPECIALCIRCUIT/MISC. ♦ E
O a U I hereby aftinn Nm 1 am exempt from the Cnntmaor's License Lew for the
W Say following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.•
which requires a .1,1.conutrum,alar.improve,demolish,or repair any ntrvnorc
>� prionoitsissu ce.asomquirestheapplicantformahpermittofileasignedstatement POWER DEVICES DA E
pj nJ'pp that be is licensed pmmunt to the Provisions of the Contractors License Law(Chapter
n.ao� 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC - VALU/y'�I�
❑ao or that be is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCfIFS-FIXTURES 3oea u=
F-Z Q Section 7001.5 by any applicant for a Permit subjects the applicant m e civil penalty of
ronot more than five hundred dollars($SW). NFWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
ElLasownerofNepraperty,ormycmploymewithwegesastheirsole compcasapon,
W willdo the work,and theswctumis not intendedoroffaed fm We(Sec.7044,Husmoss
and Professions Code:']he Contractor's License Law does not apply to w owner of
property who bu ilds m improves thereon,end who does such work b i ravel f or through his
own etnpl(jecs,provided that such improvements are not intended orofferedforsale.If, OCC.GROUP RPS.UNITS
however,the building or improvement is sold within oneyesrofcompletion,the owner- .1
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,azownerof theproperty,um exclusively contracting wiNlicensedconwcton to QTY. PLUMBING PERMIT FEE FLOOD ZONE AI'N ,
construct the project(Sce.7044,Business and Professions Code.)'I he Contractor's
License Lawdoes not apply loan ownerofprapeny whabuildsor improves thereon,and PERMIT ISSUANCE
who contracts forsuch projects with acommotons)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WA'1'I?li IRA) FEE SUMMARY
❑ I am exempt under tics ,B&PC for this reason BACK FLOW PROTECT.DEVICE I SIDE.F:,
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y N
❑ Ihereby affirm that l have a cenificate ofcoment to self-insum,or a certificate of FIXTURES-PER TRAP RIECEIPTN
Workeri Compensation Insurance of a certified copy thereof(Sec.3800,Lab C.)which PARK FE: Y N
emidlemployee'sundenhispennit. GAS=UA.SYSDiMd INC.40UT'LEIS RFCF.If #
Policy#' BUILDING DIVISION FMS
*M
WS GAS-EA.SYSTEM-OVER 4(IA) PLANCHECK FEE
erti
Enl copy is herehy Iumished.
❑ Cimified copy is filed with be city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed lfthe permit is Fostoria hundred dollars(EIM) SEWER-SANITARY-STORM EA.2000 ENERGY FEE
or less)
I certify that in the Performance of the work for which this permit is issued,I shall WATER HEATER W/VFNT/F.LGCfR
not employ any person in any mvtnce so as in become subject to Ne Wmken' PAID
Compensation Lawsof Caifomia. Dam WATI7R SYSTHMOREATING Data Receipt#
Q z Applicant
C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
,,0 become sulocomhe Workers Compensation provisions of the labor Code,you most i
1 forthwith comply with such Provisions or this permit shall bea d«med ravaged. BUILDING FEF.
k0 QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby which
that there is n construction 97,Gig agency for the perfonnunce of
♦t U O the work for which chis permit is tastes)(Sec.3097.Civ.CJ TOTAL: ELECTRIC IEE
t--t Eacale,s Name s FET.a PLUMBING FEE
F' Lande.a PhRMIT Address QTY. MIiC11ANICAL
0 U I certify that I have mad this application and,tate that the above information i,
W correct.I agree to comply with all city and county ordinances and state laws mlating to PERM IT ISSUANCE MECHANICAL FTE
i,, buildingeonswction,and hereby authorize representatives offlimairy master upon the CONSTRUCTION TAX
U Z above-mentioned property forimpectioa purposes. ALTER OR ADD'TO MECH.
(We)agree to save,indemnify and lump hvmlas the City of Cupertino against
liabi fiics,judgmems,cons and expert hicIt�yyineny waT'a�veagaromid City A IR HANDLI NG UNIT(TO 10,11(X)CFM)
in yuence of the granting of Nis Penni//�� J \r
AIR HANDLING UNIT(OVER I0,000 CFM)
Sumiallb,of APFlicam/Cmumcaar m EXHAUST I IOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO VIEW BTU) Data Receipt#
Will the amiicenlor future building occupant amrc err handle hmiumms materiel HEATING UNIT(OVER 100,000 B'IU)
as defined by the Cupenim Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0? V
13 Yea ❑Na P.N'1'ILATION PAN(SING(SINGLER851)7
Will thea licanrrfuturebulldln occu BOILER-COME(3HP OR 100,000 BTU) ISSUANCE DATE
pp g pant use equipmenmrdeviceswhich emit
hamstrirddus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 B'FU) r 1
'Dict? nn
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. Ault(
�/�
1 have read the havvdou,material,a,mumnants ander Chapter 695 of the Au R 14 g
California Icalth&Safely Cale,Sections 255115,25533 and 23534. understand that v
if fl a building does net currently have a tenant,Mat it is my respomilidul,m notify the r tt
Occupancy.antof the requirements which must In met prior to Issuance of a Certificate of /Q��Y(h- VVI' V
Owner in authorized agent Data ISSUHDBY: