24492 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CLLY OF CUPERTINO BUILDING-ELEC'T'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL. -
BUII.IIING PR(CIPC T IDEN'TIFICA'TION 24492
'-BUILUING ADDRESS: I SANITARY NO. APPLICA'T'ION SUBMITTAL DATH
79 5 �d UNIT# LOT#
OW M S .nl I � I pI1pN: s CD ' C'O 'S A E: /y�� /�x' C L/I C NIC
CONTROL#
ANCIIITECI'/EN INFER: K l/7f G/f(✓CfS.I.1(O,NO: A Ift, J�� J v"
TM
CONTACT: PHONE: QTY (ELECTRIC PERMIT FEE BUILDING PERMIT IN170
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE El El
LICENSED CONTRACTOR'S DHCLARA1'TON APPLIANCES-RESIDENT'(A],
I hereby (firm that l aniicensed under p gwith JOB DESCRIPTION
OZZ Ye pad profesionsCter and mmeocin
+1100 SedTons.and I Division 3of the Rosiness and Professions Code,and my license is in PANELS
faly F Lite., and cl 5 . -
4FZW Da n. Cla. Lies C) UP T0200 AMPS
m6y Dee Comm-Sr�Olr - 201-1100 AMPS
ZOyS AItCHITL'CT'SUECIARA'TION OVER IOW AMPS SQ.IT.FLOOR AREA $/SQ.FF.
Oz-0 I understand my plans shall IN,used as public rectors.
Fro�w SIGNS ELECTRICAL.
J Lmcnscd Professin al
�C�a OWNERTUILDER DECLARATION SPECIAL CIRCUIT/MISC.
rsx'O q I hereby of Ton that I um exempt from the Contractor's License Law for the
�1 �m following remon.(Sation]lGl t,lJusiness unJ Pmfcssions Codc:Any cityor roomy TEMP.MCI JR OR POLE INST.
1=iii_01 which requires a permit to..throet,ober,improve,demolish,or repair any smcmre
prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
M ,
ty KBO that he is licensed pursuant the provisions of the Cimantemr's License Law(Chapter
2%0�' 9(commencing with Section70n0)of Division]note Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W, normal he is cxempnhcrefrom and the basis for the alleged exemption.Any violteionof
hZa Station]831.5 by anyopplicant fora pe.itsubjce,a the applicant too civil penalty of OUTLETS-SWITCI Itis-FIXTURIE;
04 m nm.,are than five hundred dollars($500). .
CII,asowneroifthe propeny,ormy empinyceswith wages as theirsolecnmNEW RFSIDTiNT1A1.ELECB Spensation, Q PT. STORIES 'TYPE CONSTRUCTION
ty _ willdmhe work,enJ thcswmure is notimenJcdoraffereJ forsele(Sw.]of4,Busin<ss
and Professions Gale:The Contractor's License Law does not apply to an owner of
property who build or improvestheram,and whodoes such work himselforthmugltItis
ownemployees,provided that such improvememsarcnot intendedoroffemd formle.If. OCC.GROUP NIS.UNI'T'S
however,the building or improvement is sold within one year ofeempletion,the owner- TOTAL:
builder will have the burden of proving the,he did not build or improve for purpose.I'
taEl QTY. PLUMBING PERMIT FEC FLOOD ZONE nPN
❑ 1,as owner
proof th(Sec.7414, urines a prof..loong k Coth de:)
edcommemrs to
Licensed the project(Sec.oNoo Business and ywho bons Cod prove Comectoh
License Lawd«snot apply menownerofpmpenywhn buildsorimpmves thereon,and PERMIT ISSUANCIi
who contents for such projects with acantrecoods)licensed pursuant to the Contractors ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I sm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
I ltercby arfina that I hove a certificate of consent tocalf-Insure,nr o wnifente of RECEIPT#
FIXTURES-PER TRAP
ukers'Compensatinn Insurance orucenifieJ copy thereof(Sec.38W,Lab C.)which PARK FF.Ii Y N
covers
He TA h RIiCETPT#
Policy# \\ //YY g1(j�'yy GAS-PA.SYSTEM-]INC.4 OUTLET'S BUILDING DIVISION FENS
Compaa,�W X - `• L1 - GAS-LA.SYSTEM-OVER 4(EA) PLANCHECK IEE
❑ Certificicopyisherebylbmished.
"Certified copy in fled with the city itolwetion division. GRLASE/)NDUSTRI.WAS'M INTERCEPTOR GRADING ITE
CERTIFICATEOFEXEMPDON FROM WORKERS' GREASE TRAP SOILS FEF,
COMPENSATION INSURANCE
(This ardionneedma to completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or loss.)
I reality that in theperfisrmance of the work for whichthis permit is issued,l shall WATER HHA'I'ER W/VENT/I!LECTR
not employ any person in any manner aro as to become subject as the Workers' PAID
Z Compensminn Lawsof Culifomia. Date WATERSYSTEM/TREATING Date Receipt#
Q O Applicant '
0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RES)DENTAL PLMB, SQ.Fr. TOTAL:
tibeconto tatjtat ro the Warke,'s Compensation pnovixinabof the Labor Cudc,you must
> fnnhwirh comply with such partitions or this permit shall be deemed revoked. BUILDING THE
W z CONST RUE,
C'I'TON LENDING AGENCY SEI SM IC FE
^a 1 hereby arfirrn that there is a eontweti an lending agency for the pwhim osoc of
U O 0e..,it for whichthis .it is issued(Ste.3097,Civ.C.) TOTAL: ELF.ITRICIIE
Leader's Name EL
IE F Lende's Address - QTY. MECHANICAL PERMIT ELE
PLUMBING FEEU I certify that I have readmit application and xlate that the above information is
OW.. correct.I agree to comply with all city and county ordinances and state laws relining to FERVID ISSUANCE? MECHANICALFER t
F' ti building conswetion,and hereby vmhonze repreunwtivesofthiscity ro enter upon the
U 7a aMwe-memioned property far inspection purposes. ALTER OR ADD TO MEC(I. CONSTRUCTION TAX
(We)agree to save,indemnify and keep lower...the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way seers,against said City AER HANDLING UNIT(TO 10.000 CFM)
11
a. fthe ger gof thio omit.
/�o1D�9a AIRIIANDI.INGUNI'I'(OVER l0.q➢1CFM)
S�y o nr Applicm/Commcmr 11 ate E%l1AUSTHOOD(W/DUC
v PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNI'r(TO 100,000 BTU) D.1f,, Receipt IT
Will the applicant or future building occupant store or handle hv.ardous mmeritd )iBATING UNIT(OVER 100,100 BED) 'TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532DI? �,/ VENTILATION PAN(SINGLE RIS)U)
❑Pas }y,Nt ISSUA/JCE DATE
Will thea licwmr(fm_ure building occupant BOILIiR-COMP(JHP OR 10U,000 BTU) P'
pp g pan quipmentnrdeviceswhich emit a1 �f
hwmm
.ardes,air conine�msst(as defined by the Bay Area Air Quality Management BOILER 100,1100 BTU)
�. Dlstrint? I JVOI1 TF1
❑Yes No NEW RLSIDI?NTIALMECII. SQ,FT.
1992
I have read the lumaorous materials requirements under Chapter 6.95 of the -
Cnliforniellwfh&Safely Cnd,,Sections 2550.5,25537 anA 25534. [undersumdthm CITY �f `Url.�
if the building does not currently have a tenant,that it is my responsibility to notify the t
l�occu m f the requiremems which m t be met pnnr m issuance of e Ce 'true of
amhonzed agem 11,
at� TO'T'AL: ISSUED BY:
OFFICE