24474 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILUNG-ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
IIUILDING PROJECT IDEN'OVICATION 24474
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE.
2 Z V UNII�T#Rp LOT#
OWNS . Mf?: G PH NE: _ V ORIS NAM': LIC NO: lJl
Vfkl 1 T (� N/C CONTROhN
•ARCHITECT/ENGINEER: LIC NO: ADDRESS: y�
r)1 0 . T1 ❑
CONTACT: PHONE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB M'CI
PHRMITISSUANCF. 1:1 El I 11LICENSIiD CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRIPI'ION
0042 Ihereby affirm that l am licensed under powisionam'Chapten9(commencing with
WOO
Section 701))ofDivision Jof the Business and Professions Code,and my license is in PANELS
full fora and cffccy� rrI115
<< uwJ Data sF Fla•• Lic. UP T0200 AMPS U �s�
y<y Date s• t'e��--!1'3 HI Cuntr1(�(� 201-IOW AMPS
ZDyZ
ARCHITECTS
DUCTARATIO OVER IM AMPS SQ.FT.FLOOR AREA 1/SQ.FT.
O Z a I understand my plans shell be used as public records.
F aFy.2 W SIGNS ELECTRICAL.
'J Licensed Professional
�wlY< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 nm exmnp[from the Cmtmem's License law for the
Mo, following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a Permit o construct,alter,improve,demolish.or repair any structure POWER DEVICES
Y�
prior to its issuance,also requires the applicant farsuch permit m file a signed statement -
<O that he is licensed pursuant to the provisions of the Commences License Law(Chapter
dyge 9(commencin with Section 7" fDivision J ofdae Business and PmPossions Cde SWIMMING POOL ELECTRIC
on
gwi la ) VALUATION
y,may ophat tion 7031.5 by my appl Band the permit
ermtrnhe dlegNexemant to civil
of OUTLETS-SWITCHES-FIXTURM
tZQ Senir.thn5iv any S500b.tsubjecm the applicant,oacivil penally of
mnm marcthenroftherocrtyllam(Sem). NEW RESIDP.NTIALELECR S FT.
❑ 1,usnwneroftheprapeny.ormycmpinyas with wageseslheirsole compensation, Q STORIES TYPG CONSTRUCTION
q will do thewrrk, inttheswemetarot intended reoffered forade(See 7044,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property whrbuildsnrimpowes theremmem!whod.e sm,hwmk himselfocthrougM1 his
own employees,provided that such improvements urenot intended cononed(onside.If, OCC.GROUP RES.UNITS
however,the building.,improvement is sold within roe year.fc.mpleti.n,the owner-
builder will have the burden of n that he did not build or improve for u f TOTAL:
proving pov purpose
❑ I,as uwnenafthe property,amexdmively, contracting with liPTstsedmntmctonm QTY. PLUMBING PERMIT FEE pLGOD 21 NE pPN
comment the project(Sec.7044,Bminesx and Professions Ctde:)The Conhacmes PERMIT ISSUANCELicense Lawdocs nm apply to on owncrurpropcny who buildsor improves thereon.anJ
whowntracts forsuch projects with aconvaeor(s)licensed pursuanuo,he Canwcmr's
License Law. ALTER-DRAIN&VLNT-WATER IFA
) FEE SUMMARY
❑ I ren exempt under Sec. ,B&P C for this..,on BA WrFRBTF&. 3VIC DE FE S
A 1 SANITARY Y_N
•
Owner RDid.AT 1 � s r RF.CEIPI'p
DRA NS-FLOOR,iROOP,AR'A;CONO."
�/ WORKMAN that I .eia COMPENSATION bfc. .ttosa RATION SCIIOOL'TAX Y N
JIBery ConpieI hereby nmonInsrance or ificateed!copennrealf(insurc,or aanif¢amch Fl PER TRAPJ RECEIPI'p
�V�kess'Compcnsationlnxurmce orecmifiW copy d¢rmf(Sm.JSW,LabCJ which I PARK FEE YN
em all c/ilkloyaq'yunJw lNy gTniilGAS- t S .M-I INC. S RBCEIPT IVISIO#
I It ily 1V Jf/1 rrl� _ BUILDING DIVISION I EEg
Company -EA.SYSTEM-OVER 4(EA)— PLANCHECK FEE
❑ Certified copy is hereby furnished.
Certified copy is filed with the city inspection division. GREASEIINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CER9'IFICATB OF EXEMPTION FROM WORKERS' GREASE TRAI' SOILS FEE
COMPENSATION INSURANCE
(ThissecImn need net be completed if Ne permit is forane hundred dollars(SUM) SEWER-SANITARY-STORM EA.200417. ENERGY FEE
e,less.)
I eerily that in the performance ofthe work for which this permit is issued,l shall WATER HFATER WfVENT/fsLECTR
not employ any pawn in any manner sec as to become sabres to the Workers PAID
Z Compensation Lawsof Califonix Date WATERSYSTEMMEATING Data Receipt is
Q 0 O Applicant NEW RESIDENTIAL PLMB. S
Z NOTICE TOAPPLICANT:r's aftCo making Certificate of Exemption,you you must —SQ FT. TOTAL:
h
becomethwith subject id,twhp wismpensatiis pmvisionsof rhe coned evoked. must
5 fnnhwi[h comply with such pmvielons or permit shall he dermal revoked BUILDING IP.P.
Da Q CONSTRUCTION LENDING AGENCY SEISMIC FRE
Z I heechy uffirat in.,he.is a continue,...lending agency for the performunre of
O the work for which this permit is issued(Sar.31 N),Civ.C.) TOTAL: ELECTRIC FEE
w Lenders Name I
Isnd Address QTY. MECHANICAL PERMIT FEE PLUMBING IEE
I
V certify that 1 have rend this application and state that the above iws b for is
comet.caet.Ingrte,o comply with all city and county ordinances end nate laws relating toPERMIT ISSUANCE MECHANICAL FEE e
�-� hullding conoruairn,and hereby authnriae representatives offiischy[.Intel upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MUCH. CONSTRUCTION TAX
(We)agree m save,indemnify and kap hatmless Ne City of Cupertino against
Iinhihnies,judgmcros,coociand aspens which may irony oryincone agsimat,nd City AIR IIANDLING UNI'TITO 10.000 CFM)
in consequence of the gmming f,hi,perm:[.
AIR HANDLING UNIT(OVER 10,000 CFhf)
Signature or Applicant/Connxemr Data EXHAUST FLOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicmtor furore building conte,store or handle huemdoux memrial HEATING UNIT(OV
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ifealth and Safety ER 100000BTU) O TOTAL:
Code,Section 25532(x)9
❑Yes `$21Nn VENI'I LAI ION FAN(SINGLE RHSID)
Will the contaminants
ontfor,marc building by thentuse Area it mdeviateanagM1emit
BOILER-COMP(3HP OR 100,(101)BTU) ISSUANCE DATE.
�tranNnw air comxminanw m define)by the IIeY Area Air Quality Management BOILER-COMP OVER 100,000 BTU
Dinrie? '''...III ( ) PAID
❑Yes yJ No NEW RESIDENTIAL MECIL SQ.FI'. �I ,!/f
I have mind the hexa dous materials requirements under Chapter 6.95 of the OR 21 1 Igg3
California Health&Safety Ctde,Sections 25505,25533 end 25534. 1 undemmid that L
if the building does not currently have a tenant,that it is my responsibility m notify the �,„, �f r ,1pC rI��
ac ant of the rtyuircmems which must be met prior,.issuance of a Cmificate of I I' f' V V f G
c
r amhoriu agent Data TOTAL.: .QQISSUED BY: as
OFFICE