24939APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC I RIUAL
PLUMBING J IDHsInFIC
BUILDING DIVISION APPLICATION/PERMIT
IIUILIIING 1'ItOJF:<TI' IIJItN'TIFICATIf)N
PERM]TNO.
24939
BUILDINGADDRESS:
UNIT# LOT It
SANITARYNO.
APPIACATIONSUHMDTALDATE
L-tr(-A43
ON' L'RSNAME: PHONL':
CONTRACI'OR'SNAMH: LIC NO:
N/C
CONTROL#
�F
-Lo
69 s4 a
❑
� i .cam
. ARCH, LIC NO:
ADD �
CONTACT: PHON&
QTY. ELECTRIC PERMIT FEE
BUILDING PERMITINFO
BW ' RCT P� MF.CH
PERMIT ISSUANCE
LICENSED CON] RACI'OR'S DECLARATION
Iheabyarl 'hat lam licensed underprovisionsofClu er 9(commencing with
APPLIANCES -RESIDENTIAL
JOOD CRIPIION
5aden]I)00).f Division 3 of the Business and ProfessionsCode, and my license is in
PANELS
full force and effect.
Lice Is Lie.p
UI'T02IXIAMPS
e Contractor
ARCHITECTS DECLARATION
I nndermwd my plans shall he need us public records.
201 - 1010 AMPS
OVER IfX)O AMPS
SQ. FL FLUOR AREA
E/SQ /FT.
SIGNS ELECTRICAL
1.ioensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby aRnn that 1 um exempt from the Contractor's License law for the
TEMP. METER OR POLE INST.
fulmwhich ingn city nrru
alter,
(Secpermit conLm5.
a.
to improve, demolish, fury
n permit re consumer, alter, improve, demolish, or rcryrig any tatucam
r, de h, orre repair
whichin,issuance,
ssrecisions
that he its iasunnc Pa..requiresthevisios for thsuch Co#ramous License La statement
that he is lialixd pursuanno the provisions of the Conwcmr'e Licenx Lew (Chapter
9(commencing with Senion]01%).f Division3 nfthe Busines,mal Pmfessims Code)
.ober he it
s xempuhcrefmin wdthe basin fits the nlleged exemption. Any viamion of
Section ]03 .3 by any applicant (or o permit subjeeta the upplicam m o civil pen0ry of
POWER DEVICES
SWIMMING POOL ELECTRIC
^/ VALU/�.�TIONC9C7
/ oa-'� I/,�/F
UTLEI'S-SWITCIIFS-PI%TURL.S
not mom th n rive hundred dollars ($500).
❑ baso nerofthepropeny,ormyemploymswith wagesustheirsolccomperumion,
1
NEW RESIDENTIAL ELECIR _SQ. IT.
STORIES
JYPE CONSTRUCT ION
will da the x rk.and the structure isnot imm�ded.reffercA for salv(S Vie. ]044, Businnn
and Profess ns Cale: The Contrxtor's License Low does not apply to am f nor of
property wt buildsmimpmv.thrown, and whedmsauch work Nmsclforthnsugh his
wnempl yeas,provided thmsuch impruvememe urennt imenJeJ ur.ffcred Lnxnle. If,
MC. GROUP
RIS. UNITS
however. to buildinger improvement is sold withinone yearofcompletion,theowner-
build,will have the burden of proving that he out not build or improve for p it ose of
QTY - PLUMBING PERMIT FEE
t 1,.).
0 I,asowoerofthe property, an exclusivelycomuseing with licensedcomrvetors to
FLOOD ZONE
APN
onsvuct the pr,,j.i (Sec. 7044. Business and Professions Code:) The Commctor'a
Licenselawd.esna apply luanowncrefpropcnywhe buildsarimpreves theaon,and
�a
PERMIT ISSUANCE
whocanuucis forsuch projectswish acennacar(s) licensed pursue.... the C.mmcar's
license Law.
ALTER - DRAIN & V13NI' - WATER (FA)
FEE SUMMARY
❑ I nm exempt under Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE
I
SANITARY Y N
RECEIPT#
Owner Dam
DRAINS-Ff.00R,ROOFAREA,
, ,.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Thereby affirm thmlhoveeccnificamfrenum mxlLinsure, oro anifica¢o(
Worker%Cempensmimr Insurance omecenified copy thereof (See.38W, Leb C.j which
RECEIP #
1IXTURFS-PER TRAP
PARK FBI i Y N
eovere all empleyec'a under this permit.
policy If
p
GAS - IA. SYSTEM.I INC.4 OUTLETSRECEIPT
BUILDING DMS NFIE aaiaa
W^Y
Certified copy is hereby furnished.
GAS - IA. SYSTEM -OVER 4 EA)
PLANCHECK FEL' �
GREASE/INDUSTRL WASTE. INTERCEPTOR
GRADING FEF.
❑ enlfied copy is filed with the city inspection division.
CERI'IFICAI'E OI' EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 20017.
ENERGY PEE
(Ibis section need not be completed Him permit is furore hundred dollars PINK)
less.)
WATER HEATER W/VENT/ELECTR
I ccnify that in the performance efthe work for which this permit is issued. I shall
not employ tiny person in any manner set as to become subject to the Workers'
PAID
Compensation laws.&Califrmia. Date
WATER SYSI IBvbTRGTING
Dam Receipt#
Applicant
NOTICE TO APPLICAN'F:If, after makingthia Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FL
TOTAL,
become subject to the Workds Compensation provisions ofthe labor Code, you must
forthwith comply with such pmi,icra.,,his permit shall hedcfoovimvoked.
BUILDING FEE is
AN
SEISMIC FEF, O
CONSTRUCTION LENDING AGENCY
thereby affirm that hem is a construction lending agency for the pedbrtnance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
ELECTRIC FEE
Lenders Name
Leader's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEB. �..I
1 certify that I have read this application and state that the above information is
correct, T agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FIE
huddingcons0uction, and hereby authorize repmesenutives of this city manner upon the
above-mentioned property far impfOirp PPpuly's.
ALTP.R OR ADD TOMECI1.
CONSTRUCTION TAX
(We) agree to save, indemnify and kap harmless the Ciry of Cupertino against
but,Ini"mImams,consund expcnsea whichmay innny vs.,ccnmugainnxiid City
AIR HANDLING UNIT(TO 10,01MCFM)
in con. of the granting of thio it.
AIR HANDLING UNIT (OVER 111,000 CFM)
Slg�nllftare of Appliwm/Comracmr of Dum
EXHAUST IIOOD(W/DUCI)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant or future building exam,nt same or handle Junnad.m autumnalI
as defined by the Cupertino Municipal Core. Chapter 9.12, and due Health and Safety
IEATING UNIT (OVER I00,110t1 RTU)
L.
Cdde, Sad235J3(e)7
o Yes ❑ N.
VENTILATTON FAN (SINGLE RISID)
Will the nppliumerfaurs building cquipmem eawhichemit
BOILER - COMP CIHP OR 100,0(111 RTU)
ISSUANCE DAT'
PA D
BOILER-COMP(OVER 100,000BTU)
by then Bay Quality
'hfara,,? aim conmmuinants ss dcfinetl by the Bey Amu Air Quality Management
Diatnctl
❑ Yes ❑ Nn
fl I]D
APR = 81993
NEW RESIDENTIAL. MF.CIL SQ. 17.
1 have read the hazardous mano uix cluhementa under, Clwpmr 6.95 of the
Calif s,64 Health At Safety Code, Sections 25505, 25533 and 25534. 1 understand that
ifthe building does not currently have a tenant, that it in my responsibility a notify the
COY Ur I Ur-t:'II/lifl�
a
recupmi of the rcy tir men¢ which must be met prior to issuance.& a Certificate of
{,/.` /�7/•
Occupancy.
JY
ISSUED B<Y:yz•`I—I
Owner or authorized agent Data
'!
OFFICE
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