24840 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO RUILDING-ELECT RICAL FERMI'1'NO /a�1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2484 0
IIUILDING PROJP,CL IDENI'IRICA•1'[ON
BUILDING ADDRESS: ` sip /� 1--s SANITARY NO. APPLICATION SUBMITTAL DATE
r 5600 A E: --FVr^0 O — UNIT# IAT#
OWNERS NAME: PHONE: CO ACTOR'S NAME: 1.1 .N VVV
F 1/6 rJ� 2r7.y� /.q p97 SK
a IRk. O 0 NC CONIROLp �k
RCHYDICf/ENGINEER: /LIC NO:
WHAMMAD F-A1IMAW G04-bSI.7
coI�FP 66INTA PHONE:
q Oy• I0-7P�
QT P,LECfRIC PERMIT FEE BUILDING PERMIT INFO
BLDG P P MB MRCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DI'SCRIPI'ION
CIZZ Ihcrebyaffimtthm lain licensed underprovisinne ofChaper9(commencing wltM1
PACO aiun]Bfd)mDlvieion3ofmc Business and Pmfessinns Code,and mylicense is in PANELS a\��a��
y�bE fu force and effect. • 1 o
E;,ZIaI ease Clusv Counu �- UP T0IM AMPS 1
m 6 ate Convector 201-1090 AMPS i
CHITECTS 0 N SQ.FT.FLO AREA E/SQFT.
Z ,� OVER ELL AMPS
O Z 1 unJ<rstund my plans shall be used as public records.
F-J SIGNS ELECTRICAL
Ludstied Professional
OWNER-HUILUFR DECLARATION SPECIAL CIRCUIT/MISC.
°xxiOyU I hereby affirm that I am exempt from The Contractors Lie..Low for the
Fyfollowing remmr.(Seaion 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
LLOa
m J which requires a permit m construct,Ther,immune,demolish,or repair any ourn a e
K�Q� prion,its issuance,also requires the applicant(orsuch permit to rite a signed statement POWER DEVICES
R!RjnO that he is licensed Putsuanuu the provisions of Ne Contractors License Law(Chapter
XoW 9(commencingwilh Section]OW)o(Division 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC mor �
17.
� ATION�
Way or that he is exempttherefrom and the basis for the alleged exemption.Any violator of OUTLETS-SWITCHES-PIXTURPS 61 L
ES
FZS Seam.7031.5 by any aPPlicomfar.permilainects the appluentto.civil penalty of
—0 out e than Ove hundred dollars($500). NEW RIDENTIAL. S `
T Po ❑ h,nsowneroftheproperty,nrmyemployeeswiNwagesastheirsohecompenmtion, ELECrIt Q'IR.
STORIES TYPE CORSI'RUcioN
M windothe work.and the structure is not intendedoroffemd formle(Sec.'l044,Business _
and Professions Code:The Codon License Law docs not apply to irew
oner of
property who bu IIJ.v or reproves thereon,and who does such work himself onhrough M1ir
own employces,Provided that such improvementsamnotimendedoroffered hostile,IL OCC.GROUP RLS.UNITS
however,the building or improvement Is sold within one year of rompletion,the uwma.
builder wit l have the burden of proving that he did not build or Improve fur part of
sale.).
❑ I,as owneroffie property,=Iexclusively contracting with licensed cnntmnors to QPY. PLUMBING PERMIT FEE FLOOD ZONE APN
contract the project(Sec.70M,Business and Pordeaions Code:)The Contractor's
License Lawdoes notapplyto anownerofpropeny who buihdsm impuvesturcon,and PERMIT ISSUANCE
who contracts forsuch projects with acoatnctor(U licensed pursuant to the Contractors ALTER EA)
License Law. ( FEF,SUMMARY
❑ I en uempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE s
SANITARY Y N
Owner Dam RECEIPP#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, SCHOOL TAX Y N
❑ Iherehyaffirnthalhaveecertificae of consemto xlbinsure,oracertificacof FIXTURES-PER TRAP /� RECEIPT
Workear Cnmpereumnlnsumnce oracmified copy themnf(Sce.3gOq Lac C)wh!ch i PARK FEE Y N
covers all emt(nis.ection
loyee's undenhis permit GAS-EA.SYSTE,)s-1 INC. OUTLETS KECEIPT p
/ BUILDING DIVISION FEES
-_ Co GAS-BA.SYSTEM-O 4 !
ropy is hcrchy furnished. L iF,CK PFT?
Coddled copy is fled with the city inspection divisinv. GREASE/INDUSTRL W f!I R !PI' R G FEE artRl
CIE]IFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP .SEF.
COMPENSATION INSURANCE
need not he mmplemd!fthe Permit is for one hundred dollars(SIM) SI3WM-SANIJRY-STCbUft 100FT, ORGY FEIssi
or less)
I ceniry that in the performance of the work for which this permit is issued,Isha11 WATER HEAL .NT/CLECfR
not employ any person in any manner so as to become subject to the Workers PAID
Z Compensmionlawsof Celifomia. Dae WATER SYSTEM/fRFATING Dam Re
Applies.[
Z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.FT. TAL:
1- LO) become subject o the Workers Compensation puvisions of the Labar Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE ^�
0. A CONSTRUCTION LENDING AGENCY SEISMIC FEE
7-. h hereby affirm that there is a construction lending agency for the perfomance of
L) the work far which this peit is issued(See 3097,Civ.C.) f ELECTRIC
41. O rm
h Lender's Name PLUMBI
lAddress QTY. MECHANICAL PERMIT FEE
V I rOm y thm I hove rcaJ this application and stem that the above infonnetion is
cored Iagreeit)comply with all city and county ordinances and state laws relating hrPERMIT ISSUANCE MEC H ICAL FBI::
Cj� building construction,and hereby authorize representatives Till city to enter upon the
V Z above-mentimmdpmpeny far im,weliun purposes. ALTER OR ADD I'O MECH. CO TR '1'IONT X
(We)agree a save,indemnify and keep harmless the City of CuNdho against
Nabi lities,judgment,cos;and ss which may in any way secure against said City AIR HANDLING UNIT(I'010.000 CFM)
in conxquen of thggra gof this permit
s � AIR HANDLING UNIT(OVER 10,!1(111 CFM)
Sign o As,hcanUCamramor Dae EXHAUST HOOD(W/DUCT) PAID
HALARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1001X10 BTU) Dae Rmian#
Will thcapphicam or(urate building occupant smm ar handle havudous materiel HEATING UNIT(OVER IN,"BTU) TO
ax( fined by the Cupertino Municipal Code,Chapter9.12,and the Health and Safety
C e.Seri 233J2(e)7
CIYa El No VENTILATION FAN(SINGLE RESID)
❑
Will thea licam orfumre buildinoccu ant use BOILER-COMP(3HP OR IO ."ITU) ISSUANCE DATE
pp g p equipmenmrdeviceswhich emit
hmurdous air mmmunants es defined by the DayArea Air Quality Management
BOILER-COOP(OVER Ifp,OflO BTU)
DistrinP P
❑Ya ❑Na NEW RESIDENTIAL MECH. SQ,IT.
1 have read the lcty C de,mations requirements under 34, 1 un erit of 0a MAY '6 1993
iftCidhe mill ILallis Sulbty Code,Sections ate25505,t itis and 25534, 1 undersand that
ifthebuilding Anesnotnicaus yhaveatensa,thatitis myssuance or a mnotifyOf
cupant of the uquircneme which must be met prior m Issuance of a Ccnifcme of
Occupancy. 01il Vf vviran'low
owner nr Tuthorized agent Date ISSUED BY:
OFFICE