24868 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT P N ONLY / ✓ /
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. -//1 /� I/��
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L g-}H V H
BUILDING PROJECT I DENI'IBICAI'ION
BU 1 G )D SS: I SANITARY NO. AFPI.ICATIONSUBMITTALDATE
UNIT# LUL'# / s—(,1?'l3
alittli S A r/1 POM4 , T NIC CONTROL#
R'HIJJCgIiNGINi?ER: ' I LIC NO: I r n�'Jy V& V i/ El(�
CONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAI.
py.Z I hereby affirm that l am licensed underprovisionsof Chapter9(commencing with JOB DESCRIPTION
WOO Section1(:1of tvision3 Ithe Business. rofessions Code,and myJammeisln PANELS
FK� full force an ell' s. /
<z License 6 Lic.M UP T02W AMPS
,,<o. Dam Cut 201-]Bud AMPS
ZOy� c ARCHITECPS DECLARATION OVER I"AMPS SQ.PT.FLOOR AREA 8/SQ.FT.
O Z—G 1 un rsmno my plans shall be used sa public records.
Q'- 14 Licensed Pantaomnd SIGNS I!LECTRICAI, ® I
C a OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
pxOaU I hereby affirm that I am exempt from the Contractor's License Law for the
W30.co followintimason.(Section 7031.5,Business and Professions Code:Any city orcom I'HMP.METER ORPOLOINST. its 1\ n
Y.O< which acquire.a permit 9.cunstrud wrt �V••J 1 eller,improve,demolish,or acted,any snu
}�, pdmmitsissu.nce,also requime the npplicam lnrsuch Pcemina fileasigned smmnmar POWER DEVICES
C<g that he is licensed puma,to the provision mthe Cemm aox License law(Chapter
n'XOo� 9(commencing with Section 7000).(Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC DIME
W�H or that he is exam#therefrom unit the basis for the alleged exemption.Any violation of OUTLhT'S-SWITCIIFS-FIXI'USES
Z Q Sectio 7031.5 by any applicant for o permit subjects the applicant to a civil penalty of
O non mom than five hundred dollars(S500).
Q ❑ 1,asowneroftheproperty,nrmyemployeeswimwagesasnheirselecompensatlon, NEW RESIOFMIAL CLIiCTR —SQ.19. STORIES TYPE CONST'RUCT'ION
a wiltdothew.rk,.dihemctumisnotintendcdwoffercdformle(Sm.7M,Business
property Mi bac Cade:The thereon,
License Law does not apply vi on owner of
_�-, ownmwyces,pmvideiproveslhimpmvmcntnamnotintond orofffomscifor rule.his 1717 r OCC.GROUP RES.UNITS
however theea,pmvidedm improvement
arenotyear.17cmaplfined Thesis.If,
however,the have
the
arden of proem ie sold withinone year of intense for
thepose of
builder will hove the buNen of that he did not build or intense u f TOTAL:
F
proving prov purpose
ale.).
❑ I,nowncr of me property,emeadueivelyconvaning wimlicunseJ cnmranorsm QTY. PLUMBING PERMIT FF.F. FLOOD ZONE AI'N
comtrod the project(Sec.7044,Business and Profession Code:)The Commcmrs
License Lawdeeaminppry wormommeraftsmIa.y,who builds orimpmsesdoewrand PERMIT ISSUANCE
who emvacts lnrsuch projecta with a omonsemr(s)licensed punmm m the Conwmars
License Law. ALTER-DRAIN&VENT'-WA MR.(EA) FEE SUMMARY
❑ 1 am rmmpt under Sec. ,B&P C for this waun BACK FLOW PROTECT.DEVICE SANITARY_ Y D E N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm that l have acerificareufcrsnennn self-insure,ma embricamof RIECEIn#
Workers Compensation copy Fl%'TURES-PER TRAP
pcmnlnnlnumnce or acetified co meacrif(See CJ which PARK FEE Y N
oven all emplo s N er�iy��U3 GAS-HA.SYSTEM-I INC,4 OUILETS RECEIPT#
Policy# /1/ BUILDING DIVISION FEES
ComlwnY {;+- abJH�
[IGAS-RA.SYSTEM-0VFR4(EA) PLANCHECK FEE.
Certified copy is hereby�mished.
❑ Certified espy is filed with the city inspection division. GRFASRnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FTE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forms hundred dollars PS UXB SEWER-SANITARY-STORM PA.200FT. ENERGY ME
err less.)
I certify that in the perfonnunce of the work for which this Permit is issued,Ishdl WATER HFATER W/VENI'/ELECGR
.or employ any person in any manner ao as m become subject m the Workers' PAID
Z
Compensation Lawsof Colifemia. Dore WATER SYSTEWNEATING Dore Receipt#
Q O Applicant
z NOTICE TO APPLICANT:If.after making this Cerificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PL TOTAL:
become subject to the Worker's Compensation provisions of the labor Code,you most
; forthwith comply with such provisions or permit dull be deemed tevoked. BUILDING FEE
W (� CONSTRUCTION LENDING AGENCY SEISMIC PRE
I hereby affirm that there is.construction lending agency for the performance of
UO me work for which this pends is issued IS..3097,Civ.CJ 'TOTAL.: F.LF.CTRIC IEE
ULenders Name Lenders Address Q'I'Y. MECHANICAL PERMIT FEC: PLUMBING FEC
1 cenify that 1 have read this application it sure that the.1hove information is
}' 4 comet.l agree to comply with all city and county ordinances and state laws relating[it PPRMG ISSUANCE
MECHANICAL ITE
(r building coruwaion.and hereby eumnriu rcpreumetives of this citymenmr upon me
V above mentioned property for inspection purposes. AL'IT.R OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify mid keep harmless the City of Capetian against
IiabilitiesJudgmenss,costs and expenses which may in any way ammo against said City AIR HANDLING UNIT(TO 10,001)CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,M)CPM) /7 Q
Signamreof APPli...1/Curnactof Dam EXHAUST HOOD(W/DUC) PAID�� /J CZT
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(OIffit0 BTU) Date Receipt#
Will the applicant or future building occupant stow or handle hazardous material
sea defined by the Cupertino Municipal Code,Chapter 9.12,and use Health and Safety HEATING UNIT(OVER IW,000II1'U) TOTAL: 3 3 E
Code,Section 25532(.)'!
❑Yes 11 No VIiNTILA'TION PAN(SINGLE RESID)
Will applicant orfutuubuildingrncupantuupmm ma eyuienrdevicee which
BOILER-COMP(31IP OR 1011,000 BTU) ISSUANCE DATE
Onturdnus air contaminants as defined by the Buy Arca Air Qualify Management BOILER-COW(OVER 100,000 BTU)
istrictP
❑Yes 0 N NEW RESIDENTIAL MECH. SQ.FT.
I have mW the liunrdoiu materials requirements under Chapter 6.95 of the MAY 18 1993
Ca ifnmia , di S.feryCute,Sections 25505,25533 and 25534. I understand man
if the hull do notcummlyhaveammuny tl tis responsibility m notify m - CIIY Ur li Ul'GPII!IVU
occupant m uimmenrs which must be iss a of a Certificate
ixcupa tlhl
nor amhoriudagrnt a TOTAL: ISSUED BY: •s-V�
OFFICE