24644I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING.MECDANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 24644
BUIL IO ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATF
J� p UNITN LOT# �y�'i -w 7
OWNERS NAME: Q _ PHONE: Yip CONTRACTORS NAME^•j1 LIC NO: NYC CONTROL#
1915'9 19 4051
ARCHITF.CTIENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT IEE
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
OCZ I hereby affirm that l sat licensedunderprovisixas of ChaMer9(commencing with
Poo Section 70011)of Division 3 ofthe Business and Professions Code,and my licame,is in PANELS 1
ac U F full force and effect. ''
p.<e,.Z,W Licenu Cllxu Lic.p g1
UP TO 2AMP5 \\\
= Data Contractor 201-1000 AMPS I
OZ^Z ARCHITECT'S DECLARATION OVER 1000 AMPS SQST.�RA�iI� t, SISQ.FT.
pp 1 understand my plans shall he used as public records. C \Y�
r�4N
SIGNSELEIELECTRICAL
Licensed Professional
CGOWNER-BUILDER DrCIARAI[ON SPECIAL ' U T E R
.
ugOaUI hereby affirm that 1 am exempt from the Conlrannr's License Law for the w
Orn following reason.(Section 7031.5.Business and Professions Crude:Any city or county TEMP.METER OR POLE INST. DA
(:–.y� which requires a pemtii to constmm,atmr,impmve,demolish,or repair any swnure
LZ
C Q� Eriorto it,issuance.alsorequim,libeopplicnm for such pc.ino file.signed statement POWER DEVICES 44L
that he is licensed pursuant lathe provisions of the Cmtmeme.License law(Chapter
6 e� 9(commencing with Section 7000)of Division3ofdm Business and Professions Code) SWIMMING POOL ELECTRIC 1AT10N
'FF mow or that he is exempnhcretrom and the ba.xis for the alleged exemption,Any violation of iz
zG Section 7031.5 by any applicant liar a permit subjects the applicant to a civil penalty of OUTLF'1'S-SWITCHES-FIXTURES
rc m than fve hundred dollars(S5 W).usnwnmof theprnpeny,ormyempinyces with wages astheirsolecomPareation, NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
Ido the work,ord lhesoucmrc is not lmundcdorol'fered for sole(Sea 70144,Business -
u Professions Code:The Conmmun's License Law rims not apply to an owner of
p tpeny whobuilds^rimproves themon,nnd whodms such work himselforthrough his
oweemployees,provided shat such improvemcnb.m not intendednroffered forsam.If. OCC.GROUT' RES.UNITS
however,the building or impervement is sold within one year^(completion,the owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
'da).
❑ I,mownerofthepmxray,umexclusivelycontractingwithlicenudeonnetorsro QTY. PLUMBING PERMIT PER FLOOD ZONE APN
construct the project(Sec.7(144,Emmet,and Professions C.&O The Ciammeme, PERMIT ISSUANCE
License Law docs not apply to on owner of property who builds or improves thereon,and
whocammets for such projects with acnrmmctm(.,)licensed paxuarm mrhe Contractors
License law. ALTER (EA)) FEE SUMMARY
❑ 1 Amt exempt under Sm. ,B A,PC for this reason BACK FLOW PROTECT.DEVICE S.IDE FEF
SANITARY Y N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION.few DECLARATION SCHOOL TAX Y N
❑ ers'Cuyaffirmthalhaveuem.reireofconunnra.f(inauu,or abcertificate.) hich RECF.IPfp
Wmkers C^mpensatimn lmurance nracertifal copy @ertof(Sec.3800,IabCJ which FIXTURES-PER TRAP PARK IEE Y
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
ElComCenificd copy isbercby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK IEE
❑ CcnifieJ copy is flet witM1 Necity inapatinn division GREASFJINDUSTIL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE:OF EXEMPTION MOM WORKERS' GREASETRAP SOILS RE
COMPENSATION INSURANCE
(This action need not be completed ifthepennit is for hundraddollms(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or less.)
I reify that in the performance of the work for which this prmtit is issued,I shall WATER HEATER W/VENT/ELECIR
not employ any person in any manna so as to become subject to the Worlcn' PAID
z Compenamion Wwsof Califomia. Dote WATER SYSTE•M/IRFATING
Data Receipt#
Applicant
C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) becmm.ubjecuothe Worker's Compensation provisions of the labor Cade,you must
a
forthwith comply with such provisions or this permit shiftbe deemed revoked. BUILDING FEE �•
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a ronalmation lending agency for the performance of
L) O the work for which Ibis permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name O PLUMBING IEE F Lender's Address QTY. MECHANICAL P17RMIT FEE
V I certify that 1 have read thk upplivation land slate that the above information is
�" LlI cared. PERMIT ISSUANCE MECHANICAL FEE
bscddingconsouccon.wtd hereby still arim representativcsofthis a ter upon the CONS'TRUCT'ION TAX
L) .hove-mentioned property for inspection pugxrves. ALTER OR ADD TO MECH.
(We)agree to save,indemnBy and keep hamtless th ity of Cupa o against
Ii.bilitics,judii to ila.,.uswhichmuyinun uy.ca,.i.g s id City AIR HANDLING UNIT(TO 10,M CPM)
nsegnem of gotI wpeoric.
ore
AIR HANDLING UNIT(OVER 10,"CPM)
r gn.mre of p cv Common. �—// Da EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MAI BRIALS DISCLOS/FI • HEATINGUNIT(TO 100,00013TU) Date kwa,,,N
Wilma applicant or furore building occupant marc nor handle hamrd.us mated.] HEATING UNIT(OVER 100,000 BTU) TO
as defi1
ned by the Cupertino Municipal Cute,Chapter 9.12,and the Health and Safety
Code,Section 255320)7
❑Yes ❑No VENTILATION FAN(SINGLE.RFSID)
ISSUANCE DATE
Will Neapplicantrrfmumbuildingmcupant uuequipmcnmrdevica whichemit
BOILER-COMP(THP OR IM."BTU)
harardons air contaminants as defined by the Bay Area Air Quality Management BOILER-COM#(OVER 100.0011 BTU) p
Dismct7 aKl B gy
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. � Gd
1 have read the Instar s materials requimmetds under Chapter 6.95 of the
California Health A,Safety Code,Sections 25505,25533 and 25534.I understand that Q7
if the building does nm conically have a tenant,that it is my reslamsihility,to notify the
occupant of the requirements which must be met prior in issuance of a Certificate of //r Ur
Occupancy. LVrC f
X7
T^�^+
Owner or emhodeed agent pate TOTAL: ISSUED UY:it FJ•
OFFICE