24727APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO DO ILDI G- ELEC71 RICAL
APPLICATION/PERMIT PLUMBINGMECHANICAL
BUILDING DIVISION BUILDING PRH.IECT IDENT'IFICA110da
PERMITNO.
24727
BUILUINO AIJDRC55:
SANITARY NO.
API'LIC�AII/OrN'SUHMITTAI.DATE
G LOTM
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OWNERS NAME: PHONE:"TRACTOR'
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NAME: hCNIT.
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NYC
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ARCIII'1'ECI'/liNGINEER: LIC NO:
ADDRESS: /e
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CONTACT: C �PHONE:
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Q'I'Y, ELECTRIC PPRMI'r FEE
PERMIT INFOsss,
B :L W B ME
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7
3
PERMIT ISSUANCE ��
LICENSED CONTRACT'OR'S DECLARATION
I hereby a(Btm thin 1 am licensed underprovisionsn(Chupter9 (eammcncing with
APPLIANCES- SID L
JOB DF.SCHIPTION
Section)001 Division 3.f Ne Bnsioessand Professions Code. and no, license ismppryBVS
full force and effect.
/ ���
License Class Lie.Is
P 02 M
i\..,
Date Contractor
H PS
ARCHITECT'S DECLARATION
1 undemmd myplans shell heusedm public records.iff
V, 000 AMPS
SQ. FT. FLOOR AREA
S/SQ. Pr.
120
NS ELE
ILicensed
PmfessionelOWNER-BUILDER.DECLARAI
ION
lareby affirm Not 1 em exentp tram the C.mrxtors License law for the
mane
followingmrams(Section]031.5, Buxinesv and Professions Cade: Any city or countyEMP.
ECIAL
1
'1'/MII
MY
OR rOLE INST.
which requires a Permit to construct, alar. improve, distant or repair my srrucsum
prior to its isstanee, also requires the applicant for such permiuo file a signed statement
POWER DEVICES
that he is licensed pursuant m the pmvisinm m Ne Contiguous License Law (Chapter
9(commencing with Section 7000) of Division 3 afthe Business and Professions Code)
.r that he is esempuherefrannodthe bmis(anhealleged exemption. Anyvimmi.n.f
Section 7031.5 bymy applicant for. permit subjects of themmixem tore civil penulty
SWIMMING POOL ELECTRIC
^ VALUATION
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars (S500).
.❑ 1.asownemphepropeny,ormyemployceswithwagesaztheirsolecoin ensotion,
NI:W RGSIOF.NTIAI. ELGCIR _SQ. FT.
STORIES I
'TYPE ONSTRUC ION
willdothework,md the structure is not intendedoroffereol fmsale(See 2614, BusinessO
and Professions Cri The Contractor's License law doors nm apply to i m owner ofLam
-
property wholomidsorimpowes thereon, mdwhodoes such work himulforthmughhis
ownemployecs,provided Netsuch impmvemcnrsem n.nimendcd.roffercd forsele. If,
OCC. GROUP
RES. UNITS
'f T
however, the building or improvement is sold within one yearmcompletion, theowncr-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMT FEE
sale.).
❑ I,as.wncrof the propmy,amexdusivdy comrening with licemdcontmmorsm
F10oDZ5NE
APN
construct the project (Sec. 7044, Business and Pnsfessians Code:) The Contractor's
License Lawdoesi n apply tom ownerofproperty whobuiIdaor improeon
vesther,and
PERMIT ISSUANCE
who contracts forsuch projects with a conaraanr(s) licensed punuonUo the Contracmr's
License Law.
ALTER rA
(' )
PEE SU ARY
❑ I am exempt under Sec. , B & P C for this person
BACK FLOW PROTECT. DEVICE
SANITAR N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ Thereby o(firm nhatl have acenificate of mnsem mrelf-insure, nraceni0nnc of
Worken'Compenwtion Insurance or a certified copy thermf(Sce. 3800, Lab C.) which
DRAINS- FLOOR, BOOP, AREA, COND.
SCHOOLTAX Y N
RECFi1P1'g
X U s P^ P
PARKFEG Y N_
covers all employee'. under this permil.
Policy p
-
GAS'- TEC40 5
RECEIPTM
BUILDING DIVISION FEES
CnmPanY
G S' G t S )VP,H A)
PLANCHECK FEE
S6 1k
❑ Cor d copy is hereby adm fitted.
GR • S DUSTRI.
GRADING FEE 12 19 ssiassisa
❑ CenifieJ copy is file) with the city inspection division.
CERTIFICATE IJP EXEMPTION FROM WORKERS'
GREASE5R--"f
--
SOILS FEB. `
COMPENSATION INSURANCE
S6WI3H- SANITARY -STORM PA.20fIFT.
(This section account be complamifNe permit is for one hundred dollars (5100)
Ex4lif TET: 2
or Icxs.)
WATER HEATL•R W/VENT/ELECTR
I certify that itnhe performmceof the work for which this permit is unread, I shall
a.t employ any person in my Immmcr so as m became subject m the Wmkeri
PAID
WATER SYSTEM/TREATING
Cumpenamion Ltws.f California. Data
Applicant
Dae Receil
NOR ICE TO APPLICANT: If, after annealing this Certificate of Exemption, you should
NEW RESIDEM'IAL PLMH. SQ. R.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such previsions Or Nis permit ehdl he deemed revoked.
-- �'
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE 30
I hereby affirm that is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3099, Civ. CJ
Lenders Name
O
ELECTRIC FIiE
Y
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE t
I certify that I have read this application and state 1hm the move information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MSCI IANICAL FEE r
building construction, and hereby autharin reppesctnmivesof Nis city a enter upon the
above-mentioned pmpeny far inspection purptses.
ALTER OR ADD TO MF.CI I.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabilirics,judgmeals, costs and expenses which may in my wry accrue against said City
AIR HANDLING UNIT(TO 10,00i
in entlsryucnce of the grmnin8 of Nis permit.
AIR HANDLING UNIT (OVIiR Iq(IW CIM)
Signmurc of ApplicanUCommcmr Date
EXIIAUSTDOOD(W/DUCD
PAID
HEATING UNIT (TO 100,1100 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam BeceJua
Will the applicmt or fame building Occupmt at. Or handle hamacks. mmedai
as defined by the Cupcnino Municipal Code, Chapter 9. 12, and the Health end Safety
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
Cade, Section25532(m)?
❑ Yes ❑ No
BOILER - COMP (316' OR 100,000 BTU)
ISSUANCE DATE
Will the applicantorfurore building Occupantuseeq.ipmordeviceswhichemit
u air contaminants u defined by the Bey Area Air Quality Management
trictP
strict?
BOILER - COMP(OVER 1(1(1,000 BTU)
) p
❑Yes ❑ No
~ B
NEW RESIDENTIAL MBCA. SQ. R.
I have read the hozardous materials requirements under Chapter 6.95 .f the
California l leahh&Safety Code, Sections 25505,25533 and 25534. 1 understand Nat
if the In Hili ng does not currently have a tenant, that it is my responsibility to notify the
H (/� 0,7
Cliy .93/�a`
Occupant of the requirmnems which must he met prior to issuance of a Certificate of
Oe upa
Ll)ncy. �.k 1I,�
tl
ISSUED B
Owner or mthmio d agent Data
OFFICE