24951 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB.DI G-ELECTRICAL PF.RMI'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB INO-MECHANICAL BUILDING 24951
BUILDINGPR11.IkC1'IIIFA'1'IF'ICATIfIN
HUILDINGAOORE S: 1` /^ SANITARY NO. APPLICATION SUBMITTAL DATE
w�k %%4.66%j.66%j UNIT I,OTM Lk-7
OWNLR�AME: PHONE: CO RAC3'OR'S NAME LIC NU: N/C CONTROL#
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•ARCfII C17ENGINl:B11: 1 NO: M 14A ❑ "2L
CONT PHONE: QTY.1 ELECTRIC PBR FEE BUILDING PERMIT 1 FO
q��( BLDG ELE I' PL E
PERMIT ISSUANCE ,
LICENSED CONTRACTOR'S DECLARATION pppL1ANCES-REST PN'HAL JOB DBSCR O
C2, I herebyuffinn that licensed underprovkousufchapter9(commensal,wird
00 Section 70)0)of Division 3 ofthe Business and Professions Cada and my licenseisin PANELS
ct:WF full farce and effect. v TL,
F<F..-<V,ty LiccnLic.# '1//y S UP T02W AMPS sv/
yD. Data Cannot 20 1000
F tar ARCHITECTS DECLARATION SQ.FT.FLOOR RE A S/SQ.11
0 I understand my plans shall be used as public records. AEP INWPS IC
Qg
Licensed Rnfuesionul ECIRICAL /SGQI
naw OWNER-BUILD Ek DECLARATION SPECIAL CIRCU SC nn p p {�
ae O a V I hereby affum that I em exempt from the Contract
License n 1 V' IMI E
W 3 tLyQ fallowing lesson.(Section 703 1.5,Business and Profession Code:Any cit o INS
u' J which rtquims a permit m construct,alar,improve,demolish,or.pair s e TG �p/.
}� pnonoits issuance almreyuircs
fatalistic.,forsuch permit leasI le cut PO ICES p Tp Op\
W q O that he is lime[pars...I to the provisions of the Conuamm'a Licens .o (Chapter
9tcom ening with Section 7W0)of Division 3 afthe Business and fes, ns Code) SWIMMINGPODL ECTRIC VALUATION
W^N nr that he is exempnhcrefrom and the basis for the alleged exemption. iolmlanef OUTLETS-SW CHES-FIXTURES
F < Section703L5by.ny.pplic.mforapermitsubjmutheapplicant toa civil penity of ^/
no,more than five hundred daUars($5W). 3 G l
O NEW RPSID ALELECfR _SQ.Fi'. STORIES TYPECONSTRUCION
o ❑ Lnownerofthepropmy.ormyvnplaywwithweges astheirmlecompemedon,
will do the work,and the structure isdotinanded oroffered forrele(Sm.904#,Busimsa
and Profusions Code:The Contractors License law does not apply as sn owner of
prnpeny whobuildsorilo,oves thereon,aml whodaessuch workhimselfmthraughhis OCC.GROUP RBS.UNITS
own employees,prov ideal t hot such impmvemenu arc not i.tended or offered for sole.If,
however,the building or improvement is sold within one yearofcompleiion,theowner-
milder will have the burden of proving that he did not build or improve has purpose of
We.).
❑ I,uownerofshepropeny,amexclusively.nimningwiNli..d..ctomto QTY. PLUMBING PERMIT FE..E FLOOD ZONE APN
conduct she project(Sm.7lFM,Business and Prof rasions Code:)The Contract s PERMIT ISSUANCE
License law does not apply m an owntt of progeny who builds or im proves there.,and
who contracts for such projects with acontramor(s)licensed pumuara oche Contractor's
License Law. ALTER-DRAIN&VP.NT-WA'TF.R IEAJ FEL SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICES
SANI'fAkY Y N
Owner Dae DRAINS-F100R.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ [hereby affirm that l have a certificateofconsenuo self-insum,or a certificate of FIXTURES-PER TRAP RECEIPT#
Workers Compensation Enurenmara mnifiest tbemof(Sec.380,lab C.)which PARK WE Y N
covers all employee's under this Permit. GAS-EA.SYSTEM-1 INC.4 OffILETS RECHI"#
Policy p BUILDING DIVISION FEES
C y GAS-L'A. ERA,SYSTEM-OVPLANCIIECK FEE
nified cagy is hereby famished.
Ce (01
rtified copy is EIed with Ne city inspection division. GRGSFONDUSTRL WASTE INTERCEPTOR GRADING FEE
w
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF.TRAP SOILS PEE O ��
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is farone hund dollars $IW) SEWER-SANITARY-STORM PA.200Pf. ENERGY FEL' �#
or less.)
I cmify Nm in the pedonwnce of the work for which Nis Permit is i.mad.I shall WATER HEATER W/VENIOBLECIR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Law..f Cnlifiamla. Data WATER SYSTENUTRRATINGNuc
C) ZO Appfimrd
NOTICE.TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FT. TOTAL:
rA became subject to the Worker's Compensation provisions of Ne Labor Cale,you must
�i 7 foMwith comply with such provisions at permit stall he deemed revoked. BUILDIN 1
Q. Q CONSTRUCTION LENDING AGENCY SEI. F.' #7.
s 1
z I herebyafbnn that them is a....an..lending agency for the performomm of A ECI IC FEE
`��•
V O the walk for which this permit is issued(Sm.3197,Civ.C.) O
LL P� Leader's Noma PLUMBING FEE
Lender's Address QTY. MECI IANICAL PERMIT FEE
V 1 certify that I have mad this application and nate thm the above information is
r�" C21 .nect, l agree to comply with all city and many,ordinances and state laws relating m PERMITISSUANCE '� MECHANICAL '
F-' building construction,and hereby auNorixe m,barmudvu of this city to enter upon the CONSTRUCTION X
V Z above-mentioned property for inp uon purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless Ne City of Cupertino.,.last
liabilities, cosu.nd expenses which may inany way accrue against said City AIR HANDLING UNIT(TO 10,000CFM)
incn ue ce ofihe oaf fthi,s,p�tJy
It !Zw/� AIR HANDLING UNIT(OVER 10,(100 CFM)
Si,nalum of ApplicabsCmurecmr sS/ Data EXI LAUST I IOOD(W/DUCT)
PAID
HA7ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 PTU) Dace eceipt 0
Willtheapplicant or fmurc building nccupam stere or handle haaardou materiel HEA'L'ING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and S.fety
TAalj ea*
Code,Section25532(.)) VRNTILA'1']ON FAN(SINGLE RESID)
El Yes ❑No
BOILER.COMP CI IP OR 100,11(1(1 BTU) ISSUANCE.DATE
- Will theapplicvn.rfuwre huilding.cupom usceyuipmenmrdevicen which emit g' p
hazardous air contaminants a,defined by the Bey Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU If- M
Dlsdlm7 JUL
��nT
s� ❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. JUL- N��
1 have read the laa�Safety
Code,
Sections requirements udder Chapter understand
of the
Cale buil Health s Safety Code.Sections 255UA 25533 ad responsibility
1 undenotif that
if Ihnbuildingdoesnot
mentswhave ast hm,thatitis myceferamifythe Sa}�yx�r nL.(;W1;plt$��tIIM�
nnpant of We requirements which mum b.met prior m Issuance of a Cmtitiume of HI I 1 Vs
Occupancy. \�\��/) ��'
0,som mahodzed....I Due T ISSUED BY: Va/11� sr #