24510 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO tl IL.DLNG-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING IROJRCT IDEN'TIFICA'r10N
BUILDING
ADDRESS:' L w SANITARY NO. APPLICATION�SaaUBMIITIALDA9L
�h' ✓ H��UNIk'1' IAT# 4E1�
O ERS
ME
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E:
CONTRAy� R'S NAME: LIC NO:
LI u,/ /GIGD.v/GrY- �Fa�-3S3 -1cg ./,�A . El.� L'-/6- 2/ wG CONTRGI.#
•ARCHITECT/ENGINEER: LIC NO: ADDRESS:
iynn "
FCONTA�. PHONE:
QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ` •��
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, LOB DESCRII�'Y'j QN
qy.Z, rm that l am licenseduder provisiaroidChaprer9(commencing with `�00Division 3 of the Business and Professions Cole,and my licenx is in P Q(� ��<ZW ct_�oLin.# //I t UPT02WAMPS {. �sPP/+YVlZ, �L�—�,/.�/°� �
m 6 y Dax r ! Commaor 201-1000 AMPS
ARCHITECTS DECLARATION OVER light AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
l understand my plans shall he used as public records.
r m t; SIGNS ELECTRICAL
Liccnxd Professional
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.x 0yU 1 hereby afOrm that I an,exempt fru.the Cmumicmr's License Law Tor the ret #
Wady following rcaum.(Seen..903 IS,Business and Professions Coli Any city orcounty TEMP.METER OR POLE INST,. �.� ICI ✓p It LVry
m0 which requires a Permit m construes,alter,improve,demolish.or repair any sanctionsI!
'ts3a� Pdorm its issuance,alx requires Ne applicant for such permit m fileasignedstatement POWER DEVICES L
that be is licensed pursuant mthe provisions of the C.mractols License lsw(Chapter p �� C
9(commencing with Section]WO)of Divlsian 3 ofthe Business and Professions Cods) SWIMMING POOLI?LL'CIRIC1 VA UAq'ION
Wim or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OU'1'LISfS-SWITCIiFS-
>• Section 7031.5b an a licem,fo rt rmitsubecathea Iwnll...ivil al f PTXT RGS
ZG y Y PP a J PPi pen rya AT
ern more than Live hunurcA dollvrs(f5W). NEW RI6IDEN'1'IAL ELECfR S :Ff.
❑do He
work,
streny,ormyempindedmrofwugesasale(See.m.penainess Q STORIES TYPE.CONSTRUCTION
will dothewons and the he Con isnotintendedLimm,Law
rdoes of apply
to an owner of
and Profession Gide:The Contnnor'a std who Lew uses or apply to an owner of
propertywhobuilds vi manteschemon,andtehodoessuchwork himulfedthroughhis
owne.ployeesilding r throwehi.pis sold rosin mrs,intended marched for ownef, 002,GROUP RFS.UNITS
builder ,wtheavet a orimprovementishathwithinoneyear or improve
for the ase of
builder will have the burden of proving that he did not build or improve far purpose of
5W0')' a QTY. PLUMBING PERMIT FEE FLOOD—ZONE APN
❑ Las the orofthepropcny,arneainess and Professions
r acting with licensed
enmarum the prajeot(Seo.]044,Business and ywhob builds
Code)The Courtroom's
LicenxlJlwdoeenoteppjects it acrmfprctpeny weduarddsmimpro the Cmitrn.nJ PERMIT ISSUANCE'
License raw.LrrsuchprojecD wimaconwaot(s7licertaWputsuenl to the Contrvemra ALTER-DRAIN@VENT-WATER(EA)
License Law. PEE SUMMARY
❑ I tan exempt unuer Sce. ,B&P C for 0is rcuann BACK FLOW PROTECT.DRV ICE SIDE IPPS
Owner Date
SANITARY YN
RECEIPT#
DRAINS-IlOOR,ROOP,AREA.COND,
•
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IM1erchy affirm,batt have acenificam ofconsem to xlf-insure,ore certifmute of RECF:IPTp
Workers'COmpcnwtinn lnsurunoe oruomifcd copy Omrwf(Sec.3B00,Leh CJ which FIXTURES-PER'fRAP PARK FEL? YN
covers WI employees under this permit, GAS-IA.SYSTEM4 INC. OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(IA) PLANCIIECK FEE
❑ Codficd copy is hereby Tarnished.
❑ Certified copy is fled with the city inspection division. GREASEJINDUSTRI.WASTEINTERCEPI'OR GRADING FEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASE THAT SOILS FEE
COMPENSATION INSURANCE
(Thisaecllon need not he completed Blue penal,is l'orone hummed dollurs($100) SEWER-SANITARY-STORM EA.200111. ENERGY IRE
orless.)
Icertifythat inshe perfaananttof,hcwork forwhich thispernit is isauwl,lahall WATER HEATER W/VENT/F.LECTR
I employ any pets n in Y m .be�fae uh¢ph t_tfyN4�rket% PAID
nmpen.mian ffr�J;,y'1'Dn 41e��6�// ,,SII LS 7 / WATER SYSTEMITRP.ATING pate Receipt#
z NOTICE TO APPLICANT.ILL makinothis Cerliftche of Exem Y
8 Pmn,You should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
[n become subject the Worker's Compensation provisions ofthe Labor Cade,you must
a :, forthwith cmnplY with such provisions or this permit shall he deemed revoknl. BUILDING FEE
G [] CONSTRUCTION LENDING AGENCY SEISMIC PEE
: z I hereby affimt that them is a construction landing agency for the Performance of
U Q the work for which this Pemtit is notted(Sec.3097,Ci Y.C.) TOTAL: ELECTRIC FEF. `
V. Lender's Name PLUMBING FEE
Isndels Address Q'I'Y. AIECIIANICAL I'IiRMIT PEE
0 U I certify that I have read this application and store that the above information is
correct,l agree to comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorirs repmsentntives ofthis city roomer upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTHRORAUDIGMECIL
(We).gree to save,indemnify and keep hamlcss the City of Cupertino against
Iiabilitim,judgments,costs and expenseswhich may in my wayacerue against rend City AIR HANDLING UNIT(TO IO,"CFM)
in cars, the petini,.
AIR HANDLING UNIT OVER III,(IW CFM)
xis
S ¢of Applicant/ ommcmr Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNYT(TO 100,000 BTU) Date Rtte,to#
Will,he applicant or future building moccasin store or handle bavardou t material
as defined by the Christina.Municipal CM,Chapter 9.12.and the Health it Safety HEATING UNIT OVER 100,1100 BTU) 'TOTAL;
Cale,Section 25532(a)?
11 Yes ID No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HPOR 1W,WIIBTU) ISSUANCE DATE
Will menpplicant orfmux builJingouupanluxcquipmern urdevices whichemit (y�
• hmardous air contaminants as defined by the Bay Amo Air QualityManagement BOILER-COMP(OVER 100,000 BTU) P sQ^ 0 v
District?
11 Yes ID No NEW RESIDENTIAL MELT. SQ.Ff. NOV 199 I have read she henrclomorde
us ,drus rupdremems under Chapmr 6.95 of the 2
Culifomis Ileul,h&S.fbty Cade,Section.25505,25533.nd 25534. 1 undcrsmmd that
if The building docs not curmmly have u mnnt,that it is my respmsibility,to notify the 611r est, Q` „
occupant of the mquimmenu which must be met ririnr,o issuance of a Cenificam of
Occupancy.
Owner or auhariaed agent Dote TOTAL: ISSUED BY:
OFFICE