24856 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILIIING MMAAAECHANICAL NICA PERMITNO. as
APPLICATION/PERMIT 1'FNMIIIN(ECI:IHNI ICAC ly1(55{6
BUILDING DIVISION IIUILUING 1'NOdRCI'IURN'1'IfICA'1'111N
BUILDING A 1- -3: '///// SANITARY NO. APPLICATION 'AL DATE(/ �l4/b _UNIT p''q� I'M'N 3
ORS NAMG:_ PH NF7 �/ CON" AC' :SNA LIC N
7 NIC CON'1'ROLp
00
ARCH TECTE"' LER: IC NO: i55:
AONTACT: ' A PHONE: BUILDING PERMIT INFO
r � UZ /�� QTY. ELECTRIC PERMIT FF,E
BLDG ELECT PLUMB MGC11
PERMIT ISSUANCE 1:1 El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDEMIAL - JOl;y)ESCRIPTION
p
I hemby affirm inti I an licensed is dinimmi,m s ofChri,mr9(commencing with JV�1f,\J�QjI(YY`J
Iai00 Senion7aa(q of Diviaion3 of lbe Business and Pmfessinns Cod,and my Imenmisin PANELS
rese Clan ul UP TO 2(NIAMPS
Licensqe ClaAss Lica
sen?y Dac_�" Conu¢t r 201-IOW AMPS SQ,IT.FLOOR AREA $/SQ.FT.
l�NZ ARCHITECTS UE A'I OVER I0010AMPS
OZ-0 1 t ndennmd my plane shall he used us public anobb.
OmFla SIGNS ELECTRICAL
fJLicensed Professional
,OI� ® IN(�
W¢ OWNIiR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. � f� N
KOp,O I hereby affirm that I am exempt from the Conuamrs License Law for the vis .-
W3LLy rollnwingarxnn(Section 70315,Bu.om,,md Professions Cade:Any city.,county TEMP.METER OR POLE INST. �demolish. P TE
taONwhich requires a permit to conswct.ali
ter, mprove, emolish,or repair any.swemre POWER DEVICES '/jn J IR
ytu3QE pnarmitsissuancc,til,relmocs theopplirma gestalt perad,1.file.signal statement
�m p p that he is licensed pursuam to the Provisions of the Contractors License Law(Chapter SWIMMING PIJOI.ELf:CTRIC1
9(commencing with Section 71N0)af Division 3 ofthe Business and Professions Corte) AINATION�
x00�m or that be is exetopnherefrom and the hasis for the alleged exemption.Any violation of OUTLETS�SWITCIIIS-ENT
Y Section 7031.56 applicant a perritsub t the 1 rte a civil ❑ f 'URIS
tzQ ,any app icon jces pp icon pens ya
m morethan five 6 mina)dollars($500).
L NEW R[SIDENfIALELECIR —SQ.IT. S"I OftIF3 TYPE CONSTRUCTION
W1.
K F-� ❑ warestastineirsole
will dolbewons Cod:: rhe Con isnot iS Lice slor Law
dos not apply 7(H4,Business
� and Pmfessinnv Gde:'ITe Comramor's License Luw Jas not apply to an owner of
proper,wholoodsorimpmvestheLeon,redwhodoessuch work himselforthrough his OCC.GROUP RES.UNITS
h Wemployees,provided that such improvements:ve nm imendec or offered Tarsale.If,
ever.the buddingor improvement is Sold within oneycxr ofcomplction,theowncr- TOTAL:
builder will have the burden of proving that he did not build or improve for puHxmse of
sal`')' QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
❑ I,asownerofthepmpeny.amexelusivelycommningwiNiicensedcon.,..,.
Linstruct the project(Sec.7144.Business and professions Code.)The Contractors
icense Law does not apply In an ovpm ofpropcny who builds mimpmveethe,eomund PERMIT ISSUANCE
whocralowls forsuch projects with a centimeters)licensed pumam,to the Contractor's
License Luw. ALTER-DRAIN&VIiNT-WATER(EA) FEESUMMARY
❑ 1 an exempt ands,Sec. .B A,P C for this reason OUTSIDE FEE
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOIi ARCA,COND. RECEIPTa
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IM1ereby offum thalhave.cenificam ofconunnn self-insure,mattrificaro of PIXTURBS-PER TRAP `''��-1/// RECEIPTp
Workers Compensation Insurance or acenificd copy thereof(Sce.3800,Lab C.)which Y PARK FEE Y N
covers all cmplo cc's under this permit. DIVISII'a
Y GAS-fiA.SYSTEM-]INC.INC40lPLETS �� BUILDING DIVISION IFF,S
Policy M
Company GAS-EA.SYSTEM-OV HR 4(IiA) PLANClIGCK PEE
❑ Certified copy is hereby
❑
Certified atopy is fled withth eM1ed.
the city inspection division. GRFASWNDUSTftL WASTE INTERCEPTOR GRADING FEE
C17RTIFICNIL OF EXEMPTION FROM WORKERS' GRL'ASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need not he completed if Ne permit is garner hundred dollars(SIW) SEWER-SANITARY-STORM EA.20(1 EN TOY ME
or less)
I crony den oil.peffonnanccnfthework for which l6ispemnilo,iS.xned,l shall WATER IWATER W/VENT/F,LECIR
not employ any person ' rr m' ncrX 43'a co ''Cyte,,the Workers PAID
Compensation lswyyf Cayfomi D31lLR_ ���/-S WATER SYSIEM/IRGTING Have Rettipta
Oz APPlicunt &M-E f iwIX1,
Q ND'1'IGE TOA 'LICAN'a,She, �dII nribi.,Certificate of Exemption,youshould NEW R17SIDEWIAL PLMB. SQ,FT. TOTAL:
(q become subject to the Worker's Cyy tpEn..Oon provisions of the Labor Cade,you must
� ; forthwith comply with such pmvgsions or this permitxhall be doemedi revoked. BUILDING THE
[� CONSTRUCTION L17NDING AGENCY SEISMIC FEE
1 hereby affirm n
that there is a conruction lending agency for(lie e perfuruof
.7. Z the work far which this permit is ixwed(Sce.307,Civ.C.) T �� ELECTRIC PEE
U rlarder's Name
U" F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V 1 certify that I have read this application and stale that the done infomsmmn is MECHANICAL FEE
>' Lkl correct.l agree to comply with all city and county ordinances and stale laws relating to PERMIFISSUANCE
E' 0. building construction,and hereby auNonre representatives of this city to enter upon the CONSTRUCTION TAX
(� 'Z abase-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harm s the City of Cupertino against
lithil'nics,judgments,rota,and expenses which any wayaccrur ainatsui City AIRHANDLINGUNI'1'('I'OIO,IXXICFM)
m of the granting of this perniL AIR HANDLING UNIT(OVER 10.000 CFM)
s7mmeof Appllcan4Cn.meta, A1Sate EXHAUST HOOD(WMUC)
PAID
HAZARD fATEIUU1SCLOSURE HEATING UNIT(TO 100,000 B'I'U) ])are Receiptp
Will the applicant re In uilJingove.panlsmm or hadle broadens mmcnal
xs defined M1y the Cupcni luridpalCale.Ch.,,e,9.12.andlbe He.lOand Safely HEATING UNIT(OVER 000.000 BTU) TAI.
CmI..Section 25532(a)'1 VENTILATION FAN(SINGLE RISID)
❑Yes ❑No ISSUANCE D G
Willtheapplicanturfummbuildingmcupamusecquipmernur Jeviceswhichrmit BOILER-COMP(3HPOR Joy"BTU)
gandaus air contaminants as defined by the Buy Area Air Quality Management BOILER-COME(OVER[100,007)BTU) MAR
�IlxnisO
El Yes No NEW RILSIDF,NTIAL MECH.-SQ.IT. 121993
Lbuilding
read the hazardous contend,requirements coder Chapter 695 of the rid)Y Uf GUrtN env
Calga I nes n ofcry eptly h ve ars ard,th t it is and sponsi I andaeland that
g Joes not curtrnJy have a meant,IM1a it is my rcsrymsi6iliry to orifi,the
the requirements which must b:met poor to issuance of a Cer ific rte ofthorized agent Date TOTAL: ISSUED BY:
OFFICE