24734 (2)is
10
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO
- nom,.m'G-ELECTRICAL,
PERMITNO. e
APPLICATION/PERMIT
PLUMBING - MECHANICAL.
(�
BUILDING DIVISION
BUILDING PROJECT LUF,NTIFICATION
BUILDINGADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATE
11C� ��
3 (�
UNIT# LOT#
OWNERS NAME PHONE: //5' �/� PHONE: t7
Mf`�1. l 1lL ZS2-1e,!�,I
RAC R'SNAM ,.L �( n .IL.IC 01
�JLIJ J V AVr I4)
NIC
❑
CONTROL#
RCHUECCENGINEER: LIC NO: ADDRESS:
/J
i
S
CONTACT: PHONE:
QTY. ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
❑ ❑
LICENSED CON'TRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
I hereby affirm that l am licensed underponvisloreoUhapter9(commencingwith
w
`e
�/ C
�/A
Section 90(10) of Division 3 of thBusiness and Professions Code, and my license is in PANELS
Poll force and effect.
��
License Class Lic.#
UPT02WAMPS
Date Comracam
201 - 1000 AMPS
ARCHITECTS DECLARATION
OVER IOW AMPS
SQ. IT, FLOOR AREA
$/SQ. IT.
I understand my plans shall be used os public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby of ran that 1 am exempt from the Conmdmors License Law for the
fallowing reason.(Section ]031.5, Business and Professions Code: Any citymcounty
TEMP. METER OR POLE INST.
which requires a permit to construct, alter, improve, demolish, or repair any structure
.(� A
prior to its issuance, alsorequires the applicant for such permit to file a signed statement
POWER DEVICES
t ® O N
that he is licensed pununat In the provisions of the Contractors License Law (Chapter
N
9(commencing with Section 9000) of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
1
.,that he is cxempuhercfrom and the basia for the alleged exemption. Any violation of
Section 0031.5 by any applicant for a Permit subjects the applicant to a civil penally of
OUTLETS - SWITCHES -FI%TURES
n❑ Lethan rivehundred
not than five hundred dollars ($500).
dy,orm$500). yeas with wagesastbeirsol¢compensation,
NEW RESIDI?NTIAL ELELTR SQ Fr.
DATE
ES TY CONSTRUCTION
J
will do thevonk,and the swcmm fano, inrendedmofe,ed metric(See7004, Business
-
and Professions Code: The Contractor's License Law does not apply to an owner of
propertywhnbuilds orimpmvesthereon, and whodoessuchwork himselforNmugh his
own employees,provided that such improvcamomarenot iateadedorofferedformle. If,
OCC. GROUP RES. UNITS
however, the buildingor improvement is sold within one year of completion, the owner-
TOTAL:
builder will have the burden Of proving that he did not build or improve for purpose of
sale).
❑ Las with sed
clad
QTY. PLUMBING PERMIT
FEE
FLOODZONE
APN
et the pmjmt (Sow.
the Project (Son. Dol Btameas The Contractors
Business and Professions Coda) The
Professions
s
License Laws to
Liceerosionse and
pply ct ar oh therea ,and
whosed
PERMIT ISSUANCE
!
acontproperly
who contracts forsuch puorimpmv eConeon,
nrsuch pmjedswithac.nvumor(a)licenced pursuannotM1e Convactnr's
FEE SUMMARY
License Lew. -ALTER -DRAIN&VENT - WATER TA)
Law.
❑ 1 am exempt under Sea , B & PC for this reason
DO TSID FEES
BACK FLOW PROTECT. DEVICE
SANITARY YN
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS -FLOOR, ROOFAREACOND.
, . .
SCHOOL TAX Y N
I hereby affirm that l have a cedificate of consent to self -Insure, or a cenificam of
FIXTURES - PER TRAP
��
RECEIPT'#
PARK FEE YN
orkers'Compensation Insurance or a certified copy thereof( Sec. 3800, Lab C.) which
covers all employee's anile, this permit
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Policy #
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy Is hereby fumished.
GRADING ME
❑ Certified copy is fled with the city inspemion division. GREASMNDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE '
ENERGY FEE
(This section nrednot be completed ifthepennit is furore hundred dollars($100) SEWER - SANITARY - STORM EA. 20(1
Or less.)
I codify that In the performance of the work for which this permit is issued, I shall WATER HEAITR W/VENDELECTR
not employ any person in any manner so as to become subject to the Workers'
PAID
Compearation Laws of Califomia. Date
WATER SYSTEM/IRENTING
Dam Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL FUME. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a construction lending agency for the performance of
the work for which this permit is Issued (See 309], Civ. C.)
T
/
ELECTRIC FEE
Locators Name
Lenders Address
QTY, MECHANICAL PERMIT
FEE
PLUMBING FEE �..
I certify that I have mad this application and abandon the above information is
MECHANICAL FEE
corm,. I agree m comply with all city and county ordinances and state laws relating m
PERMIT ISSUANCE
building comtructim, and hereby authorize representatives of this city towner upon the
CONSTRUCTIONTAX
above-mentioned properly for inspection purposes.
ALTER OR ADD TO MECH.
(We) age¢ m save, indemnify and keep harmless Ne City of Cupertino Nnumt
liabilities,$d.��menI, costsandexpea, swhieh may in any way aeemw against said City
AIR HANDLING UNIT (TO 10," CFM)
incgran
fthetin o man.
� �— o
AIR HANDLING UNIT (OVER 10,000 CFM)
PAID
L_/—��
Signature of ApplicanVContracmr Data EXHAUST HODD(W/DUCP)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO Imimf BTU)
Dom Receipt#
T A '
Will the or fume building atnre m le nal
the Carat
as defined by the the Heardh cardous
o Municipal Coda Chapter 9.12, and the Health and Safety
Came, Chap and Safety
HEATING UNIT (OVER I FLOW BTU)
Cale, Section 25532(¢)9
32(a)?
❑ Yes ❑ No
VENTILATION FAN (SINGLE RPSID)
ISSUANCE DATE
Will be apPlicantorfuwrebuilding.ccupantrsecquipmenmrdeviceswhichemit
BOILER-COMP(3TIPOR 100,000 BTV7
zunions air contaminants as defined by the Bay Area Air Quality Management
strict?
BOILER - COMP(OVER 100,000 BTU)
f,1,
LLd'
❑Yes ID No
NEW RESIDENTIAL MECH. SQ. FT.
1 have read the hazardous materials requirements under Chapter 6.95 .f the
�c ,� nn
Columbia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
y �JOon�
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be to issuance Cerlificate
CITY n
Uy/h��.,vrer
met Prior of a of
Owenparcy.
!
tt�
ISSUED tlY
Owner or authorized agent Dam 'TOTAL:
OFFICE