24716 (2) T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL
CITY OF CUPEPRMIT No.
BUILDING DIVISION
1GN APPLICATION/PERMIT PLUMBING-MECHANICAL E
BUILDING PROJECT IDENTIFICATION 24716
BUILDING ADDRESS: SANITARY NO, APPLIOVDONSUBMITT'ALDATU
UNIT# LOT it
PHONE CONTRACTOR'S NAME: LIC NON/Cj1 11TECT/ENGINEBIL LI NtWNQ�RSNE
I O p
GN'TACT: PHONE:
�— QTY. ELECTRIC PERMIT pEE BUILDING PERMIT INFO
PERMIT ISSUANCE
BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pMZ Ih7")affirm JuO amlice Business
and ksismofO Code,
mmecense with JOB DESCRIPTION
�i100 Section 7")Of Division 3of the Dusinas antl Professions Cole,and my license is in PANELS
M.uUIE
no
force end cr t.
FyW Limnx Chas - Qic.p_� UPT02W AMPS
r/I Q M Dalt C(77S D
ON OVER
-I"AMPS SQ.❑'.FLOOR AREA $/SQ.FT.
ZzNZ ARCHITECTSDEClic morON OVER IUW AMPS
OZ_t O 1 understmd my Plans shell be used u public records.
K_a� Lmenxd Pmfesamoal SIGNS ELBCIRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. f� .
X 01 F I hereby off Nat I am exempt from Ne Cantractor's License{aw fm the �^I �7
W3WOm following as..(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST, r--,, r 1-1 -�
which requires n permit W canswn,alter,improve.demolish,or repair any structme
C�Qf poor wits is--,also regains theapplicant forsuch Permit fileasignei statements POWER DEVICES l�
OO Nat he is licensed pursuant to the provisions of the Cono antes License law(Chapter .+-.
X.� 9(commencing with Sermon700 )ofDivislam 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC DAI VA UATION
1-.as M met he is exempt t rodown sad the basis for the alleged exemption.Any sodiuon of
nmre Section 7031.5 by say applicant for a permit subjects the applicant a LETS
a civil penalty of OUT -SWITCHES-FIXTURES
O t othan five hundred dollars($50%
Wt0. ❑ I,®ownerofthepmarty,ormyemployeeswithwagnztheirsolecompeas&tion, NEW RFSIDENTIALELECIR _SQ.IT. STORIES TVPIi CONS'1'RUCITON
M322 will do re work,aM the structure is not intended orofferd for safe(Sce.7044,Business
and Professions Code:The Contmcmr's License Law does not apply to an owner of
property who builds or improves Nereos,and who does such work himsel fm through hi s
'wnemP'oyces*Mvid ffialsochimprovcmenuercnotimendedoraffa forsde.If, OCC.GROUP WES UNITS
however,the building or improvement is sold withinon,year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
We.).
❑ Las mmerafNe property,sm exclusively contracting with licensed comuctouW QIY. PLUMBING PERMIT FEE FUNJDZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Command's
Umnselawdocsnotapply WanownerofM,Mwhabdldaorimpmvesthercon,end PERMITISSUANCE
whtcpatraara forsuchprojectswithacmn tor(s)licensedpunuanuothe Contnctars
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE SID-I'E
SANITARY Y__N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND, REC[IPTN
WORKMAN COMPENSATION UECIARATION SCHOOLTAX Y_ry__
�Ihembyvffirm thmlhavicecatificex ofcomcnuo self-insure,on ttrtificam of
FIXTURES TRAP RECEIPI'p
Fl
Worken'Compenxtion lnsuranceor acenificdcopy thertof(Stt.3g00,lab CJ which PARK FEE YN_
Pal ccoven«II employee's unJcr41 anti Ut. a d GAS-EA.SYSTEM-I INC.40UTL21'g RECIiIPf p
Company Jig f�a� BUILDING DIVISION RES
fieJ copy is hereby famished. GAS-FA.SYSTEM-OVER4(EA)
❑ CeniPLANCHECK FRE
Certified copy is fled with the city inspection division. GRIASFVINDUSTRL WASTE INTERCEPTOR
GRAVING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This acctian need not be completed ifthe permit is fortune heated dollars($10s)) SEWER-SANITARY-STORM EA.200FT. ENERGY FEEor leas.)
I certify that in the perfornunceofthe work for which this permit is issued.],hall WATER HEAT ER WIVE IE-LECfR
not employ any person m any manna ao as W become subject to the WorkersPAID
z Cmraemation laws of California. Dem WATER SYSTEM/TRIATTNG Date fttteipt#
Applicant
ZO NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.Pf. TOTAL:
r (A became subject to the Worker's Compen&tion provisions of the Labor Code,you must
a. 7 forthwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FRE
Ila Q
CONSTRUCTION LENDING AGENCY
4 SEISMIC FEF.
.U. z Ihereby inthtisprswthem is aconstructionlending agency for re performance of
V O me workLeader Nfora which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE.
U. � tenders Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and srate than tha stave informationis
�" 600E comet.Iagmetoon,comply
and withy leityanereparyotdinancuanJ entre luwsrelatin the PERMIT ISSUANCE MECHANICAL FEE
U y abovengcormmalomert herebyeuthorlurprtxnmivcs ofthis city loentaupan the
U 7 above-mentioned pmpcnyfm inspection purpose.har. ALTER OR ADD TO MECH. CONSTRUCTION TAX
F7 (We)agree W save,indemnify and keep harmless the City of Cupertino against
Utah ilities,jud c ":d expenaes which may in my way xnume,ainst said City AIR HANDLING UNITOO 10.000 CFM)
to con q.nce of she gmntin (this
AIR HANDLING UNIT(OVER 10,VOUC17M)
Signuureo tcant/Contra Q�'���/ /t�" Ei(HAUST HMD GVMUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.00)BTU) Receipt#
Will the applicant or farm building occupant erre ohndlh hawdous material
asdefinedby the Cupertino Municipal Cade,Chapter9.12..anddthe Health and Safety HEATING UNIT(OVER 100,000 BTU) V TAf-:
Cade,Section 25532(e)'f
❑Yes ry No VENTILATION FAN(SINGLE RESID)
Willthe nppliwm offmurcbuildingoccupantuxequipmemnrdevi¢a whichcmit BOILER-COMP LHIP OR 100,00)0 BTU) ISSUANCE DATE
hmurdous air comemitums as defined by th
District? e Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) dY '
❑Yes -krNO NEW RESIDENTIAL MECH. SQ.FT. gTon161993(a
�7
1 have mad to hauNous materials requirements under Chapter 6.95 of the 9 11 V.mss 19 3
California Health&Safety Cade,Sort.,Sort.,25505,25533 and 25534. 1 understand Nal
ifthebuildin does not curemly have a tenant,that it is my responsibility to notify the 1f1TT1--k th-
the circ ta wust be met prior to issuance of a Cempeateof �_v, V$IrC11j I/yf.ei
Occupancy. v�r�
Dam
n Ihonud eg nT Date TOTAL: ISSUED BY:
OFFICE