24766 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL FERMI TNO. 24766_
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL
BUILDING PROJECT IDEN'FIF'ICATION
BUILDING ADDRESS:2 ,I/ SANITARY NO. APPLICATIONSUUBBaaaMITTALDATE W UNIT LOT#
OWNS MF:: PHONE: 'S NAM LIC NO00 .01l AWIP.M. : `c
NIC CONTROL#
ARC E EEIU LIC NO: ADDRESS: ❑
CONTAcr: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El 71 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIVI ION
OZZ I hereby affirm that l on licensed underprovisionsofCWptn9(commencingwith
WO0 Section 7")of Division 30fthe Businassand Profexsions Codo,nd my license is in PANELS
Fy full Ione and effect.
<ZW License Class Lia# UP TO 2W AMPS
Qy Dec Contractor 20I-R W AMP
ZOyZ ARCHITECTS DECLARATION OVER 1000 S SQ.FT.FLOOR AREA S/SQ.IT.
O Z—O 1 andcmtand my plans shell be used as public records.
Its
Fm SIGNS ELE ICAI kk .
Fti_ - \tl,
04 2, Licensed Professional
a:W< OWNER-B UILDER DECLARA DON SPECIAL CIRCUIT/. IS mss , tt P
Xowu I hereby affirm that I mm exempt from the Combination's aLicense Isom for the 0 /I p�
tal3ay Illusion,reasom(Section 7031.5,Business ad Profession.Code:Any city or serum, TEMP.METE, OR POhE INST. u p
which requires a permit to construct,alter,improve,demolish,or repair any structure
SWYS poor mits issuance,alsorequiresthe applicantfor such permiuofileasigned statement POWER DEVLES UATE
,=Do that he is licensed pursuant to the provisinnsofthc Contractor's License Law(Chupmr
d XQKtr' 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exemptM1erefrom and she basis for the alleged t
W—trihe pen. cichpinalty of OUTLE'T'S-SWITCHES-FIXTURES
F%a
Section' thad by hundred
doll rs(Sfar.Permit subjects the applicant toacivil penalty of
nm sre then five hundred dollars(SSW).
K � ':v
r of Ne pngnrty,nrmyctnploycaswilb wages uvM1eirsulecompensatinn, NEW RIiSIDEM'IALIiLECTR SQ.IT. S'1'ORIIS TYPE CONSTRUCTION
y3— he work.andm someone is oatmmrtdedoroffcrcd fm sale(Sao 7044,Business
nJ Professions Cede:The Contractor's License Law does nos apply to an owner of
reperty who builds or improves thereon,and who does such work himeolfor through his
employees provided Nat such impmvemcndsarcnod intended rroffemd fursala.If. OCC GROUP RES.UNITS
however,the building or lntpervemem is sold within one year of completion,the owner
builder will have the burden of that he did not build or int for f TOTAL:
proving prove puryoser
sale).
C) 1.is owner ofthe property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE ANN
construct the project(Sec.10,EL Business and Professions Code:)The Contractor's 1
License Liwdoes not apply loan ownerofpmperty who builds or improves thereom and PERMIT ISSUANCE
wbommmets for such pal with acommotm(s)licensed pursuant o the Cumraco's ALTER EA
License Law. ( ) FEE SUMMARY
❑ 1 run cscmpt under Sec. ,B&P C for this reason - OUTSIDE FEES
BACK FLOW PROTECT.DEVICEOUTSIDE
Y N
Owner Data RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherehy affirm thael M1avevicenifieam of consent ms<IGinwre,oracenifcae of FIXTURES-PER TRAP RECEIPT#
Workers'Cnmcensntion Insurance nr aceniEW copy Ncreof(Scc.38W.Lab C.)whicM1 PARK FEE Y N
covers all employa'z under his permit. GAS-EA.SYSTEM-I INCA 01111.FS RECEIPT#
Policy M BUILDING DIVISION FEES
any
0 Certified copy is hereby fumisM1eJ. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
en
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OI:EXEMPDON FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is forone hundred dolfars(SIW) SEWER SANITARY-STORM EA.200FT ENERGY HE
Ices.)
Icertify that in theperfonnaneeofthe work
forwhichNishntmistseucdrsM1all WATER HEATER WNNT =LECfR
PAIDnot employ any person it any masr an to become su0hWokeJ
CompemmionLawsofCalifomiaDate
WATER SYSTEMOREcTING Data Receiptp
C) z Applicant
zC) NOTICE 10 APPLICANT:If,after making this Cenvicam of Esmption,you should N 12W RES]DENTIAL PLMB. SQ.FT. TOTAL:
become subject the Workers Compensation provisions of the labor Code.you must
7 forthwith comply with such pmvisionsorhis permit shall be Joemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby afRmt that there is a construction lending agency for the performance of T 1 ELECTRIC FEE
U O the work rte which this permit is issued(Sec.3091,civ.C.) t
s—s Lenders Name
0 t-' Limal eAddress QTY. MECHANICAL PERMIT FEE PLUMBING IEE
W I certify that 1 have mad this application and.sure that the above information is
correct. lugreemcomply withall cityanJ county ordinances and some laws eantingto PF.RMITISSUANCE MECHANICAL FEE
F" building consmedoo,and hereby audience representatives ofthiscity or order upon the
U z abrsamomioned property for inspection purynses. ALTF.RORADDTOMECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep hanrdess the City of Cupertino against
liabilams,jud costs and expenses which ma nanywmymoneagainsesaid City AIR HANDLING UNIT(TO 1I,00)CFM)
in come,to cof 11-'ranti of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sig reu rd terCl Date EXHAUSTHOOD(W/DUCO PAID
SrMe
IIAZARDOOSMATERIALSDISCLOSURE BEA DNG UNIT(TO IW,OfItI BTU) Date Receiptp
W ill the applicmen or fuore building occupsm germ or handle Instructions material
as def tied by the Cupcnin,Mnnieipal Cede,Chapter 9.12,and the Ilmlth and Safety HEATING UNIT(OVER 100,00)BTU) 'TOTAL
Coda,Section 25532(m)';
13 Yes ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP QHP OR I W,M BTU) ISSUANCE DATE
Will air co icanmr is as dcilined b c the
nBay equipment reality Management
tent Qy B.
h ionel?s air conwmimm�x as JefineJ by the Bay Arca Air Quality Management BOILER-COMP(OVER 1flo."BTU) Ir
Distrix?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. ��� 1
1 have mad the ha>abous materials requirements under Chapter 6.95 of the a� 1993
Califomia Health d Safety Core,Sections 25505,25533 and 25534. 1 u olon,ond that
if the building does not mends y have a tenant,that is is my responsibility to notify the CITY Ur wr5�I IIY V
if the building
of the es not currently
which must an met prior m issuance of it Ce notify
of
Occupancy.
Owner or authnrisA agent Damq'OTAL: ISSUED NY:
OFFICE