24835 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL"ING-ELECTRICAL TERM[I'NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL, n A Q!� C
BUILDING DIVISION BUILDING PROJF.C'TIDENTIF'ICATior; L 4 o J J
BUILDING ADDRESS: G y..� �j SANITARYNO. APPLICATIONSUBMHF.
TALDAT
i F- 5 1 V D �„ - UNIT# LOT If
OWNERS NAME: PHONF;: CONTR%CfOR'S NAME: LIC NO:
We iCr ` 7 CONTROLp
ARCHUUCT43NGINEIiR: LIC NO: fQ ADDRESS: [ a�##O ❑
,7 CONTACT: h0� P-HONE.
\�Yi:, QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
-• BLDG ELECT PLUMB MF,
PERMIT ISSUANCE '�od 1Tt p} Of gl
LICENSED CONTRACfOR'S DECLARATION '+ APPLIANCES-RESIDENTIAL •C� JOB DESCRIPTION "•LL]IYYI
0"Z Ilands affirm Thal lam licensed under provisionsafChapter9(cmmmencingwith
42001= Section 900(1)of Division 3 of the Business and Professions Code,and my license Tsar PANELS
F�Ud3 Liestrrceaadef ed. L /y K 1a� RemW1'T/1
La.,Zm fall fu<Chas -1 Lia# O UP T0200 AMPS
to<o, Date - Conrado' 201.1000 AMPS
Z OTnZ ARCHITECTS DEC1, TIO OVER 1000 AMPS SQ.FT.FLOOR AREA b/SQ.FT.
O Z�❑ I understand my plans shall be usW as public records.
Ftnl_'j SIGNS ELECTRICAL
QY�,� Licensed Profcssi.nal
�y.CQ OWNF;R-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOCU 1 hereby affirm That 1 um exempt from me Contractor's License Law for the
m3atF followir,oncon.(Section 90315,Businessand Professions Code:Any city.,county TEMP.MET ER OR POLE INST.
F�-co; which rtquires o pnmiT to conswa,alter,improve,demolish,.,repmr any swaure
poor to its issuance,also requires theapplasontfor such permit o file a signed statement POWER DEVICES
K O That he is licensed pun'uan to the provisions of the Contrac'tor's License Law(Chapter
e'yo�s 9(commcncing with Section 9W0)of Di 3 offle Nosiness and Pnefessluns Calc) SWIMMING POOL ELECTRIC VALUA'T'ION
�_To .What he isexempt Therefromand me basis for allegedexemplion.Anyviolationof FIXTUR-S
I-•Z_Q Section 0031.5 by any applicant for apconil subjects the applicant to a civil pcmahyof JS OU'ILE'I'S-SWITCHES-
$ not mom than five hundred dollars(8500).
YI�p ❑ Lasowncr.fine preperty,ormyemployeeswith wages astheirmlecompmmlion. NEW RESIDENTIALELECIR SQ.FT. STORIES 'TYPE CONST RUCTION
will dix The work,and llmnmence is not interdealer offered mastic(See7044.Busirers
and Professions Code:The Contractor's License Law docs not apply to an owner of
property whobuildcorimpmveethemon,andwhodsessuch work ldmsd(orthrough his
empinyces.provided ThaLsucM1 improvememsarena imendedoroffertdforsale.IL Q OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one year ofeompletion,the owner- TOTAL: ] Z
builder will have The burden of proving that he did not build or improve for purpose of
sale.).
❑ Lus owner.fthe pmperty,amexdusivelyeontraning with licensed conoremrs to QTY. PLUMBING PERMIT FEE -ODD_ZONEAPN
construct the Project(Sec.7044,Business and Professions Cale:)The Contractors
License Law does not apply Toanownerofprnpeny wholsoldsorimpeves Thereon,and PERMIT ISSUANCE .d
whocommesfmsuch p-jectswitlitcomactor(s)licensed pursuant mthi C.nwemr's
License law. ALTER DRAIN EA
) FEE SUMMARY
❑ I am exempt under tie. ,B&P C for this reawn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner RDateAT RF.CF.IPTp
5 FL R, OOF AREA,COND.
WORKMAN COMPFNSofooreECLARATION SCHOOL TAX Y N
❑ em'Coneby affirmlhmlhave a rancecertificate
or a cein.f copy therof(Srsure,er Lab C.))ca Tv RECEIPT#
Workens'Compcnsatinn Insurance oracertified copy there.f(Sm.3gTN),Lab CJ which) Fl lSRF3lI'E - (y t)� PARK FEE Y N
covers all<mployc<'s under this permit. +AS- lyiyi[;f.-lN 4 RECEB'r#
P!MPolicy# 6 9"�" BUILDING DIVISION FEESmp
Coany GAS-EA.SYSTEN VFR4( ) PLANCHECK FEE
ElCerifiW copy is hereby(umishel.
Certified copy is filed with the city inspection division, OR GRADING FEE
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissemion need not hernmplemA lithe permit is Torre hundred did]ars($1001) SEWER-SANITARY-S'POEM ITA.200FT. ENERGY FEE
or less.)
I certify Tbar int he perl'.msance ofine work for which this permit is issued Ishall WATER BEATER W/VENDELECR
not employ any person in any m +as i. hecome subject m the Workers' PAID
Z C.mpensationlawsof Cnlifomia.manner
s WATER SYSTEMTREATING Duo Receipt#
Applicant
ZQ NOTICE ED APPLICANT:If.aOcr making this Cenifemeof Exemption.youshould NEW RESIDENT AL PLMB. SQ.FT. TOTAL:
f" become subject to the Workers Compm
emiun provisions ofthe Labor Cordy,you Toast
� > forthwith comply with such provisions or this permit shall be directed revoked. BUILDING FEE -DO
lIJ FZ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a conswetion lending agency for the performance of TOTAL: ELECTRIC FET;
UO the work for which this pemninisissued(Sec.3097,Cry.C.) .ty Z.2..1
Lenders Name D
QU Lamers Address 1 QTY. MECHANICAL PERMIT FEE PLUMBING FEEYfl O
1 certify Tho 1 have read This application and state that me above information is �� MECHANICAL FEE correct.Iagree 1.comply with all city and county ordinances and state laws relating To PERMIT ISSUANCE ' S_v
buildingronscraion,and hereby aumorze repreacrudives.f This city turner upon the CONSTRUCTION TAX
U Z shove-ranoonrl properly fur inspecti pugnosea ALTER OR ADD TO MECH.
We)agree to save,indemnify ke p harmless the City of Cupertino against
liabilines,judoonts,cons and en which may in any way accrue against said City AIR HANDLI NO UNIT(TO 10,000 CFM)
in consequence of Tmgof .it.
AIR HANDLING UNIT(OVER 10.1100 CFM)
Signain .I'App' nUCcrnmctor Date EXHAUST HOODOATUC) S
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000[ITO) Date Receipt It
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,00f)BTU) TOTAL: La
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Session 25532(a)Y VENTILATION FAN(SINGLE RESID)
❑Yes k.
Will thea Iicaut or future building occupant BOILER-COMP(3IIPOR 100,0WBTU) ISSUANCE DATE
pP goecupan yuipmemordevices whichcmit p
.•:hN
acaous air contaminants m defined by The Bay Area Air Quality Management BOILER-COMP(OVER 1 W,000 BTU) P yp-�� A D
N jDuvicr!
1' ❑Yea o NEW RESIDENTIAL MECH.-SQ.FT.
!N .f I have read the hazardous materials re omenta ander Chapter 6.95 of the MAR — 5 1993
'CTlifomm Health&Safely Cade.Sectionsss +'255)3 and 2.5534. l understand that
if The buildingdas not currently pso arena )het it is my responsibilitymnotify the CiIY Ur LIUr tTiIIIVU
occupant of T hi',h must me prior T.issuance of a Certificate of
Occupancy. ` ,onto �.T1 AMO
/s '
Owneror authorized agent Da¢ TOTAL S ISSUED BY: \ I e1kVCa
OFFICE