24819 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINTO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
HUII,DING DIVISION IIUII,UINGPROJECTIDENTIFIC �8ATION L l9,/
BUILDING ADDRESS: SANITARY NO. AP^PLICATIONSUBMfITAL DATE
l r-CS 1T# LOT
OW N 'W': PITO t CONTRA 'S LIC NO: J
4 rh _ >� O WC CONTROL#
A CHITIiCf/F, ,INFER: L a
32-76
CONTA . PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
L ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
QWX Iberebyam Nan
ffirallJicensed underpmvisionsofaripter9(commencingwith
u00 Section 7")of Division 34 the Bminess and Professions Code,and my license is in PpNF;hti `
y�ut all fomC imdeBCcl. G �J
FZtr: Dole Class Li meacho 1� �3/h UP T0200AMPS I� �
wQy Date Gom SD 201-IfNp AMPS
ZQ NZ ARCHITECTS DF, ,AR 'PION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z—O trade nd my plans shall be used as public records.
Fmf—� SIGNS ELECTRICAL
d � Licenced Professional
CC OWNER-BUILDER DECLARATION SPECIAL CIRCUYDMISC.
KOiiU 1 hereby affirm that I am attempt from Ne Comracmes Licenxe Law for the
m3avFi following mason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INS']'.
H��; which requires a permit to construct,alter,improve,demolish,or repair any structure
2t�Y� priorto iss issuance.else requires Ne applicant ben such pertnivo Gle asignrd statement POWER DEVICES
ty <0 that he is licensed pursuant to the provisions of the Contrectors License Law(Chapter -
ta. 9(commencing with Section 7000)or Di—ion 3 of the Business and Professions Code) SWIMM ING POOL ELEC UC VALUATE
XW_,� or 703exemptnyappomend the bsectis subjeasegedettemptt to civil
of ^ D�
FZQ Section is 15 exempt
domplieanndte pennitsr the all the exemption,
na civil penalty of OUTLETS-SWITCHES-FIXTURES ((�f
not more than five hundred dollars($5M).
_ I,asownerofthe NEW RESIDENTIALELECR —SQ FT.�o ❑ propcdy,mrmycmployeexwithwagesasdmirxole<ompcnsation, Q STORIES TYPECONSTRUC ION
y3 ep will do the work,and the structure is not imendedoroffered forssle(Sec.7BkL Business
and Professions Co dc:The Contractors License Law does not apply to an owner of
property who builds ter improves thereon,and who does such work himself ter through his
wnemployms.pmvidMNatsuchimpmvementsarenotintendedoroffetadfmr e.If, OCC.GROUP RIS.UNITS
however,the buildingor improvement is sold w hhin oneyearofcompletion,tbeovener- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ I,axowner ofthe popery,amexclusively contracting with licensedcontmerorsm QTY' PLUMBING PERMIT FEE Fl LO APN
Lresect the project(Sec.7(N ,Business atd Professions Code)The Contractor's
icense Law does not apply toanownerofpropcnywho builds or improvesthemon.and PERMIT ISSUANCE
whocontruq$fm such projects with acomrecmt(s)li<mscd pursuant Contracmr's gLTER-DRAIN&VENT'-WATER EA
License Low. ( ) PEE SUMMARY
❑ 1 am exempt unJer S<c. ,B&P C far this reason BACK ROW PROTECT.DEVICE OUTSIDE FE PS
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
49111114 WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihercby affirm the l have n eeniGcae mfcotvent 1.self-inm¢,ora cenificamof FIXTURES TRAP RECF,I PT#
Workeri Compensation lnsurvnm orecenified copy thereof(Sec.3S00,Lm C.)which PARK PEE Y N
all
employee's under tit. GAS-liA.$YSTRM-I INC. 0UTLETS RECEIPT#
Policy M BUT,
DI VISION FEES
G y GAS-EA.SYSTEMOVER4(EA) PLANCHECK PEE
CcniGc c p t. cry fi(o751f£J. �r�
Ceniliedcopy is filed with the city nspmtiom division. GKEA$EJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERSGREASE TRAP SOILS PGE
COMPENSATION INSURANCE
(This section need nm be completed ifthe permit is for oro hundred do[].($IW) SEWER-SANITARY-STORM EA.200FT.
las") FEEm
I eerily that in[he performance ofthe work forwhich this permit is issued,I$hall WATER HEATER W/VENT/ELEC
not employ any person in any manner an as to become subject to the Workers' PAID
z Compensation Lawsof CaliPomia. Data WATER SYSTEMITIREATING� Data Recei
Applicant to#Q NOTICE,TO APPLICANT:It, to,,making this CeNficate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. KPAID
OTgL:
I" � become subject to the Workers Compcnation provision of the Labor Code,you must
� > forthwith comply with such provisions or this Fernit shall be deemed revoked. EE
CCONSTRUCTION LENDING AGENCY E
z 1 beroby affirm that them is a cmnxtructmn lending agency for the performance of
U O the work In'which this pump' (Sec.3099,Co.CJ TOTAL: EE,
Lenders Name—
0 0
U Landers Address T QTY. MECHANICAL PERMIT FEE FEE
I certify that I have read this a aplicoion anA,ham thnt the above information is
Fr" 0a. conece lagan to comply with ell airy and county ordinances and stem laws relating to PERMIT ISSUANCE L FEE
rA budding construction,and hereby authorize representatives ofthiscity to enter upon the
U 'J aMwe-mentioned property fminspcctfon purposes. ALTER OR ADD I'O MECI L IONI'AX
C (We)agree to save,indemnify and keep harmless the City of Cupertino.,most
Iiabilities.judgmentx,costs and exIames which may in any way acerae against said City AIR HANDLING UNIT(TO 10,0i CFM)
in consryuence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,010 CFM)
Signature of ApplicangCom icor Dam EXHAUST HOOD(W/DUCI)
IIgLARDOUSMATGRIALSDISCLGSDRE HI1sTING UNIT(TO 10.000 BTU) Dae Receipt#Will @e applicant or forum building occupant store or handle hezadous materialusdefinedbytheCupcninm Muni al CndeChapter 912and the Ilcahh d SfIIBATINO UNIT(OVER IOO.WO BTU) TCOk,Seeti13 25532(e)p
❑Yen n VENTILATION FAN(SINGLE RESID) I
BOILER-COMP ISSUANCE DATE
Will the applicant orfuture buildingoccupanwaequipm<ntnrdeviceswhichemit (JHP OR I01,0q BTU)
havardous air conmmittanes n def by the Bay Arca Air Quality Management BOILER-COMP OVER 100,fI(IOBFU
DLatricR l )
❑Yes No NEW RESIDENTIAL SUCH, SQ.IT.
Lread the hazardous materials rrquimmems under Chapter 6.95 of the
zdth&Safety Code.Seutin is 25505,25533 and 25534. 1 understand that in
g elms nit camas w have ichm m be met prior my reuance bility m nficat thethe requiremmu whieM1 must be met prior to iasuanm ofa Cenificute ofhon>.ed agent Date TOTAL: ISSU�Ifj
OFFICE rcnJurl�