24930 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n II 4 J J LOO
BUILDING DIVISION BUILDING PROJECT]DENT IFICATION G
UILDING ADDRESS: /' - / / / / SANITARY NO. APR.ICATIONSUBMITIAI.DATI
V'
s / fS U /V 9x 6
3/ UNITE LOT#
W RS NAME: // PHONE: CONT CI'OH'S NAME LIC NO:
Z KU jW '�AJ N/C CONROL#
IFARCH I'fECI'/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE El El CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
�E4 ElI hereby firm that l am licensed under fa 9(commencing with JOB DESCRIPTION
Metzya provihionsu per ����
P400 Suction AlI Division 3ofthe Hmine,sand Pmfessl.ns Codes and my lkmw is in PANELS
X OF full force mJ dfect.
v~ai DN Lica.Class Lic lItJ[IO, UPT02MAMP$
201-1000 AMPS
ZOyZ ARC]UTECTS DECLARAI ION OVER If100 AMPS SQ.FT.FLOOR AREA VSQ.FT,
O'L o I understand my plans shall be used as#Mlle records.
F t?~ SIGNS ELECTRICAL
Q Y j I icensed Professional
Ly�6 OWNF,R-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOiO I herchy mE,m tbm I am exempt I'tam the Contractor's License Law fur aha
In3 y following reason,(Section 7031.5,Businccs and professions Cale:Any city or cowry TEMP.MISTER OR POLE INST.
I_a < which requires a permit to construct,alter,improve,demolish,or repair a.,svunum
prior to its issuance,also requires the applicant for such permit la file a signedslmement POWER DEVICES
,=e o than he is licensed#room.,,the pra,kiiaw f,he Commaeon,a License Law(Chapter
Ikea 9(commencing with Scation]WO)of Division 3 ofthe Busur,,and Professions Code) SWIMMING POOL ELECTRIC ^y VAIUAT�Q6
py_y or that he is exempt therefrom sod the basis for the alleged exemption.Any violation of VO� (JV
LZa Section 7031.5 by y applicant for a permit subjects the applicant to a civi l penalty of OUTLETS-SWITCHES-FIXTURES _
ere than live madmildollars($SIX).
pcnsa NEW RESIDEN'I'[Al.ELECI R S .ET.
C pan the wrk,an thestrerty,ormy empendedorofwageszsthe(Sce.cont tion, Q $l'ORIES TYI'Ii-CONSTRUCTION
#y d dotheC d e: he Comisnol is Licame Law doessed not
apply 704i,Business
d Professions Crile:The Conuacmr's License Iran eh not apply tom owner of
own eny who builds or improvesch mpo and who dues oo<h work himssHo,through his
employee,thsprogori improvement
witsmenet earroctended moftion.ficued theo c. r- OCC.CROUP RES.UNITS
builder will
have
the
burden of anent is hath within one year or improve
for the owner- APLUMBING
TOTAL:
builder will have the buNen of proving that be did not build or improve for puryou of
sura.).
❑ Las ownerofthe property,am exclusively contracting with licensed contractors to QTY' FEE FLOODZONE APN
instruct the project(Sec.0044,Business and Profession,Cade:)The Contr...m's
Ucensclrwdmsnotapplyaoanownerofpma nywhobuildsorimpmvmhcrmn,and PERMIT ISSUANCE
whoc ,masts Ersuch projects with o contracmrts)licensed pursuant lathe Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Ser. B&P C for this rcavon BACK FLOW PROTECT.DEVICE OUTSIDE FEES
f SANITARY Y
Owner Dau DRAINS-FLOOR,ROOF,AREA,CO RECF.IPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ers'Coyafnrmon Insurance
or menifie copythloself-inxure,nr Lab C.)chid FIXTURES-PER TRAP RECEIfT#
WmkerACumpene,x ad,samncemacenifiW copy lherwf(Sec.3800.Irb CJ which PARK FEE Y N
• rovers all employee's undcnhis permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company
❑ Cenifi<J cupY is hereby famished, GAS-EA.SYSTBM-OVEN 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASE(INDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGRIASETRAP 5011.5 FEE
INSURANCE.
(This section need not becompleled ifthe permit is for one hundred dollars($Ud) SEWER-SANITARY-STORM EA.200FT. ENERGY FEEor less.)
I certify that in the pecomerceorthe work(.,which his pernit is issued,Tmall WATER HEATER WNENTELECTR
not employ any person in any manner so as rot Mcom,subject to the Workers' PAID
z Compereaka rwsof Culifomia. Dam WATER SYSTIiMTREATING Dae Receipt#
Q Applicant
Z0 NOTICE TO APPLICANT:IL after nuking this Certificate of Exemption,you should NEW RESIDENTIAL PLM D. SQ.ET,r14 IberiIberians,
cumsubject ,,the Worker,Comnsm
pei.n visio
pron,of the Labor Code,you must
TOTAL
forthwith comply with such ppermecmerevoked.
provisions or this it shall be Jd
('L 7 BUILDING FF.Ii
LUL CONSTRUCTION LENDING AGENCY SEISMIC FEE
rZ Ihereby affirm that is a construction lending agency for the performance of
U O the work for which this Introit is issued(Sec.3097,Civ.C.) TOTAL: ELECI RIC FEE
I<nder's Name
QU Isndcr's Address Q7Y. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that T have mad this application and slate that the above information is
F W comem. Iugme ioeomply will all city and aountyordinancesund,um Ew,mlatingm PERMIT ISSUANCE. MECHANICALITF.
_ building construction.and hereby authorize representatives ofthiscity m enter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep bam less the City of Cupertino against
Iiubilities,judgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,00(P CFM)
interim
re of the grmfng of chis permit.
AIR HANDLING UNIT(OVER 10,tXp0 CFM)
ore.(ApplicanVCnmracmr 1-late EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTI) Dam Raeipt#
Will the applicant or future building trcupam note or handle haurdous material
as defined by the Cupertino Municipal Cale,Chapter 9.12,a ad the Health and Safety HEATING UNIT'(OVER I UB(l00 BTU) AI.
Code,Seen 25532(0)'!
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will Neo applicant or future buildin BOILER-COMP QHP OR 100.000 HIT) ISSUANCE DATE
PP g«cuhe Bay Arco Air Quality swlichemit
hoeardnua air comaminunu as defincA by the Nay Arco Air Quality Manugcmem
L
BOILER-COMP(OVER 10(I,UW BTU) /n�
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A p D
e real the hazaalous materials requirement'
under Chapter 695 of the I
lculth&Safely CWe,Sse iors 255(IS,25533 and 25534.1undomwdthatprt�� �0
ing Jms mol currently have u mnwa,thin it is my rcsponxibitity m notify Ne /f the requirements which must be mel prim m issuance of a Certificate of, rillwhonzed agent Dam 'TOTAL: ISSUED BY: I IHyU
OFFICE