24958 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BALDING-ELFICTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n JI
BUILDING PROJECT IDENTIFICATION. 2 4 J CO o
BUILDING
E
SANITARY 0. AI'1'LIIONSUN
MI'PI'AL DATIi( � , ` S- ,W'IODAve—To IATM -
OWNINSN IPHONE: CONTRACTOR'S NAME: LIC NO: —:
eG N/C CON
ARCH]'DCNR: Ctr
LIC NO: ADDRESS: ❑
Is CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT[NFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Iherehyuffmonthatl a mlicenaedun&rpmvisiomofaapter9(co mcingwiih ,�'Y
POO[ Section 9IXl0)of Division 3 of the Business and Profesomu Code.end my license is in PANELS
GwU hd oocCnsne ! Lic.p [rN./� // ' f 1 ` '
[_UzW ��////p UP T0200AMP5 S/ �
ro<y Uate�Conp.mm Mtl-IfN10 AMPS
ZONZ HCHITECTS DECLARATION OVER IOOOAMPS SBFT OER� ' �$ .FT.
O Z—❑ 1 understand my plans shall be,used n public raords. G..e l0,
F,ytt�i SIGNS ELECTRICAL \ 1� f-�
Q�a� Licensed Professional � P
a V1 OWNER-BUILDER,I. I DECLARATION ON SI'F.CIAL CIRCUIT/MISE. g$7I II
LJOyF I hereby affirm That 1 um exempt liam the Tension Co License Ixw for the
F�Orn which requir s a(Section const&Busimr,improve,
demob h,or Ad,re to city structure
'l1iMP.METER OR POLE INST. D WE
which requires n#maim re construct,alter,improve,demolish,rfi repair maty swcturt
�25Y0 Adorers slicensnro ormism 1. h providlcamfohe ch Colossuses
Licefilense
La statement POWER DEVICES.
��<p that be islicensedwith Sction7heproviivisinf the the Business
Licenrela ions Co ter
p�- 9(comrncnaing with Seetiun]II(10)of Division 3 o @e Buslncse end Profusions Cale) SWIMMING POOL ELECTRIC - VALUATION
y'^rn or that he is exempt thereliom and the basis for the alleged exemption.Any violation of 0111'1 PTS-SWITCIIFS-
-C,Y
Section 7031.5 by any applicant for a pecoutsubjects the applicant a civil penalty of FIXTURES
E C not mom then live hundred Radian($500). NEW RFSIDHbFDAI.ELECIR —SQ.FT.
K m ❑ I,usownerofNepmperty,ormyemployeuwithwegesastheirsolecampensation, STORIES TYPE CONSTRUCTION
y willdothework,andthesimciumknoiintendMoroffer forsale(Sec.]04LBminess
and Professions Code:'I'he Comm doe's License Law does not apply to an owner of
property whnbuildsorimproves theron,and whodoes suchwork himselforthrough his
own employees,provided mhatsuch impruvementsue notintendedmufferedforsule.If. OCC.GROUP RBS.UNITS
however,the building or improvement is sold withinon,yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
vele.).
❑ I,mowner lithe propn
property,am exclusively contracting with licensed c,ntmcmm QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
onstruct the mocct(Sac.9144,Business and Professions Cale:)The Contractor's
License Law does not applyto an nwnerofproperty who buildsnr indPowes thcrcon,and PERMIT ISSUANCE ,
who rommcufm loch pmjenawiNecunuector(q Imenxllf,..arnm Ne Conuecwfs ALTER-ORAINffi VENf-WATI?R(Ii))
License Law. FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C far Nis meson BACK FLOW PROTECT'.DEVICE. O l:
SANITARY Y N
Owner Duo, RECEIPT N
WORKMAN COMPENSATION DECLARATION ❑NAINS-FLOGR,ROOP.ARTA,COND. SCHOOL TAX YN_
❑ l hereby affirm that l have a certificate ofcousenuo self-insure,or a certificate of RECEIPT#
• Workers Com EIXTURFS-PERTRAP
Compensation nler this
copy thereof(Sec.3,00,Lab C.)which PARK FEE Y—N
—
covers all employee's under this pcnnit. GAS-CA.SYSTEM-2 INC.4 OUTLETS RECEIPT M
Policy p BUILDING DIVISION FEES
Company GAS-LA.SYSTEM-OVER 4(EA) PIANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspmtion Division. GREASEANDUSTRL WASTE INTERCEPTOR GRADNG FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GRFASRTRAP SOILS FEE '
COMPENSATION INSURANCE
('This section need not he completed ifthe permit is loran,hundred dollars($TMH SEWER-SANITARY I STORM EA.2001T. ENERGY FEB '
mless.)
I certify that in the performance ofthe work for which this permit is issued.l shall WATER HEATER W/VENTIELECTR
not employ any person in any termer so as to be w tors Ne Worker' PAID
z Compensminn sofC form. Dare � -- _ WATER SYSTEM/TRFATING Date Receipt#
Applicam
� 0 NOTICli T11 PPLI NT:lf.uRcrm.kingthis CeniFlcateu ?xfnilF n,yonsho.ld NI7W RESIDENTIAL PI.MB. SQ.FF. TOTAL;
r/)
become subjectto the Workers Compensation provisions of the labor Code,you must
FFF"' > forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
a >
Ri Q CONSTRUCTION LENDING AGENCYQ SEISMIC FEE
U z I hereby affirm that then is a comwction lending agency for the performance of (�0 .
O
the work for which this pcsmit'nie ed 3097,Civ.CJ TOTAL: ELECTRICRip.
U. Lender's Nome 4=(/ (See.
O Lender's Address QTY. MECI IANICAL PERMIT FEE PLUMBING PEI: u
1 certify Nat I have mead this application and some that the above information is
correct.l agree to comply with all city and county ordinances and state laws mlatingo, PERMIT ISSUANCE MIiCHANICAI.FRE
V) building construction,and hereby authorim representatives of this city to enter upon the CONSTRUCTIONTAX
L1 7 ulwve-mentioned property for inspection purposes. ALTIiR OR ADD 9'O MECH.
.^. (We)ogre,m save,Indemnify end keep httnoless the City mf Cupertino.,.lost
llubilitiu,judgmems,coms and expenses which may inany way accrue against saidCity AIR HANDLING UNIT(TO 10,00,7I CFM)
I.consequence of the granting ofthis permit.
AIR HANDLING UNIT(OVER 10.01))CFM)
Signamm of Applicam/Comms Dam EXHAUSTHOOD(WNUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI'r('1'O INt"BTU) Ute Receipt#
Will the applicants future building occupant store or handle harardous material
as defined by the Cupertino Municipal Cale,Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER 1110,000 BTU) TOTAL:
Code,Section 25532(.)? VENTILATION PAN(SINGLE RESI D) -O
❑Yes f1dNo
tlOILER-COMP(314P OR 10fL000 BTU) - ISSUANCE DATE
Will the acirmarntom.as building by
nBay equipment dIdd ces Mandagenach mt P p I D
herardom sir commninanu ss defined by the Bay Area Air QuNity Mawgem<nt BOILER-COMP(OVER IOO,WO BTU) N
'.
District?
❑Yes 9 `o NEW RESIDGNTIAI,MECH. SQ.Ff. _'VY ask,.�,SaS^ys
I have mad the hazardnm materials requirements under Chapter 6.95 of the APR
California Health&Safety Crde,Sections 25505,25533 and 23534. I understand that
ifthe building does not urrondy have a anan.that it is my responsibility to notify the
arCITY Uf VUr CT1111VV
upent of the requi menu which muss be et prior m issuance of a Cedificme f
Occupant �� mss_
Owncro authors,d el gene-��
OF OTAL:TISSUED BY: LU