24538 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-EAXIRICAL PERMIT NO. 24538
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APPLICATION/PERMIT PLUMBING-MECHANICAL 2 /I 5 3 Q
BUILDINGDRESS: SIGN BUILDING PROJECT IDENTH'TCATTON L'7 A
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
A0 7 S UNIT# LOT# 1���i�L
W 'RS NA PHONE: CONT0. R'S NAME: LIC NO:
SIC CONTROL If
R-HITUC`OENGINEER: LIC NO: v ADDRFSg: n
CONTACT: PHONE: S ❑ HUILDING PERMIT INFO
'L QTY. ELECTRIC PERMIT FEE
�Qy-# BLDG ELECT PLUMB MBC
PERMIT ISSUANCE fI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
qyz [hereby offirmthat l sm licensedumlerprovisiomofC pter9(commencing with
p100Section'700hof Division 3 of the Business and Podessions Cok,mal my lice...is in PANELS ,
y65 full fotce-it'Law al-
Notw „3
License Clazs(i_j�Y9 ` Op ��� UPTO200AMPS
Dam-14.2—/A Cnmrunor 201-IOW AMPS
ZOyz —'w ARCHITECTg DE ARATION N SQ.FT.FLOOR AREA SSG.Fr.
Z04— I understand my plans shall be used as public records. OVER 1qp AMPS
� � SIGNS ELECfRICAI, ® I A'
Licensed Professional tl v
OWNER-Bempt from the Contractors
SPECIAL CIRCUIT/MISC. ALEn paw
�j a,l I hereby affirm Not I and exempt from the Convegor'e License Law for the n TE gaa�
{� :o.m¢' following reason.(Section 7031.5,Business mal Professions Cade:Any city or county TEMP.METER OR POLE INST. J j/�.
teJ O.1 which requires a permit to construct.alter,improve,demolish,or repair any structure I /)#
}� to its iuumce.also the applicant such Permit file a signed statement POWER DEVICES Gp
prior q pe, Ilona gn
a�'p 0 Nm he is licensed pursunm to Ne provisions of the Commnor s License Law(ChapterDATEiL
9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATI
yr^y
Or he is exempt therefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
�MSection 7031.5 by any applicant for a permit subjects the applicant m u civil penalty of
G of more than five hundred dollnm($500). NEW RESIDENTIAL ELEM S .PT.
W a n❑ I.asownerofthepmNay,ormyemploymswiNw.gesmtheirsolecompenution, Q STORIES TYPECONSTRUCTION
ywill dothe work,andthe structure is not irtendWoroffered forsale(Sec.]U44,Business
and Professions Code:The Comtrecates License Low does not apply to an owner of
property whobuilds or improves thereon,and wanders such work hirmadforthroughhis
owmOCC.GROUP RES.UNITS
employees,p Ing in improvehimprovementsironer intended orpletioddre O c. r.
however,the buildingorimprovementisnulde didnot yam or improve far
theowner TOTAL:
builder will have the burden of proving that he did not build or improve for pufwu of
ale.).
❑ Lasowner OOhe propcny,amexclurivdyrontratingwithlicenxd cammcmrsm QTY. PLUMBING PERMIT PEE I1.00D ZONE APN
construct the Project(Sec.7044.Business and Professions Code:)The CUmmcmr's
Liana lnwdma not applymanownerofpropeny whobuilds orimpr..alflmnin,and PERMIT ISSUANCE
who contracts for such projects with aconractor(s)licensed pursumnothe Contractor's
Licea Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑nl am exemp under Sec. .B&P C for Nis reason BACK FLOW PROTECT.DEVICE SANITARY TY D 4E N
Owoer Date pRA1NS-FLOORROOFAREACOND. RECEIPT
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
4enI hereby affirm that l have a confess,ofcousmt to self-insure,or a arifcate of FIXTURES-PER TRAP RECEIPTp
or 'Comnsa
peuan ltmranab ce ar a certified copy thereof(Sec.380.LC.)which PARK FEE YN
coven elle der Nis pemrit GAS-G.SYSTEM-I INC.40UTLETS RECEIPTM
PO try 10%3 3 � 4' BUILDING DIVISION FEES
Company�( All-w•- Of GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CertifeJ copy is hereby fumia eJ.
Candied copy is filed with the city inspection division. GREASEANDUSTRI.WAS'IE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not be completed Hire permit is foroae hundred dollars($100) SEWER-SANITARY-STORM EA.200PT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER WIVENT/ELECfR
not employ any person in any manner so v I.become subject an the Workers PAID
Compensation Laws of California. Date WATER SYSTEMITRGTING Dam Receipt#
O zApplicant
Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW USI DENTIAL PLMB. SQ.FT. TOTAL:
O t become subject to the Worker's Compensation provision of the Labor Code,you must
FFFa"' forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
Cal (] CONSTRUCTION LENDING AGENCY SEISMIC FEH
1 hereby uffrm that constructionaen
he.is.consction lending gcy for the performance of
U OTOTAL: ELECTRIC FEE.
the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name
OF 1<maer.,paateax QTY. MECHANICAL PERMIT FEE PLUMBING FEE
CJ 1 certify that I have read this application and state that the above information i> MECHANICAL FEE
correct I agree in comply with all city and county oNinmas and state laws relating to PERMIT ISSUANCE
ybuildingeonstruction,and hereby amhoriu represematives ofthis city reenter upon the CONSTRUCTIONTAX
(•) z above-mentioned property for inspection purposes. ALTERORADDS'OMECIL
(We)agree to save,indemnify and kap hmnlev Ne City of Capmin0 against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(7010,0(10 CFM)
qumce of Ne gm di f Ni555pppe t.
r/\17,�/� /(^�¢_e{D � �'1�� ^/�/D'Q AIR HANDLING UNIT[OVER IO,OW CFM)
$jmamm of Applicenpanor Data ] E%IIAUST HOOD(W/DUCT)
U PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT 100,1100 BTU) Data Receiptp
Will the applicant or future building occupant store or handle hswdous material HEATING UNIT(OVER 100,W0 BTU) TOTAL:
us defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cod,.Safo.25532(0):' ❑No
11 Yes VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR IOQ,OW Bq'U) ISSUANCE DATE
8 Will tair contaminants
manus s defined
by the ay Area Air
Quality
Management
t P1 A ' D
DistNnm air cnntaminvms us defncd by the Bay Area Air Quality Management BOILER-COMP(OVER IW,IXq BTU) _ Y' M
District]
❑Yea 0N NEW RESIDIIIALMECH. SQ.FT. DEC lU IJ
I have read the hararah.materiels requirements under Chapter 6.95 of the '1(]92
California Health&Safety Cole,Sections 25505,25533 and 25534. I understmd that
if the building does not currently have o tenant,that it is my responsibility to notify the Ciir OF CL
occupant of the requirements which must be met prior 10 issuance of a Cri ifale of
Occupancy.
Owner m amhadred egem Dam ISSUED BY:
OFFICE
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