24783 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMIT NO.
;. CITY OF CUPERTINO PLUMBING-MECHANICAL
G, 2 4 7 6 3
BUILDING DIVISION APPLICATION/PERMIT BUILDINPROJECT IDENTIFICATION
NG DDRESS: SANITARY NO. APPPLILIICAT�IONSUBMRTALDATE
UNIT# LOT# (/,1O
AME: - �� HONE: CONT ACTOR'SNAyL� A LIC NO:
y �Fyr�IrL N/C CONTROLM
IR CHITECTENGINEGR: < LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
B D ELECT PLUMB MECH
�,� [/ PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION .
Oy.Z Ihereby affinnthal l amllcensed underpervisions of Chapter9(commenciagwith
¢100 Section 7000).(Division 3 core,friae.Imel Professions fostered my license is in PANELS
pFFGf. Full force and effect
azo Liermse Class- Lic.# UPT02MAMPS
co<d Dale Contautm - 201.1000 AMPS
F y y ARCI IITEU S DECLARATION SQ.FT.FLOOR AREA $/$Q.H.
I understand my plans shall be used as public records. OVER 1000 AMPS
OO=�
SIGNS ELECTRICAL
Licensed Professional
0.'Q OWNER-BUILDER DECLARATION SPECIAL CI
yy O y V 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W wF following reaso..(Section 7031.5,Business and Professions Code:Any city or county TEMP.MET NSTO
which requires a permit to construct,alcor,improve,demolish,or repair any suucthre
}� prior to its issuance,also requires the applicant forsuch permit to fileasignedswtement POWER DEVICES
W �O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
p+Ma� 9(commencing with Sec[ion]IXq)of Division3of the Business end Professions C«fe) VALUAT
Www or tam he is exempt therefrom and the basis Earths alleged exemption.A.,,kdmion of OUTLETS-SWITCHES
-FIXTURES I �O I
4 Section7031.56y vny applicant for a permit subjects the applicant on.civil penalty of
o are than five hundred dollars(5500). -
O NEW RESIDENTIAL ELECTR SQ.FT.
p sowneraMe'no
( employeeswiftene sas theirsolecoan owner STORIES TYPE CONSTRUCTION
°.° illdo he work,and the smuc[ure isnotimended.'offered f.rsale(Sec.71VW,Business
and Prefcssions Code:The Con'sent's License Law does not apply to an owner of
property who build,artimproves thereon,and who Icessuch workhimselfmurno lh his
own employees,provided thatsuchimpf.vrntentsare not intendedorofferee.
dforsalIC OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofaomplelion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOODZ.ONE APN
❑ hasowveroRhep Ay,em seca"elyc <tivg wbh licensed.onveetors to
conswet the pro'a'c((Se ]044,0usines d Profee ns Coda)The Connector's
License Lawd snot Iy w itumner roperty who but sorimproves thereon,and PERMIT ISSUANCE
whoc.ntra f chproject, ith acurpOlicemed .,,.an,to the Conmacons ALTER-DRAIN&VENT-WATER EA
Liaem e ( ) FEE SUMMARY
❑ e pt un .B&P C holds reason OUTSIDE.FF:
BACK FLOW PROTECT.DEVICE SANITARY Y N
ORKMNM ° Or DRAINS-FLOOR,ROOFAREA,COND. RECEIPT#
An
SCHOOLTAX YN
❑ I hereby affirm that l have. ,ilif.uo.luoism to self-Insure,or a certificate of FIXTURES-PER TRAP - RECEIPTN
WorkersCompensation Insurance or a certified copy thereof(See.3800,Lab C.)which PARK FEE Y N
ars all employee's undenhis pewitGAS-EA.SYSTEM-1 INC.4OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Coupled copy is hereby famished.
❑ Certified copy is riled with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS EEEJ
COMPENSATION INSURANCE
(This section madnot be completed ifthe Pewit is foronehundred dollars IS Urn SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or le".)
I certify that in the Performance of the work for which this pewit ishoued,I shall WATER HEATER W/VENT/ELEC'rR
not employ any person in any m as to become subject to the Workers' PAID
Compensation Lawsof Celifomia. Date-so WATER SYSIEMITREATING Dam Receipt It
O Z Applicant
7-. 6 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL TIME, SQ.FT. TOTAL;
F H become subject o the Workers Compensation provisions of the Labor Code,you must BUILDING FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
I-QSEISMIC FEE
�] CONSTRUCTION LENDING AGENCY
1 hereby which
t Net there is i construction lending agency for the ped.wance of
z' the work for which this pewit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Q Lender's Name
Lenders Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V I certify that 1 have read this application and serethat the above information is MECHANICAL FEE
4k correct.I agree te comply withal]city and county currencies put state laws relating to PERMIT ISSUANCE
'Drs" building construction,and hereby authorize representatives.(this cityto enter upon the - CONSTRUCTION TAX
U 4
above-metni inspection pu ALTER OR ADD TO MECH.
agree to save,i oemnify and ep harmless the ity of Cupertino against - s
Iia' ties,judgment codex en amayinanywa accrueagainstsaid City AIR HANDLING UNIT(TO 1Q000 CFM)
o the g [in wit ' AIR HANDLING UNIT(OVER 10,000CFM)
cofitanOCo ra or w Dem EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant score or handle hazardous material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING TO L:
Code,Section 25532(a)4 VENTIL' (SI B )
❑Yes ❑No
BOILER-COMP(3HP OR 10(IpOp BTU) OISYA {VJ
ICBIDATE
Will the applicantorfumrebuildingoccupantuse equipmentordevims which emit // AH
zarmi
dous air contanants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100.000 BTU)
DisniaP FEB (] '93}
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. B 10 19
1 have read the hazardous materials requirements order Chapter 6.95 of Ne
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that _ CI-f 1V
UE V UI'L-'1111!V
lithe building does not currsn0y have a tenant,that it is my responsibility to notify the
occupant of he regmo mems which most be met prior to Issuance.f a Certificate of
Occupancy. 73sem/! �, ,
Owner of authorized agent Dae TOTAL: ISSUED BY:
V/"�f��p�j��
OFFICE