24949 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY 3
CITY OF CUPERTINO - BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24949
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. ,APSPLICAT^ION SUBMITTAL DATE
U ���� UNIT LOT# vim^
TOWNER AM O y PH C ACfOR'SNAME: LIC NO: ` V
L N/C CONTROL
I Ci1T�.a^T/ENGINEER: LIC NO: ADDRESS: ❑
If ..w- CONTACT. PHONE. BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
DL EL PLUMB MECH
PERMIT ISSUANCE ❑ ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWz I herebyaffinnthallemlicensed underprovisi°nsofChapter9(commencing with
µA00 Section70(al of Division 3 of the Business and Professions Code,and my license is in PANELS �/�C♦
y F full eu
ffe .
6 IyV Licensense anmild Lic.# UP TO 200 AMPS
y G. Date Contmaor
F.pm - 201-11100 AMPS
ZOyp ARCHITECT'S DECLARATION OVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O'Z^[vvll I understand my plans shall be used as public records.
N
SIGNS ELECTRICAL
Lsenxed Professional
a, OWNER-BUILDER D ECLARATION SPECIAL CIRCUIT/MISC.
XOaU I hereby affirm that I am exempt from the Contractors License Law for rhe
FollowW PIC a which requing re s a Inc unit in]031.5,Business and Professions Code:Any city m county P.METER OR POLE INST.
m.] which requires a permit m consimcr,alter,improve,demolish,or repair any swmure
Nab prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
a I'O p that he is licensed pursuant the provisions of the Contmcmis License Law(Chapter
a�' a(commencing with Section]WO)°f Division 3oftbe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W^,y either he is exempt and the basis for the alleged exemption.Any violation of \DO
FZ¢ Section 0031.5 by any applicant for a permit subjects the applicant a civil penalty of OUTLETS-SWITCHES,FIXTURES D
of re than five hundred dollars($500).
O NEW RESIDENTIAL ELECTR _SQ.FT.
C� I,asowner°fthcprnperty,ormyemployms with wagesastheirsolecompensarion. STORIES TYPE CONSTRUC ION
y3r wit t 'virk.unit thestructure is not intended proffered for sale(Sea 7044.Business
and Pr sions Code:The Comramor's License Law does not apply to an owner of
prepeny s ohuildsorimproves Nereun,andwhodoessuchworkhimselfonhroughhis
own employees,providelthat suchimprovements meactimmndedoroffered forsnle.If, I. E ITS
howevegillhathe v ldu burden of rent thatsolhe
of completion,purpose f ,i,
builder will have the burden of proving that he did not build or improve for purpose of V
sale.).
Cl I,as ownerofthe pmiscry,amexclusivel contracting QTY. PLUMBING PERMIT FEELOOD E (f
yc gx with The Contractors
�% tl/N
construct the project(Sec.9044,Business and Professions Code:)The Comrndor's
License met,fosnm apply loan awnerematio s)ty whnsedpulds arimpto the Comme.andces PERMIT ISSUANCE
whence Law.forsuch projects wiNac°ntracmr(s)IicensW pursuant to the Comracmis ALTER-
License Law. DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for thio reason PACK ILOW PROTECT.DEVICE O TSIDE FEES
Owner Dare Y Y N
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION AX Y N
❑ *iJ�by affrn that l have a certificate ofconsenuo self-insure,or a cenificate of FIXTURES-PER TRAP RECEIPT#
Worken'Compeneation Insurance ora certified copy thereof(Sec.3800,Lab CJ which Y N
covere all employee's ander this permit. GAS-LA.SYSTEM-1 INC.4 OUTLETSRECEIPT#
Policy# BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER CK PEE❑ Certified wpy ishueby famished.❑ Certified copy is fled with rhe city inspection division, GREASE9NDUSTRL WASTE.INTERCEPTOR FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP 'COMPENSATION INSURANCE
(This section need not he completed iHhe permit is fomite hundred dollars($IW) SEWER-SANITARY-STORM EA,200FT. EE
or loss.)
I certify that in the pertormante of the work for which this permit is issued,l small WATER HEATER W/VENT/ELECI'R
not employ any person in any manner so as in become subject to the Workers'
z PAID
Compensationiumsof Califomia. Date WATER SYSTEMITREATING Dare Receipt#
Applicant
7-. NOTICE TO APPLICANT:If.aper making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIU SQ.PT. TOTAL:
�+ q] become subject to the Worker's Compensation provisions of the Labor Code,you must
�i ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
U 0 the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
U Lewes Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
1 certify Not I have read this application and stare that the above information is MECHANICAL FEE a correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
�^ In building comstruaintind himebynuduadim repoesero wesof Nis rhyto ame,ti nth¢ CONSTRUCTION TAX
U 7 above-menti erm pmpeny for inspection purposes. ALTER OR ADD TO MECH.
•7 (We)agree to save,indemnify and keep harmless the City of Cuperino against
liabilaies,judgments,c°sisand expenses whic a yin ywayacameagninstsaid City AIR HANDLING UNIT(TO I0,000CFM)
Ia runic uenc fNe dng of this peemit.
AIR HANDLING UNIT(OVER 10,000 CFM)
41C 16-161
lg urea Applicana/Co geam EXHAUST HOOD(W/DUCT) -
PAID
s HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or Fare mildimg occupant store or handle hazardous maierial
be defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)P
11-Yes El No VENTILATION FAN(SINGLE RFSID)
_
applicant or equipment BOILER-COMP IMP OR 100,000 BTU) pIXt10D
in
Willrhea
pp building use ent or devices which emit P (�
hk"ous air contaminants as defined by the Bay Area Air Quality Management BOILER (OVER IW,000 BTU)
District?I pOAPR
YYY��
r - ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FL Y11Y a !N 1AA3
A YYYY���, ur 99
. 1 have read the hazardous materials requirements under Chapter 6.95 of the r
California Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that ' Ur UUrttt 1 II
if the building does not currently have a meant,that it is my responsibility to notify the - _
cupant of the requirements which..at he met prior m issuance of a Campeau,of
Occupancy.
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE