24721 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLECTRIAI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 24721
BUILDING ADDRESS: SANITARY NO. ♦♦♦`AP��..PLICAATIO—N SUBBM�MITTAL DATE
UNIT# LOT#
"44( 4 PHONE: CONTRACTOR'S NAME: LIC NO:
aa! A Al 441O Q N/C CONOL#
ARCHI'TECf/ENGINEER: L C NO: 09
TR
- / ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE HUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE E] ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
owz I hembyaffimt that l am licensed under provisionsofampter9(commencingwith TOB DESCRIPTION
�UOC Section of Divisum 3 of the Business and Professions Cade,and my licenx is in PANELS o- ^�` ,�ws�
<Zly License Clas �� Li<.M I �2 UPTO2m AMPS ��+.
y60- Data V.q a !gj Co.[rvcror GC:I, 301-I"AMPS
ZOy� ARCHITECTS DECLARAIION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z Ap I understand my plans shall be tied as Public..Ms.
g;y F:W SIGNS ELECTRICAL
6��]' Licensed Professional
aN�a OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X04p. 1 hereby affirm that 1 am exempt from the Connector's License law for the
Iz13f+.m following Mason.(Section 7031.5,Business and Professions Cole:Any city or county TEMP.METER OR POLE INST.
which requires n permit to construct,alter,improve,demolish.or repair any structure
prion,its issuance,also requires the applicant for such permit to file o signed slemmmit POWER DEVICES
yy ¢O that he is licensed pursuant to the provisions of Contractors License Law(Chapter
9(commencing with Section 7080)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
WS2 or he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
GSection]031.5 by any applicant for a permit subjects the applicant to u civil Penalty of
G not more than fivahundrcddfilic yh rs or my
NEW RESIDENTIALELECTR _SQ.FT, STORIES TYPE CONSTRUCTION
❑ othe as work,anthestructuermyempinded eeswiNwed forsale(Sec. 1144,Bsiness
p, will Jothewons aide:Theaureracto immense La does of apply to an owner
and Professions CNB:Ips vo lhemm'a License Law does not lino lf an owner of
is
properywyees,pdsorimprovcuhimpnumdwho manotctende oroffem throughM1ir, OCC.CROUP RES.UNITS
own employees,lding r improvement thussuchimprovements a not intendedmmfferod Tortola.If.
however,the building Orer ofpin that
within one yearof completion,t urpose f TOTAL:
builder will have the buNen of proving Not he did tai build or improve for purpose of
sale.).
❑ I,as ownerofthe property,ma exclusively contracting with licensed commnomm QTY. PLUMBING PERMIT FEE. FLOOD ZONE APN
construct the project(Sec.7044,Business and Professlnns Cole:)The Cmuicam'e pLRMIT ISSUANCE
Licenx Law does not apply man owner of property w ho b ui l ds or i m proves thereon,and
who amounts torsion projects with a contractor(s)licensed par{rp���t h s�Ivaoollpprr
B' II /'.'ls L O N -WATER(PA)
License Law. JJ / Il PEE SUMMARY
❑ 1 con exempt under Sec. &P C IS,this ease. ORiq. R .DEVICE SANITARY Y S N
Owner Da t ,R OF,AREA,COND. RECEIPT#
WORKMAN COMPFNSAI'ION DECLARATON SCHOOL TAX YN
.❑ Thereby affirm that l have a amificem ofconxnt toselGinsuryryppn,pp�AttWµBane U TRAP RECEIPT#
Woken Compensation lino nceoraa bledcopy th fISec.1pP1.11�. PARK FEE Y N
mvIPTN
a.all employee's under this pe . l�w�— _-.GAS--EArSYSTEM=1'1 .4 OUTLETS BUILDING DIVISION FEES
Policy N O
Compmty I1* ICA GAS-EA.SYSTEM-OVER 4(CA) PLANCIiECK FEE
❑ Certifiedcopyis herebyfumished.
O
Certified copy is filed with she airy inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
l� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is for one hundred doUms(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfrrmance of the work for which this Permit is issued,l shall WATER HEATER W/VENT/ELECfit
not employ any Person in any mummer so as to become subject to the Workers' PAID
Compenxtionlawsof Celifomia. Data WATER SYSTEM/IREATING Dam Receipt#
O Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F" Ln become subject to the Workers Compensation provisions ofthe Labor Code,you muss
forthwith comply with such provisions arthis Permit aleft be deemed revoked. BUILDING PEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afftm that there is a construction lending agency for the Performance of
V the work for which this permit is issued(Ser.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
❑+
Q U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
CTa 1 certify a it)1 have road this city
un cou and state that she stove information is MECHANICAL FCC
6, correct.legree mcomply with all city and county ordinances and antro laws relating to PERMIT ISSUANCE
sisi
building consuucsimr road hereby omhoriee represcmotives of this city to enter upon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
CONS'TRUCI'ION'I'AX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,0m CFM)
e of the gmn' nt thie permit. n��
!�a-� AIR HANDLING UNIT(OVER 110,0X1 CPM)
ignu n pPlicumVContrvctnr Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MAT BRIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Reccile#
Will the applicant or future building occupant state or handle hazardous material HEATING UNIT(OVER 100,1100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the health and Safety
Code.Section 255320d?
11 Yes 11 No VENTILATION FAN(SINGLE R[SID)
BOILER-COMP U1HP OR Int,"BTU) ISSUANCE DATE
Will Nmrc
eapplicnnrfumbuilding« nt
rvpuuxm
eyuipmcordeviceswhichemit
r hazardom air connections as defined by the Bay Arca Air Quality Mmtogement !_
DisuicR
BOILER-COMP(OVER Im,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 2 0 1993
1 have read the hezallons momrids requirements under Chapter 6.95 of the APR
` r]\,���syy�J
ifflum uil ing lthdo&Safety Code,Sectily have
to 35505,r it is and responsibility
1 undersand Nm V
ifcuplum of
he requirements
which most
be
poor my manceoilirymnficatefy of fs'II ur �#UFL
Occupant of the reyuiremenrs which must M mm prior to issuance of a Certificate of V
Occupancy. \�►/ y/'y#(—fir
Owner Or authorized agent Data ISSUED BY: Vl/V LII
OFFICE