24846 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINU.ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IOENTIPICATION 24846
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
''• /� 2 66 Gn fL'/d'Y C C'UNIT LOT# 'w
OWNERS N E: PHONE: CONTRACT'OR'S NAME: LIC NO:
Gn 2 Vo 113/$1c ewe t a NlC CONTROL#
• ARCHITF. /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MCC"
PERMIT ISSUANCE fp ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Oyez I hereby affirmthat l amlicensed underpmvisionsof Chapur9(emmencingwith {!\ rT�
0.100 Section 7")of Division 3 ofthe Businus and Professions Code,and my license is in PANELS GOvoPaa
�u� fun farce and effect L,
License Cleo�(/{j—Lieu# 72Z Zf to UPT02MAMPS
y6y Dna Cmnlmctor�y�i�Me•�e 201-IOW AMPS
ZOEoK ARCHIECPS DECLARATION OVER,000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O Z—O 1 uNmund my plans shall be used u public records.
rW SIGNS ELECTRICAL.
9WLicensed Professional
OWNER-e exempt
iRR DECLARATION N SPECIAL CIRCUIT/MISC.
1 hereby r.(m that 1 ore exempt Ir an the ficaaetor's License Lew for the
W 3my following rcaeon.(Senion]OJLS,Business and l'rofuxinns Cafe:Any city or county TEMP.METER OR PoLE,NST,
which requires a permit to construct,alter,improve,demolish,or repair any structure -
aY� rimmitsisvoccom,also re hey licnm for such un file nsi red smtement POWER DEVICES
II+s1l p 4uim pp Peon g
0p 9(comisncinuJth Sectmtot010)of provisions of the Contractor's License LsionsC der
IM,
M, 9t that
heisexemit therefrom 70010)of Division to theaIle Businesstio.Any violation
SWIMMING POOL EhT;(.TRIC VALU /#
pr^y Sor cctm h70315 exempt and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES I �DAy
no,ran'b LS by any applicant far u permit nuhjccu the opplicam m o civil penalty of 6
not morc,hanfrvethepro Jollmsyemp. NEW RFSIDENTIALELECTR —SQ.f1',
❑ othe wnero0 the
oro mcd for o(Sme compBusinen, STORIES TYPE CONSTRUCTION
y will Aothewons and the he Cortcture isnor's Lidesor ofwdoes not aPpcc.]OJn Business
end Professions Code:The Contrectals License Law dues not apply lf on owner of
is
owncnywho loyme,ldsorimpravuth improvements
dmssuch week tendeditnseBanhrough Ns OCC.GROUP RES.UNITS
never,oycea,pingur ithutauch imp is sold hire not eyear fcomplffered fiersathea e.B,
howevegthe
avet a brimprovementis soldedidnoneyeat or improve
omm efor purpose f TOTAL:
builder will have the burden of proving Nat he did not build or improve for purpose of
sole.).
❑ I,movocrofthe property,amexclusivelycamracting with licertsedconuacam to QTY. PLUMBING PERMIT FEE ROOD ZONE APN
construct the project(Sec.7/144,Business and Professions Code:)The Contractor's
License Lzwdou notapplym anowncrofl+apany whobuildsorimproveathereon,and PERMIT ISSUANCE
whmcmnwcb forsuch projects with acontracoms)licensed putsuanuothe Cono-acmrs
License Law. ALTER-GRAINd:VENT-WATER(EA) FEE SUMMARY
❑ I sec exempt under Sec. ,B&P C for Nis mown OUTSIDE
HACK FLOW PROTECT.DEVICE SANITARY YN
Owner Date q RECEIPTp
• WORKMAN COMPENSATION DECIARATION I D. 115- R.R .CO SCHOOL TAX Y N
❑ t N
Thereby affirm that l have aceniftute ofcormnuosel6imure,cracenificateof RECEIPT#
Workers'Com FIXTURES-PER:RAP
pensationlmurwce or copy Nereaf(SaJBW,Lab CJ which PARK FEE Y N
love.allmploy1 STJ%I'1-I 4 _ RECEIPTp
Policyp /bl 9s/ AS ' BUILDING DIVISION FELE
n
Company GAS-EA.SYS Vft A) PLANCHECK FEE
C1 Certified copy is hereby famished.
19_1Cenified copy is filed with the city inspection division. EAS STE INN LIP GRADING HE
CERTIFICATE Of'EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissee innneed not hecampleted Hit.permit is for one hundred dollars($IN) SEWER-SANITARY-STORM EA,2WPT. ENERGY ME
or less.)
I certify that in the penormanceaf the work for which this permit is imuN,I shell WATER HEATER W/VENT/ELF.CR
not employ any Person in any manner so as to becosubject to the Workers' PAID
Compensationldwsnf Cmifamia. Date WATER SYSTEMyBEATING Date Receipt#
C Z Applicom
NOTICE TO APPLICANT:If after making Ibis Certificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
rA become subject o the Worker's Compensation provisions ofthe Labor Code,you must
forthwith comply with such provisions or this Permit shall he deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
rrR--tt I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which then permit is issued(See309],Civ.C.)
IY Lender's Name
O Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
{2a 1 certify that 1 have rad this application and state that the above information is MECHANICAL FEE
correct I agree to comply with all city and county ordinances and state laws relating an PERMIT ISSUANCE
f--' U) building construction.and hereby authoriec representativuafthis city menter upon the CONSTRUCf10N TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agrce to save,indemnify end keep harmless the City of Cancan.against
Iiabilitim,judgmems,emu atW expenses which may in my way acerae against said City AIR HANDLING UNIT IT)10,W CFM)
in conseque f the grunting of this permit.
AIR HANDLING UNIT(OVER IM CEM)
i I ?2ly
Sig Appian for Dene EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO 1 W,0011 BTU) Date Receipt#
Will the applicant or future building«capon,smut or handle harardous romenal
as defined by the Cupertino Municipal CNet Chapter 9.12,end the Health and Safety HEATING UNIT(OVER IW,WO BTU) TOTAL:
CNet$Milan 23532(a)7VENTILATION FAN(SINGLE RESID)
El Yea TI?No
BORER-COMP(SHE OR IN,11011 BTU) ISSUANCE DATE
hazaWill the eeducatiorfuturc building by the
A...Air Quality
Mazatilmmit -
Distrdoue air conuminnnu as ddnN by the Buy Area Air Quality Management BOILER-COME(OVER I W W BTU)
Distract] p a
El Yes No NEW RESIDENTIAL MECH. SQ.IN'.
I have read the hazardous materials requirements under Chapter 6.95 of the
093
C,lifnmin I lenith A Snfety CNet Sections 255115,25573 and 25574. ,understand that aa
ifthe building Jct ret cunently huvcutennnt.Ihm it is my rcspansihility to notify the �s ���,eBY
Mcupam ofd u ems which must he mm prior to issuance of s Cenificme of Cp r uh C
Occupon . •13'- S AU�r
Own m u zed cm Date TOTAL: ISSUED BY: J�T
OFFICE
: Citi of C*r ifio
. A 0.95 500
10300 Torre wcnuc
Cuperl1n0,CA 95015-15-0500
CupW(inO,CA 75014.3255
Telephone: 1400) 252-4505
rhX: (400) 252.0753
COMMUNIfy DrVO.OPM[N7
O
sumcr: SMOKE QUIT IOR CERMFICATE OF COMPLIANCE
I understalnd and comply with Section 1210a of the Uniform Building Code.
Section 1210a requires when repairs to a single family dwelling exceed
$1,000. , a smoke detector will be installed, mounted on the ceiling or
wall in each sleeping room and at a point centrally located in the
corridor or area giving access to rooms used for sleeping. purposes. If
existing smoke detectors comply, no new detector shall be required.
'• I understand the above requirement and certify that we now have smoke
detectors installed that do comply.
ADDRCSS: 1 6//� k a w�r-eu C� • CuaeY4 K a
P=T NUMBER: b� 4
HOMBOWNERS SIGNATURE! C�11
D7 rr: 3 /u
SM OF1'C(BL )G92/1)
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