24915 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x ILDIN:-F,LECI'RICAL PERM]'I'NO.
APPLICATION/PERMIT PLUMIII%::-MF.CHA\lCAI, 24915
BUILDING DIVISION BUILDING PROJECT IDE\TIFICA"I ION
BUILDING ADDRESS: / SANII"ARYNO. APPLICATION SUBMITTAL DATE'
S 6c {S !y UN I'Y0 LOT#
OWNER NAM w9' - PHONE: A OR'S AME: LIC NO: N/C CONTROL
/V� G
AR HITI;CT/ GINEER: LIC NO: SS: 9'a✓
CONTACT: PHONE: QTY, ELECTRIC PERM'1/TAr FEE BUILDING PERMIT INFO
BCUG [CECT PLUMB MECII
PERMHISSUANCE: �0 ❑ O
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
py•7 I hcrebyam Nx
ffiral l amlicenunderpmvisionsof0apter9(commcncingwlth x108 DESCRIPTION r
HOC Section]000)of '" n 3 of the Bnamesa and Pmfessin Code d my licensa is in PANELS
ty UO fullforccand 1. ) UPT02MAMPS "'—
Fyw Licenx la, s Lica
y7y Dute Comm<m 201-10(18 AMPS SQ.FT.FLOOR AREA S/.S'Q.IT.
O[0=;�, ARCHITECTS :ChARA'f10N O/!�r OVER IfXYJ AMPS
p 1 undenuand nrr plans,hull he used as pahlie nceoN.v.
SIGNS ELECTRICAL
QY�,Jj Liccnsrd Professional
C d'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUEDMISC.
XOaU I hereby affirm that I am exempt from the Combat ,License Lew for the c
,Mfollowing reason,(Section 7031.3.Business and Professions Cale:Any city or county TEMP.METER OR DOLE INST.
which requires a permit reconstruct.altar,improve,demolish,or repair may structure
5 }5 prix to its issuance,alsnreyuires the applicant for such Front to file a signedsaatemenl POWER DEVICES
WOp that he is licensed pursuant to the provisions of the Contractor's License Law(Clarder
aao�' 9(a.mmuncing with Section 7001pof Division Sof the Buslncsa and Professions Code) SWIMMING POOL ELECTRIC VALUATION
X'ny onhnl he is caempuherefmm and the basis limhe alleged caemptt to. civil lathy of OUTLEB-SWITCHES.FIX'1VRE3 �f
tKQ Section 703 L5 by any applicant for a permit subjects the a pplicanuoacivil penalty of f�4--
not mom than five hundred dollars 13500).
fisc NEW RESIDENTIAL ELECfR SQ.FT. STORIES TYPECONSTRUCHON
❑ I,asownerof theprnpertY.ormremployreswith wagesastheirxlecomperuauon,
will da the work,and e: aruemeractor's License
Law dos not a(Stt.7Wn,Rumness
and property
whollm Cade:The ses Contractor's License Lew such
not apply m an owner of
own enywbubund,orimprovesthereon,andwho are not in work oroff fed Through his
employees,provided WmsucM1 improver¢ntaare nmimendedoroffared Torcula,If, OCC.GROUP RES.UNITS
however,the huddingin improvement is sold within one yew of completion.lhe owner. TOTAL:
builder will have the barren of proving that he did not build or improve for purlro m of
salt.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
❑ hasoe pmjw ce.70k,em Business
and ontraaiions Clicen The Commema's
construct the projecs(Sec.ormo Business and Professions Code)The Comrarand
License Lawd«snot apply man ownerofpropcny whobuildsorimpmvevM1ercon.wd PERMIT ISSUANCE
whncuno-ea,,far such projects with acmntra<mr(a)licensed pursuanuo the Conuamor's
License Law. ALTER DRAIN&VENT-WAX (EA) FEE SUMMARY
OUI
❑ I am exempt Indo Sm. ,B&P C for this reason BACK FLOW PROTECT.I). ICE SIDE FEESSANT"I'ARY Y N
Owner DmeDRAINS-FLOOR,R 1'.ARIiA,COND. RHCCII'1'a
WORKMAN COMPENSATION DECLARATION SCIIWLTAX YN
❑ npIXTURES-P AP RLCIJPTp
Workerafrompenmtinn Braintree copythereo`(Sre.3800.LC.)which
PARK ITE YN
YSTEM.I INOUTLETS RECEIPT
Pink ssle CaC-� GAS BUILDING DIVISION FEES
C party Cd74 Z G -I:A.SYSTEM-OVER 4(EA) I'LANCIIECK FEE
❑ C ed an,is hereby famished.
enlfed copy is filed with the city inspersion division. GREi SIVINDUSIRI,WAS" NPIIRCEI "O GRADING ITC
C[R'1'IPICATE OIs EXEMPTION FROM WORKERS' GREASE TRAP SOILS FHE
COMPENSATION INSURANCE
flbissectimn need not be completed ifthe permit is forone hundred collars(EI00) SEWIi -SAN :STO FT. ENERGY ME
nr less.)
I cavity that in the performance of the work for which this,permit is is,uN,IsM1all WA ' W I:I�N CI'R
not employ any person in any manner so as to become.subject m the Workers' M PAID
y Con.pcnsai.o Lawaut Calilismla. Date—
z
5 F.M/TRfiA'TING Date tptM
0 •Z Appllwnt
z0 NOT ICE TO APPLICANT:If,after making lhis Ccnificutc of Exemption,you should :WRESIDENTIAI,PLMB. SQ.PI'. OPAL:
F' y become subject to the Worker's Compensation provisions of the Lehr Cale.you muss jV/
forthwith comply with such IF BUILDING FE
❑] [PAID
MIC F'E
0. Q
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
V Z the work for which this permit is issued(Sec.3097,Civ,C.) TOTAL: CT
WIcodcL,Name
1—' I'ndcr's Address QTY. MBCIIANICALPERMIT FEE MBING FE.
0 0 1 cenify tbm 1 have read this application orad nude that the mdse information is MECHANIC)(FEE
F17 correct.I agree m comply with all city and county ordinances and state laws mining to PERMIT ISSUANCE
I-" building construction,and hereby aathoris reprerntativers ofthmsity m anter upon the SIRU. ION TAX
V Z mose art nned property for inspection purpose,. ALTERORADDTOMECIL
(Wa)agree to save,indemnify and keep harmless the City of Cupertino against
habilifics.judgments,costs and expenses which may in any way accme against said City AIR HANDLING UNIT(TO 10.000 CFM)
in cumeyacnce of the granting or this pvarml.
AIR HANDLING UNIT(OVER IO.W)CFM)
Signature of Applicant/Contmctor Dam EXIIAUSTHOOD(WIDUCI]
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Receipt X
Will the applimmo m rmure building«capanl,ware m bmldle haamdom mmerial
as defined by the Cupanino Manic' Me,Chapter 9.12,amt the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Cale,Section 25532 V I/ya�� VENTILATION FAN(SINGLE RESID)
❑Yes C7 No FS AT
Will thenpplieantor l'uturebmlJing«cu nusceyuipmenmrdevleeswhieb emit BOILER-COMP(311P OR 11X).f(XI BTU)
hazardous t t deli y the Buy Area Air Quality Management BOILFiR-COMP(OVER IW.g10 BTU)
Dismal? y JAIL 18 .I 9�
0'.ant ran s ypd'Ir NEW RF_SIDENTIAL MECII. SQ.Ff.
�. I have read the ha ado a materials requiuments under Chapter understand
or thin
CI7 Y UY WYtH I�
CA
semadHealth&Safetyehat Cole,Sections ref,ri,25533and 2553n, lur 6.95 dthat
ilgdova;,lcunendyhaveut nt.Wert it' re,ponsdolly m notify the
he rap'emm t stmt p aorta of o C'enlfiwm n
authorised ager Dam TOTAL: ISSUEUBy7IAI V
OFFICE