24740 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION
INILDIS r - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING PROJECTIDEMrIFICATION
PERMIT NO.
A A Ii O
LLQ LF
BUILDING ADDRESS:
SANITARY NO.
APPLICAaTIIGN SUBMITTAL DATE
Lalf tot
UNIT. LOT#
TT
OWNERS NAME: PHONE:
TRACfOR:SN ME: LIC
L"
NO:
O #
N/C
CONTROL#
ARCIII'I[Cr/EN LIC
ADD RIS
C6 V
NTACT: PHONE: Q
�OVVLo. itv. L,0 fa_L4,3'O L�Z,
QTY. ELECTRIC PERMIT
FEE
6UILDING PERMIT INFO
BLDG P -RCT I' UM MUCHPGRMIT
ISSUANCE
\
'e
LICENSED CONTRACTOR'S DECLARATION
I amebyaffir i ffim l am liccosed under provislamufCTapter9 (commencing with
Section Division 3 ofthc B.siness.nd Professions Code, and my license is in
APPLIANCES -RESIDFAL
PANELS
TOB DESCRIPTION
1 'II
I�R� ii Q1�.I w111�/yki
to 11 time and cffec
Licence Claw' ^ '� Lia.#
Dam Crntractar3 e�L
ARCIIITECTS DE LARATIO
1 understand my plans shall be used as public records
UP TO 200 MPS
MPS
301-IIXIU AMPS
OVER 1000 AMPS
SQ. PT. Pl00R AREA SM1Q.II'.
w i
PIALED ' V
® 1n n k� R
y\V/C1 IIY
SIGNS ELECTRICAL
LicenuJ 1'rofosional
OWNER -exempt fir. DECLARATION
1 ng. .. (Se tion 1 0m exempt from the Ccs,i. ro License Wan for the
following reason (Section 7031.5, Business and Professions Code: Any city mcoumy
PECIAI. CIRCUIT/MISC.
TEMP, METER OR POLE INST.
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior m'n.issuance. also requires rhe applicant forsuch amtitin fleusigneJ stmement
DATE
14
POWER DEVICES
that he is licensed pursuem no the provisions of the Commetor's License Law (Chapter
9 (commencing with Section 7000) of Division 3 of the Business end Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Anyviolmionof
Section 7031.5 by any opplicam for. permit wbjol:ts the applicant to a civil penally of
SWIMMING POOL ELF,C1'RIC
VALUAT'I{WL
�bO�
OUTLETS - SWITCHES- IIXTUREs
NEW RESIDENTIALELECR_SQ. FT.
not more than five hundred dollars ($500). -
.c wnerofthe prolxny,mmyemplo,ocs xithwa,rcrothrirmle compensation,
❑ Idn
STORIES
T'YPECONSURUCTION
will dnthe work, and the structure isnot intended m-offmcd furxulc (See. 70,14, Business
and Professions CWc: The Concacmr's License Law docs not apply m _ owner of
property whobuildsorimproves therearand whodoessuch work lfmulforthrough his
ownemployees, provided that such improvementsarenot intendedoroffered forsale. IL
however, he building or improvement is sold within one year of completion, the owner-
builder will have the harden of proving that be did not build or improve fur purpose of
OCC.GROUP
RES. UNITS
TOI
QTY. PLUMBING PERMIT
I°EE
FLOOD ZONE
APN
sale.).
❑ Laseamoroftbeproperty, ameaclusively rumored, with licensed contractors to
ommuct the project (Sec. 70,UL Business and Professions Code:) The Contractors
Limnsel.awdeesnmopply,.an.wmetofpropenywho builds or impravee thereon.and
PERMIT ISSUANCE
who contracts for such projects with acammmm(.$) licensed pars._, to the Contractors
License Low.
ALTER-DRAIN&VENT - WATER (EA)
PEE SUMMARY
❑ 1 ren exempt under Sec. N & P C for tM1is mazon
BACK FLOW PROTECT. DEVICE
OUTSID 11:18
SANITARY YN
RECEIPT,
Owner Date
DRAINS- FLOOR, ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm that l have a cedilicle ofconsent mxelf-insure,orn ceni0catc of
Workers Compensation Insurance or it cacti lied copy thereof (Sec. 3800, Lab C.) which
covers all employee's under this permit.
Policy #
SCHOOLTAX Y N
RECEIPT#
FIXTURES. PER TRAP
PARK FEE Y N
RECEIPT' #
GAS - PA. SYSTEM -1 INC. 4 OUTLETS
/`
BUILDING DIVISION FEES
Company
GAS - LA. SYSTEM -OVER 4 (FAJ
PLANCHECK TLE
d.
❑ Certified copy is hercbyth
GR[iASGINUUSTRL WASTE INTERC[PI'OR
GRADING FEF:
the city
❑ Certified copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS PEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
("is section need not he completed ifthc permit is for one hundred dollars (S100)
or mss.)
WATER HEATER WNENT/ELECTR
PAN
Data Receipt#
I certify that in the performance of the work for which this permit is issued, l shall
net employ any pmson in any manner No .s Ip M cohlt m the Workers
Com'mmi%n fCulifomoa. pale
/IR
WATER SYSTEMEATING
Applicant e k 1. 0 w
NOTICE TO APPLICANT Ilk after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
become subject to the Worker's Cma,mamlon provisions of the Labor Code, you most
forthwith comply whh mcb provisions or this lxrmit shift IN, deemed mvaked.
BUILDING ME
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby 0ffirm hot he. is a construction lending agency for the performance of
the work for which this permit is issued !Sec. 3097. Civ. C.)
ELECTRIC FEE {/� t
Q'I'Y. MECHANICAL PERMIT NPLUMBING
FEE
FEE e� /`
Lender'.., Name
Leader's Address
1.artily that 1 have read this application and state that the above aftsmation is
correct. l agree to comply with of city and county ordinances and sham laws relating to
PERMIT ISSUANCE
MECHANICAL M -E
building construction. and hereby authorize repmunmtivesof,hiscity toenter upon the
above-mentioned properly for inspection purposes.
ALTER OR ADD TO MECD.
CONSTRUCTION TA%
AIR I IANDLING UNIT (10 10,000 CFM)
Ostm agree to save, indemnify and keep hurmless the City of Cupertino against
Iiabilaics.judgments,c... stodes,coac, which may irony way aremeugaiostsuid City
AIR HANDLING UNIT (OVER I0.000 CPM)
in consequence of the granting of Nis permit.
EXHAUST H00D (W/DUCT)
�,
PAID ♦ J�./
Signature of Applicam/Cummetor Ilene
HEATINGUNI'r(TO IS),(k )BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receilup
HEATING UNIT (OVER 100,00D BTU)
TOTAL:
Will the applicant or future building occupant store or handle hmardoos material
as defined by the Cupertino Manic' I Cade, Chapter 9.12 and the Health and Safety
Cade, Section 25532(0)7
❑ Yes No
VENTILATION FAN (SINGLE RESID)
ISSUANCE: DATE
Will tbcapplicum or future building occupant use equipmenlmdevicecwhichemit
BOILI.R-COMP(3HPOR 100,0001311D
M1vsNous air contaminants as defined by the Bay Area Air Quality Management
Distrief /
❑ Yes 9-_
BOILER-COMPIOVER I00.0X BTU)
y� Q
NEW RESIDENTIAL MECH. SQ. FT.
I have read the hmunlous material, requirements under Chapter 11.95 of the
California Health& Safety Cole, Senior, 25505, 25533 and 25534. 1 understand that
rD
fCEg '1199 93
ifhhe building dce of currently have a tenant. that it is my responsibility to notify the
ant of the menu which mus, be me, prim m issuance of a Cerifcase of
m cup Y. re -
,
aC, .TINE
ISSUED BY: .
O i1broued ager Date
OFFICE