24655 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC I RICA], PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJEMADEN'1'IF-ICATION 24655
BUILDING ADDRESSIS / //LL SANITARY NO. APPLIGGTIONSUUBB}MITTTAALLDDATE
10 .396 PN r!IrP A� ' p LOT# r_� ^
OWN 5 A N� -F� PION' NTRR RS AME: LIC NO:
/V N/C CONTROL#
_ALI
1''111FAiNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: v BUILDING PERMIT INFO
QTY. LLECI'RIC PERMIT FEE
DO ELOPLUhJB ME❑CH
PERMIT ISSUANCE. 1�6(L
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
004Z I hereby affirm that l am licensed under provisionsofChapter9( mme
concing with
LLCC Scoir,7000)af Division 3 ofthe Business and Professions Code,and my license is in PANELS
y�WF full force und effem. )(/7 /I/�
<jm"m License Class Lic.# UP TO 200 AMPS r I�
vFs<N ILnc Commemr 201-IMM AMPS 1
Z OFy& ARCIIII PC FS DECLARATION OVER IOW AMPS 5 .FLUOR AREA $/SQ.Fp.
OZ,-,M I wtderstand my plans shall he used ns public records. �� Fits,
- Licensed Professional SIGNS L'LLC RICAL a A
d' OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC. tl I-_
xaO V I hereby affirm Nat I am exempt from the Contramaes License Law for the V
t+131r-v'�¢i following reumn.(Section 7031.5,Business and Professions Cade:Any city m county TEMP.METER OR MIX INST.
l:_' �J which rcquirea a pnmit m ometraz a@r,improve,demolish,m repair any structurefir° n poor n it,issuance,also requimsthenpplicam fn such pamiuo filen signednaarmad POWER DEVICES
pz that he is licensed pursuant m the provisionsof the Com mocia's License Low(Chapter I L
d r'4 9(commencing with Section 70ME of Diviiian 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC r' LUATION
' gym anhm h7031.5 by therefrm and the pent Iarbeep,miexemption, civilflati000f OUn.l1'S-SWITCHES. =A
® �1
6 Section 00l LS by any applicnm fnrnpermit mbjena rhe npPlicant moucivil pcnulmy of FIXTURF,S 3--r' N
not marc than five hundred Jolbma($}W). NEW RBSIDINTIAL ELECTR _SQ.FT.
❑ the
work,
anhepropenyre is ntintayeeswithwcefforeir$decompensation, \ f,^'1 S"O E YPIi WN59RUC1'ION
L _ will do the work,endlhe structure is nomimenJednroffmdfor'Me(Sce.]044,Business P
and Professions Code:The Commences License Low does not apply to an owner of
popery wM1obuildsorimproves Nereon,and whodoesauchworkNmulfonhmughhis N .UNITS
own employees,provided that such impervemems mood intended or offevd fmamle.If, DATE 'QW—w
he ever,thebuildingorimprovementissoldwithinoneyearofcompletion,theowner- IOTA-
builder will have the burden of proving that he did not builder improve for purpose of
❑ I,as nwnernfthe property,am exclusively contracting with license)contractors to QTY, PLUMBING PERMIT FEE F1.00D ZONE AN
compact the project(Sec.7144,Business and Rofessious Code:)The Commmoes ',11
License Lawdoesrud.,1y tuunnwnaofpropeny who builds or improve,thereon,and PERMIT ISSUANCE SV
who contracts for such projects with it comracsor(s)licensed pursuant to the Contractor's ALTER (PA)
License Lou, FEE SUMMARY
❑ 1 um exempt under Scc. B&P C fm Nis rcuson BACK FLOW PROIECT.DEVICE TSIDF.FF.F.
SANITARY YN
Owner Date RECEIPT p
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
r ❑ Ihercby affims thatlhavea ccnificnm of consent to self-insum,orettnificate of RECEIPT#
FI%TVRFS-PER TRAP 0,�1
Worked Compensatianlmurvnce orecertifiW copy thereof(Sec.JHW,Ioh C.)which - OV PARK FEE YN
c.ce,x W employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHUCK FEE
❑ Certified copy is hereby fumishul.
❑ Cerilied copy is filed with the city inspection division. GRBASE/INDUSTI2LWAS'IEINT13RC17"OR GRADING FEE
CERTIFICATE OIt EXEMPTION FROM WORKERS' GREASH TRAP SOILS PER
COMPENSATION INSURANCE
(This scctionneed not becompletW iffie permit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA.20( 1'. ENERGY FIND
m le s.)
I unify that in the perfamrance ohhe work for which this permit is lamed.l shall WATER HEATER W/VEN'F/ELECR
not employ any person in any manner so as to become subject to the WorkerPAID
Comp<mation Eowsof Califomia. Date WATER SYSTENIGMEATING Dom Receipt#
O z Applicant
0. NOTICETO APPLICANT:If,after making this Certificate of Exemption,you should NEW RFSIDINTIAL PLMB. SQ.M. TOTAL:
CO became subject to the Worker's Compensation provisions of the labor Code,you most
a I'nrmwlth comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
C (� CONSTRUCTION LENDING AGENCY SEISMIC FEL?
VZ I hercbyoffirmthauhem i,lirm,tumim leadingagency for the perfmmanceof TOTAL: -(� IB.ECfRIC FEE
O` the work for which Nis permit is issued Sec.3097,Civ.CJ
O V I<ndes Name
lsndeea Address QTY. MECHANICAL PERMIT TEE
PLUMBING FEE D
1 eenify Net 1 have read this application and site that the above information is
0. correct.l agree to comply with all city and county ordinances and state laws minting to PERMIT ISSUANCE MECHANICAL FEE
rA buildingconstruction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
V 7 uhrvo-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
C (We)agree to save,indemnify and keep hmmless Ne City of Cupenino against
liabilities,' gmeme,cost nnA expenses coli chmayi n any way accrue against said City A IR HANDLI NO UNI'T(TO 10,WB CFM)
in an,eq,��'cafdte y h mnI— ' I/4-93
(,fiyl eJ�,n AIR HANDLING UNIT(OVER 10,W0 CPM)
. gnaum of Appl(fuComrvcmr Dam EXHAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1100,000 BTU) Date Receipt#
Will the applicant or future building occupant seem or handle hmrmal material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0(10 BTU) TOTAL: ,Q
Code.Section 25532(a)?
❑Yes ❑NO VENTILATION PAN(SINGLE RESID)
BOILER-COMP CHP OR 1 W,WO BTU) ISSUANCE DATE
Will thenpplicantor fmurcbuildingoceupnm useequipmemonleviceswhich emit pp
( mz.Non,air con(anumanls as defned by the Bay Area Air Quality Managenim BOILER-COMP(OVER I00,000 BTU) P4
� District?
❑Yes ❑No NLAi RESIDENTIAL MECH. SQ,17,
I have read the hazardous mamnala requirements under Claimer 6.95 of the J A N — 6 1993
California Health&Safety Code,Sections M505,25533 and 25534. 1 understand that
if the building does not currently have a tenant.Not it is my responsibility to notify the CITY Ur t♦vr en ulry
occupant of the requirements which must be met prior m issuance of a Cenificme of
Occupancy. IA—WI?
/ 'T.
Owner or authorized agent Dote qfit.'O'TAL: ISSUED BY: —W 11Tf"s Uk'^CC(�
OFFICE