24534 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO It ,DIN.-REITRICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL
OUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMITNO.
24534
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APPLICA'GON SUBMITTAL DATE
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QTY.. ELECTRIC PERMIT FEF.
T
BUILDING PERMIT INFO
BLUE ELECT PLUM I MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ih7MBoTdv!,orlam licensed underpmvieinmofChupter9(commmaingwirM1
of Division 3 of the Business and Professions Code, and my license is in
Sectiorcead
APPLIANCES. RESIDENTIAI.
JOB DFSCRIPI'IUN
o�� �'
PANELS
full force ad 1, e e I.
1
Licen. Chs � I.iaN�
IIP 10 200 AMPS -
a �� I
-
Dare Commcmr
ARCHITECTS DECLARATION
1 to dersmnd my plans shall be, used m public records.
201 - 1000 AMPS �
OVER I(JIM AMPS
ti Fi'. 'A � SQ. PI'.
e
as
SIGNS ELECTRICAL
M U T E
Licensed Pmlesei0n:d
OWNER -BUILDER DECLARATION
SPECITEMP. LCIRCUR
I hereby affirm that 1 am exempt to. he Communities License Low for the
METER OR POLE INS]'.
POLL.
city orcountyTEMP.
following retesaPSemon]O3LS,Business mrProfessions h. die Anyor
which
which requires issuance, permit re conswa, ulmq improve, demolish, or repair ed awniure
prior to requires the statement
C
G
POWER DEVICES
heir lcenedpursuant visionnofor thesuch Copenniuo License La
than he is licensed with Section the provisions of the Comuanrs and Pro Lawns (Chapter
9(cnmmencing with SaOon]IXp)ofDivision 3of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or'hm he is exempuherefmm and the basis for the allege.) exemption. Anyvialationof
Section 7031.5 by any applicant for u permit subjects the applicant to a civil penalty of
OUTLETS -SWITCHES - FIXTURES
nm marc than rive hundred dulls, ($500).
C3I, usownemfthepropeny.array employeeswiN wagesusmheirsol<compensatioo,
NCW RISIDEN]'IAI. F:LECI'R _SQ. IT.
STORIES
TYPECONSTRUC ION
willdorhe wo lcand the structure is not inandedoroffered forsale(Sec.]OG4, Business
and Profusions Cole: The Contractors License Law does not apply to an owner of
Property who buildsorimprovesthereon, and whodoessuch work himselforduoughhis
own employees, proar
vided that such improvements monot intended or offered forsale. If,
OCC.GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one year ofcompletion, the owner-
builder will have the burden of proving that he did nm build or improve for purpose of
QTY. PLUMBINGPHRMIT FEE
sale.).
❑ I, as osucrofmhe property, am exclusively contracting with licemadconwnon to
FLOOD ZONE
APN
anatruet the project (Sec. ]Oa4, Business and Professions Cade:) The COntuetues
License Law does not apply m on ownerofpmperty, who buildsorimproves thereon, and
PERMIT ISSUANCE
who contracts for such projects with acontracmr(s) licensed mandim tothe Contmcmee
License Law.
p1.TER-DRAIN&VLNT-WA'IER(G)
FEE SUMMARY
❑ I am exempt trader See. , B & PC for this reason
BACK FI.OW PROTECT, DEVICE
O SIDE FEES
SANITARY Y N
RECEIPT#
Owner Das
WORKMAN COMPENSA'T'ION DECLARATION
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX Y N
FIXTURES - PER TRAP
(herebyoffirmthmlhaveaceniflemeofe...I mself-insure, ma certificate of
rkeri Compensation lnsiuncema cmifit,d copy thereof(Sec. 3800, Lab C.) which
RECEIPT'#
PARK FEE Y_N
GAS - EA. SYSTEM -I INC.4 OUTLETS
coven elle sups�r tpispe�py
Policy# � �l i P"
RECEIPT#
BUILDING DIVISION IT?I?S
ComVtnY 'I`�M-) F
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GRFASIVINDUSTRL WASTE INTERCEPTOR
GRADING PER
❑ CmificJ copy is filed with Ne city inspcnion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
OR FSP. TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA. 20017.
ENERGY PER
(This section aced not he completed ifthe permit is forane hundreddollaca (S BOB)
or less.)
WATER HEATER W/VIiNT/ELI3CTR s
I certify that in the perfmmanceofthe work for which this permit is issued, isball
not employ any person in any manner an as an become subject to the Workers'PAID
Compensation laws of Califnmiu. Date
WATER SYSTEMITREA9'INC
Date Receipt#
Applicant
NOTICE TO APPLICANT: If. after making this Cmificare of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
Income subjcm [,,,he Worker's Compensation provisions of the Labor Gide, yon must
forthwith comply with such Provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONS]'RUC'DON LENDING AGENCY
I herebyaffirm'hauhe.is. camwctim lendingagency f", performanceof
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL: nJ D
ELECTRIC FEE
Lender's Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
s
Lender's Address
1 certify Nut I have read Nis... ficalfict uad mute that the above irmonoinn is
correct. I agree to comply with all city and county ordinances and sate laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives alibis city mender upon the
movo-meatlaned property for inspection p trpnes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and kap harmless the City of Cupertino agents'
linbili'ics,juQgg ants,costs and expenses which arm,m ny wuyeccamagai I dCity
AIR DAN DLING UNIT (TO 10,000 CFM)
C in counta of arnn'ng of h' prtni Q
�/�
AIR HANDLING UNIT (OVER 10,000 CFM)
Si�pplaaMCot Data
EXHAUST 14WD(W/DUCp
PAID
HEATING UNIT (PO 100,000 BTU)
IIA! DOUSMATERIAIS DISCLOSURE
Date Receipt#
Will Neapplicaut future building occupant sore or handle huadous material
as defined by the Capetian Municipol Code, Chapter 9.12, and the Health end Safety
IIEA '1'ING UNIT(OVER 100,0110 BTU)
'TOTAL: ,.i
VENTILATION FAN (SINGLE. RF_SID)
Cale, Section 25532(.)'1
❑ Yee ❑ No
BOILER - COMP CHP OR 100,00!1 BTU)
�q ISSUANCE DATE
P A ! h
/'7
Willtheecoultunmrfutum building
by the Bay Area Air Quality Management
hbzardmn air rnmaminams as defines by ate Bay Area Air Quality Management
DicvicT!
BOILER -COMP (OVER 100.060 BTU)
6/
❑ Yes ❑ No
F1ll
nnnn nn 1993
y RR
WAR
NEW RESIDENTIAL MECII. SQ. FT.
1 have ¢end he hamrdous materials requirements under Chapter 6.95 of the
W J
Sections s 25500. t it is mad 25534. 1 understand that
CaliforniabulHg does Safety Coda have
if the does not have a sober. That it is my responsibility to notify the
CI I Y Uf WI -i: I llYU#
ant of e meatscomantly
occupant nhhe requirements which must be met prim m issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or eu'horized agent Dom
TOTAL:
OFFICE