24611 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE 'I'RICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING C-1 IDENTIFICATION
^4 6 11
HUILDINC PRfIJHCI'IDEN'I'IFICAtTON L lhJ
flU1'/L/�U1�N/[Gt AUUX/RFSS: /J //�� ��//�D SANITARY NO. APPLICATION SUBMUTAL DATE
Ci ✓�`+ f , UNrrp LOT is
O FN4V _ / (� ♦�I�
PHONE ON' (f "NA LI�
N/C It, ROLA
ARCI HI ECT/ENGINEER: LIC NO: AUU + ❑
s
CONT PHONE:
^/— QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
pSI� PERMIT ISSUANCE BLDG ELECT PLUMB MEpfi
❑ ❑ ❑
L 'INSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAI.
QWz I herebyaffirn Thal tum licensed underprovis;o of Chaper 9(commencingwith LOB DESCRIPTION
4100 Scctian 70W)afWc,"'fc,
Bminessa C ,ad license is in PANELS
ty dF- toll l'nrcc and efpllpr..fce tln . �`K
GG Vjr1 Liceme Cl sLi J UP TO 200 AMPS C�l�/Id
y y DomCommclor 201-I"AMPS /VV
ZOriiL ECTS DECLARATIONOVER I"AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O Z,,O I understand my plans shall be used as public recoNs.
F.,rn I=q SIGNS ELECTRICAL
KQ �J Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUTOMISC.
yO°°''Y- 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
Wx+ Ii.w following reason.(Section 7031.5,Business and Professions Code:Any city or county 'TEMP.METER OR POLE.INST.
�pFna� which requires a permit In construct,alter,improve,demolish,or repair any structure
prionn its issuavice,alm raryiro,flnee plictin for suchpenial 11 H.a signed statement POWER DEVICES
Qp that he is licensed pursuant to the pmvisinns ofthe Commctor's Llcomv Low(Chapter
9ecmmencingwith Secianim00)o(Division 3 ofthe Business and Professions CustO SWIMMING POOLELECTRIC P INV AInOal
,_,a, anhm he31.5 by my
yappomnt for
Formal
suthcaseged asempti to civil
of OUTLETS-SWITCHES-FIXTURES I� (� T
EZQ Section 7031.5 v a hundred
fore permit subjects me epplicwnoacivil Pendry of M t
fZi] not mom than five hondmb dollars($500).
C m ❑ I,asownmoFlhe progeny,nrmyemploy«swish wages as lheirsolecnmpemation, E R
NEW RFSIDFIJ'DALELIiCIR _SQ.FT. OHS ECONS'IRUCHON
SB— will do the work,anathestructure isnot imendedoroftemlbatiste(Set,7B44,Business TE
and Professions Code:The Commcmr's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himxel f ser Ihmugh his
own employees,provided that such improvementsumnotimendedoroffcred forsala If, OCC.GROUP RES.UNITS
however,the building or impmvemenl is sold within one year of completion,the mwner-
builder will have the burdcnnl' that he did not builder ins TOTAL:
proving prove far nhmnae nr
sale.),
❑ Les the proRt(S..70ol exclusivelyconaracting Proessiowhhfcensedcomreaorsto QTY. PLUMBING PERMIT FEE Fl.00D ZONL' nPN
mswn the project spec.to an
Business and Professions Code:)nates Contrnemr's
License Lawdocs non f..,opply jects ownc.....peny whobaildsorimpattheC rton,and PERMIT ISSUANCE
wbomm�actsfmsuch proKcbwithecmmmcmr(s)littnsed pursuannothc Canvanar's ALTER HLA)
License Lew. ITC SUMMARY
❑ I am exempt under Sec. ,I&P C far his reason BACK FLOW PROTECT.DEV ICE t UE FEES
SANITARY Y N
r Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX V N
I hereby affrrit that l have n ecdifcale ofecosent to ti
sent of pIX'I'URES-PLR TRAP RIiCEIPT#
'i ern Comp Mian Imm. L n py Q JSW,Lab CJwhlch PARK FEE Y N_
covers Pulley#all crop uG.I I .^ o }perr= Pte.. RECEIPT#
}}}%// eV ��mm (�� [r— GAS-EA.SYSTEM-I INC.40UD.E1'S BUILDING DIVISION FEES
Company d.- GAS-EA.SYSTEM-OVER4(EA) PLANCFIECK FEE
ry�y/-•oiled cophed.
meq'/Certified copy,is filed with the city inspection division. ORGSPgNDUSTRL WASTE INTERCEPTOR GRADING ME
(/ CERTIFICATE:OF EXEMP[ON FROM WORKERS' GRCASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissoctlon mishit becnmpleted ifma permit..formic hand.[dol Ism,1$100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
r less.)
I cenirymat intheperformanccof the work for whichlhis payout s issued,l shall WATER HEATER WNENT/F.I.ECTR
and employ any person in any manner so as m become subject to the Workers' PAID
CompensaGia.u.,of California. Dole WATER SYSTEM/fREAn'INC Dole Receipt#
O z Applicant
ZNOT ICE TOAPPLICANT.If,after making this CenificdeofExemption,you should NEW RESIDENTIALPLMB. SQ.FT. TOTAL:
E" V] become subject 1 the Workers Compensation provisions of the Labor Code,you must
fmnhwilh comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
6i (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby effort that there is a construction lending agency for the performance of
U O the work for which this pennh it l sslmd(See,3(197,Civ.C.) TOTAL: ELEM RIC FEE.
Isnder's Name r PLUMBING FEE F Lenders Address Q-I'Y. MECHANICAL PERMIT FEL.
L) 1 certify that 1 have mad this application and smR thm the alcove information is
correct.I agree to comply with all city and county ordinances and stale laws retailing to PERMIT ISSUANCE. / MECHANICAL FEE
E-' buildingeonswefion,andhmbyauthodumpremnmtivuoflhisdlyteeninruponlhe CONSTRUCTION TAX
V z move-mentioned pony for inspection purposes. ALTER OR ADD TO MSCI I.
(We)a to ave,indemnify and Joe,p h City of Cupertino against
liabauies,j .1.costiondesterve yes any way acctc agai st sfd� AIR HANDLING UNITOG IU,00oCFM)
in.mosey n l s l mI
AIR HANDLING U?4IT(OVER 10.000 CPM)
Sitimmreof ApplicamtCmarnaor Date EXHAUSTHOOD(W/DUC'I)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Date Receipt It
Will the applicant or John,building oocupsnr store or handle h aardous material
as defined by the Calcnino Municipal Code,Chapter 9.12,and the Ilealth and Safety BEATING UNIT(OVER I W,fX10 BTU) TOTAL:
Code,Section 25532(a)7
❑Yes CI No VENTILATION FAN(SINGLE RESID)
Will the npplicam or furore building acupant use eyuipmem ordevicee which emit
BOILER-COMP(LHP OR 100.00(i ISSUANCE DATE
huzcrdous,air cmmmtdnants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,1110 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MI°CII. SQ.FT. � p ' D
1 have read the hazardi1
hazardous materials requirements under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that JAN - 5
H the building does not commit,have a temmt don it is my responsibility 1 notify the 1994
cupanl of the reguirearems which must be met prior to issuance of a Certificate of
Occupancy. 171 1 C Y
Ownermreamorized agent Dote TOTAL: ;flf ISS 12UR 111
OFFICE