24527 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILOINIr-ELEGFRICAL P17RMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 24527
BUI1.1)LNCs PRO,IECr IDEN'1'IPICA'1'If1N
IIIIILDING1 ADURPSS: �I�I .rar//�������� SANITARY NO. APPLICAT30N SUBMITTAL DATE
4 f �n o P, UNIT# I.OI'#
OWNERS NA B: / Cpp PHO E: CONTRAC'TOR'S NAME LIC NO:
E'— :rjW IS H N/C CONTROL#
ARCHITECUENGINEER: LI O. ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG EL0C7� PLUMB MECII
PERMIT ISSUANCE � \t¢/sll `({�> ❑ �jI
LICENSEDCnsed un CTOR'$UECLARATION AI'PLIANCF.S-RESIDENTIAL 0 �' JOB DESCRIPTION
q ysz Thereby affirm CEN urn licensed underpmviaDECL RATIO (commencing with [CSI
[ 00 Sooner,70011)nf Division Sof the Business and Pndcssions Code,and my lieense is in PANELS
C V full force and ebbed. UP TO 200 AMPS O
�6z License Cleo Lic.p
yQy DateCrntmcmr 201-1000 AMPS
ro `1 titill
ZOyz ARCI[ITEMS DECLARATION OVER 1000 AMT'S SQ.IT.FLOOR AREA $/SQ.PT.
O z—I] I understand my plans shall be used as public reeno s.
EQ SIGNS ELECTRICAL
qq''YY�'J Licensed Professional
eJ rd�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Mlu I hereby Hou"hat I am exempt from no,Common's License Law for the
00'3 ti rFo fallowing mumn.(Section 7031.5,B.drocas and Professions Code:Any city or county TEMP.METER OR POLE INST.
u' which requires a Permit m emeareel,eller,improve,demolish,or repair any structure
te'Y� Prior m its eanaegalmmyuires thea Iicant 6such paniIto filati,iIniedinatorecon POWER DEVICES
ly��pHotcense
9(e hnametwir,with
Section 7").f
the Comedo ,aidProle.uw(Choake)
SWIMMING POOL ELCCTRIC
dada in he,h i,escwith Section0000)he basis
3Mmeied sen and Professions Code) VALUATIOt(Lgli�
•_y Sectiohelsex by irm
tefromard the Permit subjects
Any virin'ion of tiss
JUTIEfS-SWITCHES-FIXTURES
G Section?O31.S1 any applicant I hanorupermil subjecu the applicant toecivil penalty of C
t Imrre shun 0vc hundred dollars 13511111' NEWRESIDENTIALELEC'I'R _SQ.IT.
WI,esownerofthepropmy.ormyemployeeswith wagesestheirsolecompensaron. STORIES 'TYPE CONS'1'RUC'fION
a 22 wi Ida Ne work.snd the structure is nor intended oroffered farsaili 70FL Business
and Professions Cade:The Contractor's License law does eat apply to an owner of
property whohnildsorimpruves thereon,mtdelmdoes such workhimselforthrough his OCC GROUP RES.UNITS
own employees,provided that such improvements are not intended or offered for sale.IL ft
however,the building or improvement is sold within one yearofer mplerion,the owner. 1
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owner ofthe pmperty,am exclusively contracting with licensed roaredrrs to QTY. PLUMBNG PERMIT FEE D.00D ZONE APN
ow,
ns <i the Project(Sec,70G4 Business and Professions Code:)The Cnmracma's
Liceve Lawdcesno'apply loanrwncr nfpropcny whobuildanrimprovealhcrton,and PERMIT ISSUANCE
whrcomucisfnrsuch Pmjeas with u comractorTu licensed pursuant to the Camractors Al:ff:R-DRAIN&VF.N'I'-WATER(PA)
License Law. FEE SUMMARY
❑ I nm exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE 'SIDE,FE
S Y Y
Owner Date RECEIPT#
DRAINS-FLOOR,ROOT MRE .��,
WORKMAN COMPENSATION DECLARATION S II .TAX YN
❑ Ihemby a(Erm thallhuveecertilirete of conaem to selGinsure,ora cerlilicate of RECEIPI'p
Wmkcrs'Compcnmion lnsurunce oreanifcd copy nc�rcof(Sec.3g00,lab CJ which FIXTURES-PER TRAP \ Y R YN
covers all employees under his permil. GAS EA.SYSTIEM-I IN SV9 U RECEIPT*
Policy p HALVING DIVISION 12I7ES
Company GAS,F.A.SYS'1'' OVER 4 OATE 1 :E
❑ Cerifed copy is hereby find eJ. YnTE
❑ Cenifiul copy is fled with the city inspection division. GREASto
EBNDUSTR SIR INTERCEPTOR GRADING FIFE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEL?
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is borrow hundred dollars($100) SEWER-SANITARY-STORM FA.200FE ENERGY FETE
or less.)
I cervi ly that in the perfonuence or the work lir which th is permit is issued,I shall WA'I'TER HHAI ITR W/VENTELECI'R
not employ any Person in any m as to become subject to the Workers PAID
Ccmpensatinnlawsrf Celifomia. Date so WATER SYSI'EMITREA'ITNG Dore Raciplp
Q z Applicant
NOTICETO APPLICANT':]Leflerr making this Ceniri.tcar Excmpti.,,mr should NEW RESIDENTIAL PLMIL SQ.R. TOTAL:
I,) became suhjed to the Workers Compensation provisions of the Labor Code.you must
�i > forthwith comply withach provisions.,this panni'shall he deemed revoked. BUILDINGFEIE
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE D
rR� Iwobyoffnn that here iso ematouction lending agency fur the performance of
U O rhe weak for which'his permit is issued(Sou.3W7,Civ.C.) I TOTAL: ELECTRIC FIFE
Isnder's Name
O U Lcuder's Adi QTY. MECHANICAL PERMIT FTE PLUMBING FTE
I certify that I have read this application and state that the above ialbmta l.on it
F0. corrner.Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECfIANICAI.FEE
C4 building contraction,and hereby authorize representatives of this city to enter upsnlhe CONSTRUCTION TAX
U z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MEC11.
(We)agree to save,indemnify uoil keep harmless the City of Cupertino against
Iiubilm,vjuJ,rmnrs,msrs and espetie.which may in any way seine againsl se id City AIR HANDLING UNIT(TO 10#00 CFM)
c rseque coo Iheg m,ofthis perm'. 7
am LK&z— AIR HANDLING UNIT(OVER 10,000 CFM)
Si
Icon Contractor Dote EXHAUSTHOOD(W/DUCT) 2
PAID
AEARDOUS MATERIALS DISCLOSURE HEATING UNTT(TO UXL000 BTU) Dale Rxeip'p
l the applicant or future building occupant store or handle hazardous materlul
us defined by the Cupeninn Municipal Crde,Chapter 9.12 end toe Heahh unit Safe,, HHA'1'INC,ONI'1(OVER 100,000 BTU) '1'O
Cada Section❑Ys32(a)?�No VENTILATION FAN(SINGLE RESID)
Will air concoandrdant
nPalate bulldl d by the eBay A Air orddity Management n
MOILER-COMP JHP OR 100,000 BTU) ISSUANCE DATE
hazadoux air conmminunu as JelneJ by the flay Area Air Quiddity Management
)Bi
HOLLER-COMP(OVER 100,000 BTU) Q tl
❑Yes Vista NEW RESIDENTIAL MECH. Ip'
I have read the hazmdous materials reTircmcnts under Chapter 695 of the ' DEC — 1992
Celifomia Hadth&Safely Cade,Sections 25505,25533 and 25534. I understand that
if the building does art cmomtly have a tenant,that it is my responsibility'.ratify the
rcapin of rte temts whieb maul be are polar m iammnce of a CeniflGlle te
Occupancy. r CI I Y C' t+UP'rn f urV
o /.y <' ` I
Owncro e ' I/ C DateoeltopISSUED BY:�1'
OFFICE