24858 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1^��
CITY OF CUPERTINO BUILD ING-BLCUTRICAL PERMIT NO. 24858 n H V H
APPLICATION/PERMIT PLUMBING-MECHANICAL L(.f
BUILDING DIVISION BUILDING PROJECT[DEN'rIFICAI[ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'll DATE
# UNIT# LOT# —/
OWNERS NAME PHONE: CONTRACTOR'S NAME: LIC NO: l
f U swaa C.l - �� r NIC CONTROL#
ARCUITIi /ENGINEER: LIC NO: ADDRESS:
- 76 �% , .� C ❑ 23
IV,'—' CONIACT: q PHONE: QTY. EL UILDING RIC PERMIT FEE BPERMIT INFO
Mj�SJ(YI V,41161. 417-733r
PERMIT ISSUANCEB ELECT PLUMB 1
h �. v ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIYI'TON
py�Z Ihereb,01frm oho Ism licensed underprovisiunsofCTapur9(commencing wiiM1
1+100 Semi 7810)of Division 3of life Business and Professions Code,and my license is in PANELS /f \�
W,— mu roree;.nn errea. ,�,#� n � ,p
pQ„Zu1
License, Lm.p 96 UP TO 2W AMPS 1/
m=y Dae L Comma [Or 201-IM AMPS
ZOvNj'L ARCf1.TECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z 0 I undersmnd nay plans sM1all be used ns public rensrds.
1=. F SIGNS ELECTRICAL q
6y�J Licensed Professional9C�a OWNER-exempt ER DECLARATION SPECIAL CIRCUIT/MISC.
n�(a. I hereby affirm but 1 am exempt from alt Contractors License Law for the
W 30 which ing meson.pre rit m 703 cmum.Business, andimprove
ve de Professions demolish,
m,y city momosem,mty TEMP.METER OR POLE INST.
a0; which iq i,rcu a permit r uimst m,alma improve,dcmnliitt nr repair any swment POWER DEVICES
CW}L prinrmiu issuance,also requires the applicant forsuch pemiun file asigneJ statement
,=C Cs that he is licensed pursuant to the provisions of the Comracloes License Law(Chapter SWIMMING POOL daoLL 9(commencin6 with Section 9000)of Division3ufthe Business and Professions Cade) SVALUN
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of �S
F'ZQ Section 9031.5 by any applicant for x permit subjects the applicant to a civi lpenalty f OUTLITS-SWITOIES-FIXTURES
mo /
not re than live hundred dollars($500).
tY � ❑ I,nsatwnenrl thcpmpcny,ormyemployeea wiNwagesasthcirsolecomperssation. NEWRJSIDENTIALELECR 5Q.PT.
RIES TYPE CONSTRUCTION
aP+— set do he work,union,samemrc is not imendedoroffered for sale(Sec.9044,Rasiness
and professions Code:The Contractors License Law dress not apply to an owner of
progeny who builds or improves thereon and whodoes such work himselfor through his
employees,provided that such improvements arc not intended or offered for sale.IL OCC.GROUP RES.UNITS
however,the huddingor improvement is sold within one yearofcompleticam the owner
builder will have the burden of that he did not build or improve for f TOTAL: S
pmvin6 Prove purpoxo
ale.).
❑ T,el the project
(See eny,amewlusis and Prot adios Chet The Cadmi QTY. PLUMBING PERMIT FEE Fl.00D ZONE APN
congrva the(vsnot(Sec.9044,Business and Professions Cafe)The Commemrs
License L es;for sec apply mxnoh aconiproptny whosed party improves thereon.and PERMIT ISSUANCE
whocontmc0 fwsuch prvjecrs with acommcmr(s)licensed Oursmm m he Cnmmctors
License Law, L AlA IiNT _ A) FEESUMMARY
❑ I um caenNt under See. ,B&P C for this reawn BA L k ECT.DF.VIC� OUTSIDE FEES
Owner DateSANITARY YN__
WORKMAN COMPENSATION DECLARATION D"I S'FLOOAI ROO ,q ,C N RECEIPT#
'❑ Ihereby
mapefnimsaithat lhave acofconsum
rulf-insum,or,ucenif.cadmf � SCHOOLTAX Y
N_
lnsurameoracertfedeopytheofwFIXTURES-PERLRAP RECEIPT#
Woken
"
PARK FEE Y_ry
"ver"."
overs allem`Iet'syader�this RGCHIPI'a
Policy#
Cnmpany r�T/' iiN/Y- BUILDING DIVISION IPLS
8 Ccniful copy is hcrab furniahaL GAS-EA.SYSTEM-OVER 4(PA) PLANCIIECK IPE
❑ cenifeam y
(bT�G
copy is flet with the city inspection division' GREASIIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be compleradfront pemtit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT.
or less.) ENERGY FEE
I certify that in me performance of the weak for which this rod,is issued,Is hall WATER HEATER W/VEN FIE LECTR
m employ any Person m any manner so as m bear.subject m the WorkersPAID-til'7 G2 _amu_
Cnmpcnsannn bows of Culifomia. DateZ Appllcent WATER SYSTF,MnI ATING "pate ecR eiptp
Q
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,youshoubt NEWRFSIDEN'1'IAL PLMB. SQ.Ff. I,OTAT.
rVJ beconm subjecuo rife Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be demand revoked.
(yP �_ BUILDING FIiE Z r
V4 0 CONSTRUCTION LENDING AGENCY SEISMIC G
Z I hereby uffim that there is a conswnion lendin6 agency for the performance of O V
V O dhc work for which thin permit is ismod(Scc.309).Civ.C.) TOTAL: ,LECTRIC FEE
Lcrd,f,Name
o L) Lenders Address QTY. MECHANICAL PERMIT FEE Pl. MBINGFEE
1 cmiry that 1 have read this application and state that the above inmm,ation is
F4 come. Iu6me m comply with all city and cuumyordinanres and same laws relmingm PERMIT ISSUANCE (" �h ME ANICALFEE 0
_ building cmrstmctiun,and hereby authorize representatives ofthis city mender upon Be .1 VV
U Z above-memmred property for inspection pwpuscs. ALTER OR ADD TO MECIL CON TRUCTIONTAX
(We)agree to save,indemnify and keep hemdess the City of Cotonou,against
Inhilitiesjudgmems,swer and expenus which may in any way acerae a,mmUud City A IR HANDLING ON IT(TO 10,"CFM)
gpennit.
U en ;e ra�n Y � Z�a� AIR HANDLING UNIT(OVER IgO(IO CFM)
Signature of AppLcan4Commcmf Date EXHAUST HOOD(W/DUCT)
A1 �
HAZARDOUS MATIoccALSDISCLOSedE HEATING UNIT TO IIXI,0110 BTU) O bre Receipt#
Will the the applicant or future building de,Cam erre or handle hazardous material
C delined by she Cupertino Municipal Code,Chapter 9.12,:rod the Health wJ Safety HEATING UNIT(GYIiR I W,00(1 BTU) TOTAL: Q7s YJQ
Code,Section 25532(a)1
11 Vex 0N VENTILATION FAN(SINGLE RESID)
BOILER-COMP CHP OR 100,000 BTU)
ISSUANCE DATE
Will the air coeramorfaure banding accupoby
Bay Areequa
Quality
G'k
Imzallous sir mnmminanu az defined by the Rey Area Air Qmlity Mxnagement
Dinrin? BOILER-COMP(OVER I00,000BTU) 1p
❑Yes L$No NIiW RESIDENTIAL MECH._SQ FT.
1 have read the hazardous materials 5505, m 33 under Chapter fist of the YJ 11
Culifnmia I IcaIIM1&Sefny Calc,Smions 25505,25513 and 25534. 1 undcsand aha
inne hnt of the res nm cants which mu team,thorns my maga a of iy to notify the F C11�t�H
occupant of
Yf the requirements which meat he;net prior m issuance of a Cenifwm of �s1TV Vf
Owner or authorized agent Dae TOTAL: ' �Ot7 ISSUEDB j1
OFFICE