24473 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BTH.UI G-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24473
BUILDING DIVISION BUILDING PROJECT IDE.NTIF'ICA9'ION
BUILDING ADDRESS: // SANITARY NO. APPLICATIONSIJBMI'ITAL UATIi
,//' f/✓a. 6/J tl/��A/ // C/ UNIT# LOT# tL��
OWN[ N PHONE: C fRACTOR'SN E: LIC NO: N/C CONTROL
�uJeh 3- Alas
ARCHITECI'/ENGINF.ER: LIC NO: DRESS: 1 , ❑
ONTACT: PHONE: nuc BUILDING PERMIT INFO
QTY. F,LEC'1'RIC PERMIT FEE
BLDG ELECT PLUG MECH
PERM)T ISSUANCE ❑ El ❑ ry
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
LJS
p�Z Iherebyaffrmthall am licensed underpmvisionsof Chapter9(commencingwith
+t WU0 tell sill, ) ifDivisionJof the Rosiness and Prnkszions Code.and my license is in PANELS
y W w full force unJ eft
FjW Liccnx Lic.# ((��� UP T02(ItIAMPS
m=y Dam a_ - Camructor III' 201-IM AMPS
Z FO rV'iiz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.UE FLOOR AREA
OZ—C) Iunderstand myplansshill beused es public records. ,p`'
W SIGNS ELECTRICAL A fLI� E ® I FN
Qowu hicemeJ l'mfessionel OWNERBUILDERDIiCLARATION SPIiCIAL CIRCUEDMISC. t Y
6�Oi0 I hereby affirm fust I an exemia from the Contractor's License Law for the II II
nJLLOrn following culture,(Section 70315,Business and Professions Cale:Any city or county TEMP.METER OR POLE I NST.
t�H j which requires a proof to construct,alter,improve demolish,or repair any structure
poor o its issuance,also restores be applicantfor such permit to file a signed statement POWER DEVICES
maple that he is licensee pursuant o the provisions of the Contractors License Law(Chapter
ayo 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
m=, mm:,he is exempn i,nefront.nd file basis for the alleged exemption.Any violation.( - VALUATION
FZQ Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of OUTLETS-SWITCHES-FIXTURES
moa more than fivu hundred Jnllars(8500).
Wim ❑ hasowncr.ftneprnpeny.ormyemployceswithwagcsstheirsol¢ompcnsatiom NEW RESIDENUAI.ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
will do the work,and the sWaum is om mtcndcd oroffered forside(Sec.]NW,Business
and Professions Cale:'The Commences License Law does not apply in an owner of
proo eny who build—,improves fnmen,and who does such work himself.,through his
employers,pnrvided than suchimprovereents am unintended oroffcred for sale.If,
OCC.GROUI' RES.UNITS
however,theavete burden
of ment thaldwithinoneyear of compaction,thrower- TOTAL:
builder will have the Horden of proving aunt he did not build or intimae for purp.x of
sale.).
❑ uct the p the eco 70,,am Business and Professions
s with The nwmoms QTY. PLUMBING PERMIT FEF, Fl,OOD ZONE Apry
construct The prof ect(Sec.]014, nerofp and Professions or improves
The Contractors whocietawdrcs not applyns with acofpr.peny whobuildmumprothe Coromfand PERMIT ISSUANCE
License raw.for such projects with n eono-uctor(s)licensed pursuant to The Cnnuunor's
License 4w. ALTER-DRAIN&VENT-WATER(FAJ FEE SUMMARY
❑ 1 um eaemnt under Sec. ,H&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE F iES
SANITARY Y_N_
Owner RAT DRAINS-FLOOR,ROOF,AREA.CONE. RECEIPT#
WORKMAN COMPEeure.f NDECLARATION SCHOOL TAX Y__N
xenCoyzffirtnonIlkance or ificaraof copydomiaro,amlf-i 3800.aaIEC.) hickte of FIXTURES-PER TRAP RECEIPT
c.11 1cnsmion Insurance oreurtified copy mereof(S«.7800,lab CJ which PARK TEE Y N_
covers all ygplpyF on shi#.prYsit.N \ GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Compact l��A! o1`UYJ d. BUILDING DIVISION FEES
Company Ilk ilk�l
❑ Certified!copy is hereby furnished. GAS-EA.SYSTEM OVER 4 FAi PLANCHECK FEE
Certified copy is fled with the city mpection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASB'IAAF SOILS FEE
COMPENSATION INSURANCE
(This section need not becmnpleaed fifth,pconal is for one hundred dollars($100) SEWER-SANITARY-ST ORM ISA.200FT.
it I....) ENERGY FEE
I serif do,in performance lithe work fmoil a his proms,is issued,Ishell WATER HEATER WNF.N'I'/ELEC R
not employ ally person in any manner as m become subject to the Workers PAID
Z Compensation Laws.f Colifomia. Dae so WATER SYSTENPOTHAI ING Dare Receiptp
C Appliwnr,
z � NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FrE TOTAL:
L� V] become subject m the Worker s Compensation provisions of the Labor Code,you must
7 fonhwith comply with such provisions or this permit shall be deemed cracker. BUILDING FEE
pw,r CONSTRUCTION LENDING AGENCY SEISMIC FEE
.`7- z 1 hereby nffrm thm there ix a construction lending agency for the performance of
U OT-� toe work for which this permit is issued(See 309],Co.C.) TOTAL: ELECTRIC FEE
U. t" Lender's Name
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I terrify that 1 have read this applic.hon and scam that the above iofomudon is
0. cored IngrecmmmpiywiNalteiayandcoutlyordiranourmul .wilovstnlafingro PERMITISSUANCE C MECHANICAL FEE ��
Zl builiingconnrucai.m:and hereby authorizercpresenwuvcsoffhis citym eme,upomthe J
U Z aMve-mentioned propeny for inspection puspses. ALTER OR ADD TO MF.CH. CONSTRUCTION TAX
(We)agree 1.save,indemnify land keep harmless the City of Cupertino against
Iiabiliaies,judgments,costs and expenses which may in any way acerveagainsa said City AIR HANDLING UNIT ITO 10,0011 CFM)
fahcgramas ing Ofaoi. crania.
C-s —Cs AIR HANDLING UNIT(OVER 10.(100 CFM)
atreal AppLcant/Cono-agor Date�J EXHAUST 14MD(WNDCr)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) D' Receipt p
Will the applicant or future building occupant.store or handle hazardous material
as defined by me Calmar,Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOLON)BTU) TOTAL
Col Section
Yes "1^
❑ VILATION FAN(SINGLE RESID)
Yes No ENT
Will the applicant.rfntarebuildingoccupuaa uxecluipmena ordevices which emit BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
larommus air common defined by the Bay Are.Air Quality Management BOILER 100,000 BTU) IP ADist,ct)
t 13 Yrs No NEW RESIDENTIAL MECH. 5
Q.FT. FEB 16 1993
I have read me Safety s materials reyniremcnts under entire,dss of me
Califnmiu I Ievhh&Safery Coda Sections 85U5.255]3 and 8534. I understand that
if the building does not currently have a tenant.that it is my responsibility to notify the CITY Ut wrtrif Nu
I the rcquiman at,whit mea h mea prior to manatee of.Crmficam of
Occn authori>�agent ^ Date TOTAL
SSUED RY:
OFFICE