24916 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL. 24916
BUILDING DIVISION BUILDING PROJF-CT IDEN'TIFICAT'ION
BUILDING ADDRESS: SANII'ARYNO. APPLICATION SIIBMITI'AL CA M.
�5'� Sr �iiv UNIT# LOTH
W 'RS NAM$: PHONE: A RSIs C: I.IC NO:
eG NIC CONTROL#
ARCHI'IECfENGINEER: LIC NO: M5:, ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
R1111.D]NG PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE, R,/ El F-1 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1 BDESCRIPIION
Qyy Iherebynlflrm thus l an licersedtnderpmv lslousofChipter9 Rmereareng with Q t
00C Section 7") _Drv�1isis 3oflha Business and Promasio x de,and my license is in PANELS
�uU full fare¢ -TY"
F,Ztq Licen C Lic. - lR'T0200AMPg
tZ< Dm r Contractor 201-TWO AMPS
z8NZ ARCHITECTS . AR I OV ER 1000 AMPS SQ.n'.FLOOR AREA $/SQ.PT.
0Z—Q Iunderstand my plans shall be used as purl is records.
F y F m I SIGNS ELECTRICAL
Q LicensM Professional
L OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
3
�N0 Wit. Rin
I hereby an den I ant exempt from the Cmanso ''s License Law for the
Yl a y following rearm.(Section 1031.5,Business and Professions Code:Any city or county TEMP.METER OR P01.131NST.
F❑F❑--��� which require a permit to conamm,aImr,improve,demolish,or spea any smemrc
t,MT� prior in its issuance,also requires the applicant such pemduo file a signedamlemem POWER DEVICES
CW C C 0� that he is fleam W pumuaal to the provisions of the Contrecmrs License Law(Chapter -
a y 9(commemin with Section 7000)of Division 3 ofthe Businessand Professions Cale SWIMMING POOL ELECTRIC
W O{ 8 ) VALUATION
lil.`r'—m orthm he is c03 .5 by an applicom ant
d theher.basis for the exemption. civiny l
of Our'LIH'S-SWITCHES-FIXTURES
�zY Section than iv aandomicollars apermit subjects 0e applicemmornil pendty of
not more then rid hunarcd dollars(5500).
❑ I,as ownernl Otepmpeny,nrmyereplay¢¢swith wngesostheirsulecampensation, NEW RFSIDI3N1'IALELECTS _SQ.IT. STORIES 'TYPE CONSTRI CTION
ca. will clothe work,and the structure isnot intender]oroffered forsale(Sce.1BLI.Business
ad Professions Code:The Contracmrs License Law does not apply to an owner of
Empeny whobuilds ar improves Thera ot,unJ wtiodeas such work himsefomhemlih his
own employees,providedthal such imnr
provemenfae not intended confirmed leisure.If. OCC GROUP kT;S.UNITS
however.the building or impmvement is sold within one yearefcompletion,the owner
buildcrwdl ruvedeM1urdenol rovin nhw he JlA not build or ire for f TOTAL:
p b prove purposao
ale.).
❑ I,as ownerofthe property.amexdusivdycommctingwith licensee contractors to QTY. PLUMBING PERMIT E FLOOD ZONE APN
construe,0e project(Sec 7044,Roemer.and Profession.CW,:)The Coal...1 ria PERMIT ISSUANCE
License Law does not apply to an owner of pmperty who builds or improves thereon,and
who contracts forsuch Fmjects with acontmemr(s)licensed pursuant othe Contractor's
License Law. ALTE R-DRAIN&VENT-WAIF. 3A) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT. ICE O SID� 'BF.S
SANITARY Y N
Owner Dam RECEIPI'q
DRAINS-FLOG OF,AREA,COND.
WO,h Ml OMPENSATIONDECLARATION SCHOOLTAX Y N
Iff Iherebyaffimsrentnhaveaeeniceam ofcansemmof(See,380,Lab Cj rich RECEII'fN
FlX'1'U -PER TRAP
Workers'Compensutinn lnmruneenrucerliful copy thercnf(Sec.3fl00,Lab C.l which PARK FEE YN_
ry lie en wart RECHIITN
t / O3 GAS-13A.SYSTEM-1 INC.40UTLETS
PalicyN BUILDING DIVISION FEES
Company16J GAS-EA.SYSTEM OVER 4 EA) PL
e famisAN ICK PI3E
E3Ccopy is hereby hed.
dfmd copy is filed withthe city inspection division. lk GRF.ASF/INDUSTRL NTERCHPf G 0FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' ORGSI3 RA SOILS FEE
COMPENSATION INSURANCE
rIJ
('ITisecetion need not be completed lithe permit is fornne hundreddelhtrs(SEkE SEWE ARY-ST )OFT. 000i ENERGY FEE.
or les.)
I canify that in the performance of the work for whichthis perosil is issued,i shall WATCR IT R ..CTR
not employ any person in any m as ns became subject to the Workers' PAID
Compensation Laws of Calimmis. Date so ATER SYS'I'EM/f ATING Dom eipt N
O Z Applicant
NOTICE TO APPLICANT:If,after making this Ccnifmmc of Exemption,you should NE RESIDENTLALPLMB SQ,I'1'. TOTAL:
rte. becomith comply
the Worker's Comms or this ermitshall he eLabor revoked.
must Bull G �EE r
�i > fonhwith comply with such previsions auris permit shell be domed revoked.
GCONSTRUCTION LENDING AGENCY SEISMIC FEE
z I mmbyaffirmsrauhereiso emismanion landingagency for the performance of TOTAL: ELECTRIC FEB
U O me work fmwhich this permit is issaed(Sec.3047,Civ.C.)
Lender's Name
F Lenders Address QTY. MECHANICAL PERMIT FEL? PLUMBING PER
U I cenify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and scam laws relating toPERMIT ISSUANCE MSCI IA N[CAL FEE
building construction.and hereby nmhorine representatives oftbis city manner upon she
aoto mentioned
U 'zbto save,ifor ndemnify and purposes. ALTER ORAOO TO MLCH. CONSTRUCTION TAX
(We)agree nt save,indemnify and keep may in s the City of Ca omits against
incoisequenc of
sang expenseumnal. may in any way azcmeegeinsl said City AIR HANDLING UNIT(TO 10.000CPM)
consequence of the granting of this pesmil.
AIR HANDLING UNIT(OVER 10.000 CPM)
Simmers,of Applicam/Contmmor Date EXHAUST I IOOD(W/DUCr) PAID
HAZARDOUS MATERIALS DISCLOSURE HFA'IING UNIT(TO 100,000 BTU) Date Remain
Will the applicant or future building occupant store or handle ruminants material BEATING UNIT(OVER 100.000 BI U) 'TOTAL:
as def ncd by the Cupertino Municip nNe,Chapter 9.12,and the lleahh and Safety
Cale.Section 25532(a)'I
11 Yes VENTILATION FAN(SINGLE RREST[))o
BOIL-13R-COMP DHP OR I0E000 B'TU) ISSUANCE DATE
Willrcapplicanmr foam building.caponsuseequipmemnr Jevicewhich emit A
. hazardous air coawmim at us adeftned a Buy Area Air Quality Management BOILER-COMP(OVER IOO,fpO RTU) P
District, 410
❑Yea NEW RESIDENTIAL MECFL SQ.Fr.
1 have read the hazardous materials requirements under Chapter 6.93 of the 'SAN 18
Bilifo s alth&Safetymary ave. s 23505,t it is and 25534. I understood Ih e ��'�
Rth ail gdoeenet currCn,Sveamount,, 0halit is nsirilitymunity sonsitre
a of the requimoun must n pd sauce of a en ifeale of
wrier r imhonxed ager Ilam TOTAL: ISSUED BY
OFFICE