24714 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION LM
w
APPLICATION/PERMIT PLIBING-MECHANICAL 'LJ
BUILDING PRO.IEC'T IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICA'DONSUBMf19'ALDATL
S4 L AIEV UNIT# LOT# ii2_4GrAa
OWNERS ME: PII N CONTRACTOR'S NAME: LIC NO:
N/C CONTROL
RCUDECT/ENGTNEER: PLIC NO' AI R SS. ❑
r,
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FE
el.uc ItLEcr rl.um6 ty
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFNI'IAL JOB DESCRIPTION
py.Z Ihemby affirm Nat l am licensedunder provisionsofChapter!)hommell with
IDOO Section]fglll)of Divisinn3af the Business and Profeasinns Code,and my license is in PANELS
,WVE mnrrnecand er�aj
Fye License Claw UPT0200AMPS
�za
y=y Date Contractor 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.1`I.110^
0R AREA 5/SQ.IT.
OZ—O l understand my plans shall be used as public orards. If t^ 7 rq
Fy.W SIGNS ELECTRICAL CFt
2� Licensed Professional
CC OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC 6�
,3., 1 frothy,vmrm m
that 1 aexempt from the Convectorsla
License w for the
_ y
W�3 Di following reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
l I which requires a fourth to construct,alter,improve,demolish,or repair any structure
G� priomo its issuance,also rcyuiresthe applicant forsuch perant to Bleasignerl statement POWER DEVICES
W O that he is licensed pursuant o the provisions orule Comrarors License Law(Chapter DA
a2x a�' 9(commencing with Section]00(kof Dolslon 3oflhe Business and Professions Code) SWIMMING POOL ELECTRIC - VALUAT'ION
W_m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-PI%TURES
�ZQ Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
I] not more that five hunit I dollars($5(q).
❑ husnwnerofthepruperry,ormymnpinyeeswith wugesus lheiraolecnmpcnsvtion, NEW RESIDENTIAL EhECIA _SQ.FT. STORIES TYPE CONSTRUCTION
6'322 wil l do the work.and the structure is not imended or offered for sale(See AW4,Boniness
and Ismicadcaus Carl Us Convecmea Licenu Law does not apply to m owner of
put whotfuldsorimprovea Namon,and whodoes such work himselfonhroughhis OCC GROUT' RES.UNITS
manemployses,provided that suchimprovemema
smnot intendedoroffred formals.If,
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that ho did not build or Improve for purpose of
sale.).
❑ I,mowner offheproperty,ameaclusivdy contraningwilh Ticeraed e.ntrecmrsro QPY, PLUMBING PERMIT Flili FLOODZONE APN
m onat the project(Sec.70,14,Business and Pmfemfons Code:)The Contractors PERMIT ISSUANCE
License Lvw dcesnot apply mvnownerofprapeny whobuildsrnimpraves thereon,and
who contracts forsuch projects with acontruclons)licensed pursuant to the Contractors ALTER PA)
License Law. ( FEE SUMMARY
❑ 1 an exempt under See ,B&P C for this remain OUTSID:11.
BACK FLOW PROTECT,DEVICE ..SANITARY Y N
Owner Date RECIi117#
DRAINS-FLOOR,ROOF.AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCIIOOL TA% Y N
❑ Ihereby affmlthat I have vicenifcvteaf conunuo.f(Sfcure,arnch C.)w which
FIXTURES-PER TRAP RE"neff#
Wnrkers'Compensation lnsnrnnceorumnifed copytherenf(Sec.3g110,Luh CJ which PARK HE YN_
vers all cmtoe cyder thu Permit. GAS-EA.SYSTEM-I INC.4OUT'LETS RECEIPT'#
Policy# - PP Y5—,-- 34j s7 , 4— BUILDING DIVISION FEES
Company /s�p.Ts,c w7 GAS-FA.SYSTEM-OVER 4 CA) PLANCHECK HE
❑ Cenlfed copy is hacby finished.
;. Certified copy is fled with the city insperi.n division. GREASE/INDUSTRL WASTE INTERCEPT OR GRADING FEL
CERTIFICATE OE EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This amio.need not he completed ifthe permit is fortune hondmddollms(SIM) SEWER-SANITARY-STORM EA.2001`1'. ENERGY FEE
or less.)
T eenify that in the performance ofthe work far whichthlspermit is issued,I shall WATER I IEA'I ER W/VEN'LELECTR
not employ any person In any moaner no ua t.become subject to the Workers' PAID
Compresation Lawsof California. Date WATER SYSTEWIREATING Date Receipt#
O O Applicant
zzr NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIU SQ,FT. TOTAL:
n U) become subject to the Workers Compensation provisions of the Labor Code,you most
fKi 7 forthwith comply with such provisionxor this permit ahul l hedeemed revoked. BUILDING FEE
WQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affvm That the.is a construction lending agenry for the performance of
V O the walk far which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
pr Lender's Name p PLUMBING FEE
U Lander',Address Q'TY. MECHANICAL PERMIT FPC
0.W I certify that 1 have read this application and state that IM1e above information is
council l agme to comply with all city and county ordinances and state laws palating to PERMIT ISSUANCE MECIIANICAL IEE
F' ,as) building construction,and hereby autharize representatives ofthis city to emir upon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify and keep harmless the City of Cupertino llmu sf
liabilhm,...jutrgmeme,e pu and expenses which may in any way aceneagainst euid Ciry AIRHANDIANGUNIT(TO 10,000CFM)
inions uenceofflap rami sof this it.
AIR HANDLING UNIT(OVER IO,OW CFM)
Signamre' ¢ant m
onl cr EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE 1II3ATING UNIT(TO IM,u(N)BTU) WD Receipt#
Will IM1e aPplicam or future building accupant stare or handle hazvdous material IF
HEATING UNIT(OVER 100,W0 BTU) I �r AL:
as defined by the Caliendo.Municipal Code,Chapter 9.12,and he Health and Safety -
Cade;Section 253321})1
11 Yes OkN. VENTILATION FAN(SINGLE RESID)
BOILER-COMP LINP OR 100,000 BTU) ISSUANCE DATE
Will Neucourearat of majounu as building by the Bay Are. it Qual ,Marhich giondt PAID
® hauNous air contamiuunfs as defmW FY the Bay Area Air Qualify ManaBemenl BOILER-COMP(OVER IIXh000 BTU)
DislricR
❑Yes 9t No NEW RESIDENTIAL MECU. SQ.FT. � �J�
1 have read the hamarkrus materials ruluirements under Chapter 6.95 of the FEB
f B {6 19 J
California I Icahn&Safety C .Serious 25505,25533 and 25534.I understand the, Y
if the initial a resnm curnc.whit in that met
my responsibility tonmify The ��y' �.,.yFr�',!�
face . the ley 'rem s which m M met prior m issuance of a Certificate of CI\aaV�/rV)V��'(/.�4r%/1d]
Owner uthnriced agent u TOTAL: ISSUED BY:
OFFICE