24955 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILIJING"ELECTRICAL PC
RMrr No.
APPLICATION/PERMIT PLUMBING MECHANICAL 24955
'
BUILDING DIVISION BUILDING PROJECT[DENT'IFICAI ION
BUILDING ADDRESS: ` - - SANI'LARYNO. APPLICATION SUBMITI'ALDA'I'E
j2V �j UNIT# LOT H ��gi
�
OWNERS NAME: PHONE: CONTIe CTQR'SNAME: LIC NO: NIC
CONTROLp
ARCHITECT/ENGINEER LIC NO: ADDRESS:
5� C 1' e i l
INTACT: PHONE: - - BUILDING PERMIT INFO
QTdYp,r5 1, b CI.E,CFRIIC PERIvll'F,; FF.Ii ,
'3 }1LQGIiiLEV17UMIi MRCIi
PERMIT ISSUANCE
LICHNSEDCONHH CTOR'S DECLARATION APPLIANCES-RESIDENTIAL JpB C ON
OCZ Thereby orf Division 3 oftensulindepro Professions
Code,
add(overrunning with ^
F400mazz Sectionhereby of Division 3of the Business and Profesians Code,wdmy errunnnuis inwith ppNP1$ ` .Y
tE Licens11 e Claderre,t13 m.« 3 309/
( Za License Clms UP T0200AMP5
in<0- Dam Contractor 201-1000 AMPS p N
ZOy Z, ARCHITECTS DECLARATION OVER TWO AMPS Q' $�Q'�'
OZ-0 I undemend my plans shall blared as public records. v
4�4� J Licensed Professional SIGNS ELECTRICAL ���L�''�^^^Q���
OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC. :I
agaIdSOyF 1 hereby affirm tut I am exempt from the Cononenn's License Law for the
tr+3O m following reason.(Seldom 7031.5,Business and Professions Cade:Any city or county TEMP.MITHIR OR POLE INST. DAT
ISm� Which requires.permit to coraralt,uher,Improve,demolish,or repair any swctme
WYE prionaits issuance.also myuires the npplicem lbr such permitmlTlensigned statement POWER DEVICES
W�'�p that he is licensed pursuant to the provisions of the Contractors License Law(Capable
m �' 9(commencin with Section 7000)of Division 3 of the Buslneasand Profesaloms Code) SWIMMING POOL ELECTRIC
WW 2 (commencing VALUATION or he is exempt Wercfrom and the M1esix for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �e
Y Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
4 not mare than five hundred dollars($500).
NEW RESIDENTIAL ELECIR _SQ.IT.
Kyo ❑ 1,asownerofthepropmy,ormyemploymswithwagesastheirsoleempnsadm, STORIES 'TYPECONSTRUCTION
y3`J will do the work,and thesoucture,is not imemled oroffered Bristle(Sec. Business
ssi
and Professions Cave:The Cmmmarde's License Law does not apply to an owner of
pmpeny who builds or improves themon,and who dues such work himulforthrough his OCC.GROUP RES.UNITS
employees,providedmprsuchimprovements n not Intendedmoffend forown IL
however,
er%ill have
thngmden ofpmemishat he id one tbuildorimprovefortrposco-
ask.).rwill havcthe harden of proving that he did nrn buil)or improve for puryose of
WeJ.
Cl I,as owaerofthe properly,amexclusivelymmmctlag with licensedemarrecors m QTY. PLUMBING PERMIT PEE FLOOD ONE APN
omuuct the project(Sec.7094,Business and Professions Cdleq The Cmicool r'e
License lawdoe,s not applymanownerofproperry,whobuildsorimproves thereon,and PERMIT ISSUANCE
wholormacts forsuch projects with n conoautor(s)licensed pursuant othe Convector's ALTER (EA)License Law. ) - FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this messom BACK FLOW PROTECT.DEVICE TSIDE PE
_ SANITARY Y_N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
\ WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm that l have a cenificam ofconsent to self-insure,ora certificate of RECEIPT#
Workers'Com tion lnsomncemacedifiedc FIXTURES-PER TRAP
penes opt thercof(Sec.7800,Lab CJ which PARK FEE Y_N
covers all employee's under Illi,permit GAS-P.A. P
A.SYSTEM. INC.4 OUTLETS RECT It
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FTE Z �
rti
❑ Cefied copy is hereby f muded.
❑ Cenifiei copy is riled with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need her be,completed Edo,permit is fnime hundred do]Ws($100) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
mless.)
I certify that in the performanm orthe work for which this permit is issued,)shall WATER HEATER W/VENT/CLECfR
not employ any person in any manner so as to become subject to the Workns' PAID
Cmmpetnutinnlawsof Celifomia. Data WAT17R SYSTEM[Di RATING Date Receipt#
Q z Applicant
NOTICE TO APPLICANT:If,after makingthis Cenificere of Exem n TOTAL:
p'on,you should NEW RESIDENTIAL PLMB. SQ.FT.
az .~�. became subject to the Worker's Compensation provisions of the Labor Code,you must
1 forthwith comply wit such provisions or this Permit shall be deemed revoked. BUILDING FEE �e
W Q CONSTRUCTION LENDING AGENCY SEISMIC THE
z I hereby affom that there is a construction lending agency for to performance of T L: ELECTRIC IEE
LO e work Dor which this permit is issued(Sec.3097,Civ.CJ
enders Name
U lender,Address QTY, MFCHANICAL PERMIT _ FEE PLUMBING FEE
I certify that 1 have mod this application and sum that the above information is
correct. I agree to comply with all city and county ordinances and stone laws relating to PERMIT ISSUANCE �� MECHANICAL FEE
building construction,told hereby authorize representatives orris city to enter upon the CONSTRUCTION TAX
U Z abM
ove-meemed H.
property for inspection purposes. ALTER OR ADD TO MEC
(We)agree m save,indemnify and keep hamdess the City of Cupertino against
Iiabilitica,judgments,costs and expense which may in any way aceradinimirsl said City AIR HANDLING UNIT('I'010.000 CFM)
in von `af the doting flhis it
AIR HANDLING UNIT(OVER III,000 CFM)
Sigmmre of Applieum/Cmitucmr Dam EXHAUST fI00D(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam rip,It
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as dcfincd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(u)7 VF.NI'ILATION FAN(SINGLE RHSID)
❑Yes ❑No
Will the applicant or future building acupem use equipmem or devices which crnit ^
BOILER-COMP(3HP OR 100,0(10 BTU) ISSUANCE DA'Z'E
hazardous air comaminants m defined by the Bay Ama Air Quality Management BOILER-COW(OVER 100.000 BTU) P A
Distsiml
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Ef. /ANN
I have read the hazardous materials mgmmtdcros under Chapter 6.95 of to
rK -8 1993
ifthe udo Heahh&Safety Code,
oweam25505,25533 and 25534. Iundersumd that oil.
iftapard of
he requiremena r ts
which must
hie mhupriort il myreuance of tymifica the V y �JI- fur
ocmpum of the requimmenu which man be mel prior to issuance of o Cennifimte of 1:1111110
aaprm,y.
Owner or authorized agent Dam TO L: N 1SSI/F.D BY: