24733 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING � ,LEC 'RICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL.
BUILDING PROJECTIDEN DFICATION
PERMITNO.
^ 3
L 1/ J{ �(J
7
24733
4
EUI DING ADDRoFSg: (" (�Ta tl
8� O 'J . .i / C_ r N /� UNIT# LOT#
SANITARY NO.
p`YPI.ICATION SUNMIIT'AL DA'll?
J 1��
A`
ERS NAME: P NIS:
R A /S�
CONTR 1'OR'SNAMI?: LICNO:
e P/ y 7za I
NYC
❑
CON♦TROLp
AHCI IITECTIENGINEEW LIC NO:
ADDRESS:
CONTACT: PHONE,
QTY. F;I.ECTR PF:HMI'I' FEE
BUILDING PERMIT INFO
BLDG ELECT P UMB M
'
PERMIT ISSUANCE
❑ E
LICENSED CONTRACTOR'S DECLARATION
1 herehy off LICE 1 E licenseduACTOR'S DEmof Chaper9 (commencingwinh
APPLIANCES RESIDENTIAL
I TOB DESCRIPTION
PANELS
UPTO200AMPS
Selian 7000)of Division 3.1 be Businessand Prefcasina Cud<,und my l'mcme is in
full fame and effete
l License Class Lic.X
J
O
Doe Connote
201 - 10fID AMPS
a ARCHITECT'S DECLARATION
5 1 understand my plans shall M1e used as public records.D
a
OVER TWO AMPS
SQ. FT. FLOOR AREA b/SQ. FT.
I ,
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDERD ECLARATION
1 hereby affirm that ER exempt from N< Contractors License Law for the
SPECIAL CIRCUIT/MISC.
-
III`JO
TEMP. SISTER OR POLE INST.
following ahsan.(Suit..7B31.S, Business and Professions Cod
Code: Any city or county
I which requirea a permit to construct, alter, improve, demolish, or repair any structure
pricrut its issuance, also requires the applicant forsuch pennitto file a signed movement
POWER DEVICES
j that he is licensed pursuant to the provisions of the Contractor's License Low (Chapter
( 9(commencing with Section 7000) of Division 3 of the Businessand Professions Cade)
SWIMMWG POOL ELECTRIC
VALU
or that he is eacmp derefmm andnhe basis far thealleged exemption. Anyvielanionof
• Sermon 7031.5 by any applicant for. pe.itsubjcc, the apogean m a civil pmall, of
OUTLETS - SWITCHES - FIXTURES
m mare shun Ilya hundred Jnllars ($500).
a❑ Lasowneive handedm$500). yws wish wagesasthoirsolecompensetiun,
NEW RESIDENTIAL ELICCTR _SQ. In'.
STORMS
'TYPE CONS'T'RUCTION
will dothework, and the intendede offeredformolepply toad,
and he Contractor's
Cade: The Gmtuaon, License Law
ontan owner of
not apply owner
propProerty whiolo sucdoeh
f his
enywhohu lldsorimprw<stheram,nndwhadacnot
own croffredthough
own employees, provided that such impmvememsmm�otimendcJoroffered forsWe.IL
Intended
OCC.GROUP
RES. UNITS
TOTAL:
however, Ne building or improvement is sold within one yearofcompletion, the manor.
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
a lo.).
❑ I, asownerof Nepnotary, am exclusively contracting with licensed contractors to
FLOOD ZONE
N'N
answer the project (Sec. 7044, Business end Professions Code) The Contractor's
License Law does not apply loan owner of property who buildsm, improves thereon, end
PERMIT ISSUANCE
who contracts forsuch projects with a contactor(s)licensed Pursuant o the Contiacror'e
License Law.
At:[ ER TA
, (:)
FEF, SUMMARY
❑ I am exempt under Sec. , B & P C for this ...a
BACK FLOW PROTECT. DEVICE
1'. IDE Flil..
Owner Data
WORKMAN COMPENSATION DECLARATION
❑ Iherebyaffnrnn that l huveacerifesteofeensent to self-asual arifcateof
Wahers'Compenvuion lnsumnre nrecenificd copy Nereof (Sec.1800.1nb CJ which
TRAINS - FLOORROOF, GOND.
, ,
SANITARY Y_N
RECEIPT#
SCHOOLTAX Y N
NIiCEII'1'#
FIXTURES PER TRAP
PARK FEE Y
CAS - F.A. SYST[iM-1 INCA OUTLI 1 S
covers .11 employee's under this permit.
Policy #
RECEIPT' p
BUILDING DIVISION FEES
Co y
GAS -FA.SYSTEM-OVER 4(EA)
PLANCHECK FEE
Certified copy is hereby furnished.
Cenffied copy is fled with the city inspection division.
GRFASE4NDUSIRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This semina need not te completed ifthe permit is forone hundred dollars GI00)
or less.)
WATER HEATER W/VENVELEC"TR
I cenify that in the pc,forman.ofthe work l'.r which this permit is issued, Idall
not employ any person in any manner so as to become subject to the Workers
PAID
Comperssationlnwsof C.Iifomle. Date
AppEcmt
WATER SYSTEM/BEATING
Dole Receiptp
NOl'ICE TO APPLICANT: If, after making this Certificate or Exemption. you should
become suhiett a the Workers Compensation previsions of rhe labor Code, you must
NEW RESIDENTIAL PI.MB. SQ. m'.
TOTAL:
BUILDING FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I nerehy affirm Det He. is a vith"n mien lending agency for the perfortnmce of
ELECTRIC FEE
the work for which Nis permit is issued (Sec. 3097, Civ. CJ
Lenders Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE �•
1 cenify thou I have read this application and state that Ne above Information is
correct. l agree to comply with all city and county oninanca and state laws relatingw
PERMIT ISSUANCE
MECHANICAL FEE
building construction. and hereby minion representatives of@is city in enter upontha
above-mentioned pop ry, far inspection purposes.
ALTER OR ADD TO MECH,
CONSTRUCTION TAX
(We) a e u muse, indemnify unA b n' cas the Ciry of Cupeninm ag.inst
Iiabildies,ju nus, toxo end expert ch mayin anyway aceme against said City
wit.
AIR HANDLING UNIT (TO 10,000 CFM)
a. omaxi c fihe mining afros
AIR HANDLING UNIT (OVER 10,0(gl CFM)
^Dem/
Si net of llieanV oat r
EX I MUST FOOD(W/DUC)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt #
Will lice,T]ent or hour, hal ldim, accupanl sloe or It.ndle hazardous material
m defined by the Cup himo Municip.l Code, Chapter 9.12, and the Health and Safety
flliA'TINC UNIT (OVER fin," RTU)
AL
Code. Section 25532(a)?
El Yes El No
VENTILATION FAN (SINGLE REBID)
Will the applicant orl'uwrebuiltlingoccupam useeyuipmem urdevicem wbichemit
hanrdoua air conandinmts m defined by the Ray Area Air Quality Management
District?
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
BOILER - COMP(OVER 100,000 BTU)
❑ Yes ❑ No
I have rend the Intimations materials rcquiremems under Chapter 6.95 of the
California Health & Safety Cods, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have. tenant, that it is my responsibility to notify the
ccupant or he requimnt<nus which must he can prier to i....ace of a Ce"U'lac o1'
Occupancy.
FEB 1993
CITY Vf V V Q(I1 IL A
4/
ISSUED BY:
NEW RESIDENT1ALMECH. SQ. IT.
Owner m mils nzcd agent Ilma
TOTAL:
OFFICE