24453 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELEUIRICAL PERMIT'NO.
PLUMIINO-MECHANICALBUILDING DIVISION ]WILDING 1ROdhCTIIhN111FICAT10N 24453 4RV3
BUILDING ADDRESS: ^ SANITARY NO. APPLICATIONSUBMITTALDATT:
2 Zi 9 5" Qli► CAMen CA- ON]']'# 1,01'N
OWN tS NAMG: '� P-7 I?7'394 CO N'IRACIOR'SNAGE: A -S IICNO: 3 r •
'-1/ y' J sA M ' -SAL133 NUL CONTROLp
ARCI IITL /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
Jk }} QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
31iss4 � , \— p3 1 PERMITISSUANCE 0L LF.Cf PLUMB MECH
LICENSED CONTRAearTerSDECLARATION gppLIANCIS-RESIDI?N'f1A1- �� DESCRIPTION
y,Z thereby nffimuhat l 3 ofth Business and irofesio Ch olio,and
mmeacin,wish
00F Section 7000)of Division 3 of lM1e Business and Professions Colic,and my license is in PANELS
FUµI License Cl s - Lic.N `JO�-I 2� UPT0200AMPS
m�y Dan -Cantrealor� 201-hall AMPS
ZFN�, shal
RCHITECTSDECLARATION OVER UM AMPS
OZ-0
OZ—O I understand my plans l usual usas public records.
r LtiI SIGNS ELECTRICAL 1F Willi 1A
ft$$^�Y�-'yj Licensed Professional F1
(slC G OWNER-BUILDER DECIARATION SPECIAL CIRCUIT/MISC. ,
PR O F 1 hereby affirm thut I sat exempt from the Conlrectoux License Law for the s
3�¢ fallowing reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.MINER OR POLE INST.
rn J which res equira permit to com mel,alter.improve,demolish,or repair any structure 117
a <� prior in its issuance,also rclairesthe applicant for such Permit nfileasigned statement POWER DEVICES PTE
�p mal he is Focused puranot to the provisions.1 the Connruchu''a License Law(Chapter
o[ 9(commencin with Section 700TH of Division 3 ofthe Business and Professions Cade SWIMMING POOL ELECTRIC
yolr, (commencing ) VALUATION
yxj Mto or that he is exempt therefrom and the basis for alleged exemption.Any violation of OUTLEI'S- 1
�ZO Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of SWITCHES-FIXTURES �
K not mom than five hundred doll..($5M).
W � ❑ I,usowneroflM1eprnperly,nrmyemployeeswithwngeansNcireolecompensminn, NEW RESIDENTIALELECfR _SQ.PT. STORMS 'TYPE CONSTRUCTION
3 will do the work,aad the structure is not intended°r°ffcredf°...le(See 7044,Bmi°ess
and Professions Cale:The Contractors License Law dm not apply to an owner of
ownproperty whob,provi such
whs inner imend k uroffered through his
howempinyees,p building
or ithatvement is vememsurcne earoedmpletied thnoforae, r- OCC.GROUP RES.UNITS
builder ,,theavet a burden
of proving
issoldwithinoneyear or improve
omm efarthrpose of L
builder will have the burden of proving lhm he AiA not build or improve for purpose of
ale.).
❑ Lusownerofthepropeny,amnewsivelycontracting withlicensedcontrenorsm QTY. PLUMBING PERMIT FEE ROOD ZONE AI'N
cunsmrt the project(Sec.7 4 .Business and Professions Cons.)The Conuucmr's
License Lawdoes not applym aaw
anerofpnspeny who builds orintroves thereon,and PERMIT ISSUANCE
who cataracts for such projects with a contractors)licensed pursuant m the Commctor's
License Law. ALTER-DRAIN&VENT-WATER(F..A) FEE SUMMARY
❑ I atm exempt under Sec. ,D&I'C for this rcmtun BACK FLOW PROTECT.DEVICE SANITARY Y D L
_N_
Owner Dune RECIi1111 N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
❑ Ihertby a(frtn that lheveacenificate of nmxm mesal(-insu¢,ora cernifane a( RECEIPTN
Workera'Compersalfan Insurance ora cenifed copy lhereaf(Sec.380(1,Lab C.)which ( 10XTURES-PER TRAP /s PARK FEE Y N
covers all employGAS-EA.SYSTEM-]TNC.40U'TLITS RECEIPT
Policy Y� p
BUILDING DIVISION FEES s
Co. GAS-FA.SYSTEM-OV FR4 FA) PLANCHECK FEE
❑ Cen10M copy is hereby famished.
Cenifred copy is fled with the city inspection division. GREASR/INDUSTRL WASTE INTERCEPTOR GRADING ME
CF.R'I'IFICATE OP EXEMPTION FROM WORKERSGREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
(This section inualmt be completed ifthe permit is fortune hormaddollua(SIM) SEWER-SANITARY-STORM G.200FT. ENERGY IEE
or less.)
I certify that in the performance of he work for which this permit is issued.I shall WATER HEATER W/VENT/?LECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Z Compensallnnlawsuf C.lifnamic Date WATER SYSTEM/fRFATING
Applicata Date ReceiptN
O
Q
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESI DENTIAL PLMIL SQ,ET. TOTAL:
uO become subject to the Worker'a Compensation provisions of the Lubar Code,you muss
•`a' 5 forthwith comply with such provisions or this permit shall be deemed revoked BUILDING FEE
a [� CONSTRUCTION LENDING AGENCY I SEISMIC FEE
V z I hercbyaffitmu
thahem is a construction lcabrigagency forme performance of T ELECTRIC FEE
C the work for which this permit is issued(Sec.3097,Civ.C.)
V. p Lender's Nome
O U Leader's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V 1 certify that I have read this application and state that the above information is
W cored, la rcemttrm 1 nh alt cit dcoum Ninences and slatelaws relotin lm PERMIT ISSUANCE ^ MECHANICAL FEE
B pYwi yon yn g
� building canswetion,and hentoymannias aparsenmtivesaflais city to enter upon the CONSTRUC'HONTAX
V z above-memmned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We) ee ltu can.indemnify and keep harmless the City of Cinamon ugainsr
.. liabilities,ju xdxscosuandexpxms vhi)) ray inany.symenn ummus.id Cir, AIR HANDLING UNIT(TO 1Q000 CFM)
in consequen ofa.the
fsgN�run,ti�ng� fib
pen i f.
V g s�isC! I _• AIR HANDLING UNIT(OVER 10,1111(1 CFM)
gn pliaMCan.mcmr Date + EXHAUST HOOD(W/DUCP)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING IINITOG 100,E BTU) Dale Receipt#
Will fi a upphic m or future building me.,no score cur handle Itimoh ne matctiul
as defined by the Cupertino Municipal Code,Chapter 9.12,and lbs Health and Safely HEATING UNIT(OVER 100.000 BTU) TOTAL:
Code,Senior 25532(.)?
11 Yes W N.No VENTILATION FAN(SINGLE RFSID)
BOILER-COMP(3HP OR 100,OW BTU) ISSUANCE DATE
Will the acometranixmi s building by
Bay Ana Air Quality
p.N B
havrNow air conuminenu a+definW by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) S'�
District?
❑Ya VNr, NEWRESIDENTIALMF.CH. SQ,FT. (11®1♦
I huye read the notal us materials re imannin s under Chapter 6.95 of the NOV y 1n(��
California Health&Safely Cale,Scetions 25505,25533 and 25500. l undersund that I JJ
ifthe building does not currently have a tenant,that it is my responsibility to notify the
me, m / UrCfTflfN\—
occupant of the requirements which must be mprimissuance of a Certificate V
Occupancy, N�
Owner or authost agent Dam ISSUED BY: 1
OFFICE