24812 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /� a� 812
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJIIC'1'IDKN'DFICATION L(+
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
/OSLO ✓`� /'� UNl'Yff LOT# �TI`/�
OWNP SNAME: PITON CONa ACTOR'S NAME: LIC NO: NIC CONTROL
LA-flNt`a DIP /� s
ARCfII'1'IiCT/EN(iINEER: LIC NO; p •y1AD2. b�QL S I ❑
CONTACIf: PHONE: 7 J � QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
111 Ub LDO MELT PLUMB MECH la- 14. 553
PERMIT
LICENSED CONTRACTOR'S DECLARATION pppi.lANCFS-RESIDENTIAL _ v'r+nnS�R7®ON
p�z IM1ercbyamrtn thattote CONTRACTOR'S
DECLARATION
RATA 9(commencingwith /TV'� OBD aVli
�a100 Sectlon 9000)nf Divivinn3of the Business and Pm[uslOna Qdc,and ley liocnu is in PANELS
q full farce anJ effec
tQ1.....Zu] License Cly/ Lic.#� O UP702WAMN
t,<Z Date y[vf n�L�/�Contractor 201-IOW AMPS ,(„
zOy'Z / - i1 c� ARCHITECT,Dli LARATION OyliH IOW AMPS SQ. L RPA f/SQ.FT.
O Z I undcrsmnd my pl...hall be used u public retools. g���
W SIGNS ELECIRICAI. FLS ,R
<y Licensed Profeasionnl
�a0W OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
X W W U. 1 hereby affirm that I am exempt from the Commctols License Law for theDATE
m3wm¢ following reason.ISectow7.31.S.Busineaa and Professions Code:Any city or county TEMP.METER OR POLE INST,.
I,E,O J which"mines.pemtit to construct,alter,improve,demolish,or repair my suuaurt
!!(}� prior to its issuance,alsomquims the applicant for such pennino file a signed statement POWER DEVICES
yp0 That be is licensed womnno the pmckinuof the Convanor'a License Law(Chapter
d off' 9(commencing with Section 7")of Division 3 ofthe Business end Prefemicur Cade) SWIMMING POOL ELECTRIC VALUATION
or that yYj�y Sectiohei31.5 by nhemfromnt f the a baspewmi subjects
theducmant to civiny l
of OUTLETS-SWITCI113S-FIXTURES 5 �OD �►
G
net
me the.S five
anyhu dredimnrtor$500). suhjeme the applicant to aeivil penalty of
O 0 l,mhan c)fth pTodny.ormyem). NP.WRMIDENTLALELECTR S .FT,
C m o❑ ob wmk, otthe npeny,ormyempendeesw.ffeed s...craolec0m.11min on, Q STORIES TYPE CONSTRUCTION
pW, will dothowons Coateh The cmreiatnot es Liens Law
apply t an Business
., and Professions Cale:The Commcmrs License Lew does not apply to r owner of
proµnywyces,pdmd mprat u Naeponvenrom wevaachwmk himselftn through hisoweOCCOROUP RES.UNITS
emr.theesilding providedthatimp is sold nthin nal eacorfdarofferal foraak.IL -
bowever,thebuildingorienofemernissoldediinot year or improeifo,thrower- TOTAL:
builder will have the burden of proving that he did not build or improve for pulpae of
ale.).
❑ I,uxowncnff the property,amexclusively contracting with licensed contractors to QTY, PLUMBING PERMIT PEE Iq,00D ZONA APN
construct the proper(Scc.7044,Best..,.ad Pmfcasions Code:)The Cornerstones
I.icensehuwdo iii)tapplytounownerofpmµnywhobuildsorimprovesthcrem,and PERMIT ISSUANCE
whocamrums formch projects with.convacark)licensed p....nuothe Contruaor's
License Law. ALTER lEA
) FEESUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dale RECEIPI'p
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ I hercbyalfrm that l haveacenifcam ofeoment mself-insure,macenificareaf RECEIPfp
Workers'Compensation Insurance we certified copy thereof(See.3800,lab C.)which FIXTURES-PER TRAP PARK FEE Y N_
covemsll employ guytic t� GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPTp
Policy p ,f$$$�_!/D BUILDING DIVISION FEES
Com any M
II I GAS-FA.SYSTEM OVER 4(FA) PLANCHECK FEF.
oilier colry is hereby fulaithed.
Cccrifed copy is filed with the city insµcimm division. GREASEIINDUSTRI.WASTE INTERCEPTOR GRADING IEE.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundreddollam($100) SEWER-SANITARY-STORM EA.200PT. ENERGY FEE
or less.)
I excefyflntwine permernmecid,he work far whichthis permit is oned,],net] WATER HEATER WNENOBLECTN
am employ any µ,son in any mater vo as on hccome subject to the Worker% PAID
Compensation Lawsof Califomia. Data WATERSYSTEM/HUiATING Date Receipt is
Z Applicant
Z00 NOTICC'I'0APPLICANT:IL after making this Cenifaate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.111. TOTAL:
F' U) become subject to the Worker's Compensation provisions of the Labor Cade,you must
ai forthwith comply with such provisions or thisµ,mit shall be deemed mvnked. BUILDING FEE
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
Z I hertby affirm thauhem is a conummion lending agency lm the performance of TOTAL: ELECTRIC PEE
V O the work for which this permit is issued(Sx.3097,Cis.C) `
Lender's Name
c)IL U Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and slate that the above information is
W comet. I agree as comply with all city and county ordinances and state laws trade,to PERMIT ISSUANCE MECHANICAL FEE
ybuilding construction,and hereby authorise representativcsofthis city menterupon the CONSTRUCTION TAX
V 4 abate.-menlione i property for inspersion purposes. ALTER OR ADD TO MECH.
(We).gree us save,inskmnify send keep harmless the City of Cupertino against
liabilitice.judgmenls.costsund ex,enses which meyin any way accmeagainst mid City AIR HANDLING UNIT ITO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER ULWgl CFM)
Signature of ApplicanWwalcom, Date EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date R #
Will the applicant or future building accep.nt store of handle haamdous material EG'fING UNIT(OVER IBo,fXgI BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the health and Safety
Cale,Section 25532(e)1
13 YcaVENTILATION FAN(SINGLE RESID)
}o
Will the nconturninr futurebuilding by the Day Ana Air Qualitc Management B011,13R-COMP(JHP OR 100,fg10 BTU) ISSUANCE E
hemNom air contaminants as defined by the Bay Area Air Quality Manegemmt
❑Ia1fIrsY BOILER-COMP(OVER 100,000 BTU)
" P'il Y GY
❑Yes NEW RESIDENTIAL MECI{, SQ.FT.
1 have read the hnmrdons malerfulN requirements under Chapter 6.95 of the MARo A 1993
Califomia l lcalth&Safety Code,Se 25305.25533 and 25534. 1 understand that ! V
ifthe or at, we me cutrccitye m nut,that it ismyor,onsibility t notify the GI1r �•vj)
occupant o ✓f I vi nems achsl be mm m his su.nu o)f s nif mon(
Occupan / 3
Ow amhori a t Dam TOTAL: 1 ISSUED BY:
OFFICE