24591 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 41.11 G-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PING-MECHANICAL ICA 24591
BUILDING DIVISION BUILDING
NG PROPROIEC'1'IUEN'1'IfICATI(IN
BUILDING ADDRESS: �¢� SANITARY NO. APPLICATION SUBMITTAL DATE-
UNIT#
ATEUNIT# LO I'# t �q
OwN RSN M^ /� i Ei CORA OR'S NAME: , it / `':C, �_,I
NIC CONTROL#
—, 6 P aFo
l`i HITECT/ENGINEER: LIC NO: ApD �. rP WAA� �� �`• ❑
j NTALT: PHONE: Q//TY. ELECTRIC LP'ELRMIT FEE BUILDING PERMIT INFO
BLDG ELECT PI M MECH
PPRMI"r ISSUANCE. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DF.SCRIPI'[ON
ZXzWOO I nearby on7")ofinnthl Is.ion Sof the Business
Code,
and mmuense with � � Q 0��
b- — Section]000)of Uivision3of the business a2d Rvfcssiotrs Cada and myliccnu is in PANELS -p— 90
Dr. Clea - -� Conaactor +I-I OP TO AMPS
%Fq 6 y Date
F v Z ARCHITECTS DECLARATION - OVER I(IW AMPS Q.iTTLOOR ARG S/SQ.IT.
�� I undcamnd my plans shall M used m public records. n i 1
SIGNS F.LECI RICAL ' N
F„j Licensed Professional T E R
LaQ OWNER-BUILDER DECLARATION SPECIAL CIkNIT/MISC.
;Oa' I hereby affirm that 1 am exempt from the Conunctore License Law for the
:3 tr c o following reason.(Section 71131.5.Business and Professions Ede:Any city or county TEMP.METER OR POLE INST.
:u'OQ which requires a permit to consumer,alter,improve,demolish,or repair any structurertDAT
1W}7 prior its issuance,also requires the applicant for such Permit file a signed statement POWER DEVICES A y fA
1a 0 that heN licensed pursuant to provisions ofthe Contractor's License Law(Chapter _
'Kea 9(commencing with Section 7")of Division 3 of lire Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
m.m m that he is exempt herefrom and the basis for are alleged exemption.Anyviolmion of
FZ> Section7031,56 applicant for tmbcc9stbea applicant loucivil OUTLETS-SWITCHES-FIXTURES
Yhundre Pemti 1 PP WnAty of T /
XL: 0m omthanfivfffiepeddollormyem). NEW RESIDENTIALELECIR SQ.14. STORIES TYPECONSTRUCTION
YFo ❑ othe wnerofN<propertyre isommployedorolfcmd wegesasthei(See,compensation,
will do the nodthe he Conemmol'mm�ense Law
nam apply I.an van,of
ss
and Professions Cade:The Contractors License Law docs not apply io an owner of
propcnywyees,pdorimprovcsthemprove who are amctendedimxlredthraagh his OCC.GROUP RES.UNITS
own employee%.prosidedlhat impruch ovement
ents isidurrnot imenlfcomploi.r.ficathe owe.ner-
builder wtheavet a burden of
issoldwithinone Year or improve for urowner- TOTAL:
builder will have tM1c burden of proving that he did not build m improve for purpou of
de.).
❑ Lasownemdthe property.umexdusivdyconbactingwith licensed contranorstu QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
eonswct the project(Sec.7844,Business and Professions Code:)The nt
Coractors a
License I.uwdocanm apply in an ownetofprnperty who buildsor improves tnrnam.and IfIT PERMISSUANCE �r0
whocommets forsuch projects with acomructrn(s)licensed pursuant o the Contractor's ALTER-DRAIN&VENT-WATER EA
License Law. (- ) FEESUMMARY
❑ 1 ren exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OIfIlS1UE FliE$
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA.COND. RECEIPT#
~ WORKMAN COMPENSATION DECLARATION SCHOOL'I AX Y N
1 hereby affirm that 1 have a certificam i f consent to self-insure,ora certificate of RECEIN#
FIXTURES-PER TRAP
PARK FEB Y N
vers al mpensaion Insurance nr acenified copy thereoflSce.JgoO.tzb C.)which
Poliry# RECEIPT#
covers Nl cmpkJyc y Ice ihiv pc n GAS-EA.SYSTEM-1 INC.40UTLE15 BUILDING DIVISION FENS
'
Compact! SI�- GV Ai
P Y GAS-G.SYSTEM-OVER 4IPA) PLA.YCIIECK FEE
—❑ Certified copy is hereby fumisned.
pT Certified copy is filed with the city inaction division. GREA BTNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OI'EXEMETION PROM WORKERS' GREASE TRAP SOILS FEE
COMP12NSATION INSURANCE
pni—sam..,,dour beeompleted ifMe#,anal:breast,hundred diml.(SIM) SEWER-SANITARY-STORM EA.2(r ENERGY FEE
rr less.)
I cenify that in me Performance afar,work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any parson in any manner an as m become subject to the Worker: %J PAID
Compen.vaiionl,nwsof Califomia. Dare WATERSYSIRMOREATING Dam Receipts
D z Applicant
72 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
W became svbjcet or the Workers Cnmpcnsut on p...kim s ofine Labor Code,yea most
Y ; forthwith comply with such provisions or this pernd%hall be deemed revoked. BUILDING FEE
y Q CONSTRUCTION LENDING AGENCY SEISMIC PEE'
; O Thereby affect that thercisaamw
sction er
lending agency for the pformance of TOTAL: j ELECTRIC EEE
the work for which this Permit is issued(Sec.SFO.Civ.C.)
Lender's Name
2iF I<nders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE Jb
U I cenify that 1 have tend this application and state that the above information is
correct,lagree to comply with all city and county ordinance%and state laws relmiag to PERMITISSUANCE MECHANICAL Fl-E
Nbuilding eonsvuaion,and hcrebymilmneereprestaratives of ilik,ily 1.rare,upon the CONSTRUCTION TAX
above-immicaed property for inspection proposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnity and keep harmless the City or Cupertino against
liabilitie-'udgmenta,costs and expenses ich may in any way accrue against said City AIR II AN DLING ON]'IJO 10,000 CFM)
nfthegmmi of lois nit
` ] AIR HANDLING UNII'(OVER 10,000 CFM)
Sigstatureof Applic Cnraor Date) EXHAUSTHOOD(W/DUCn 'PAID
' RDOUS MATERIALS DISCLOSURE HEATING ONI't(TO I W,gM)BLL) Dale Receipt It
Will the applicant or faros building occupant store or handle narmdom material ]f� s
a,defined by ltic Cupertino Municipal Gdr,Chapter 9.12,and the health and Safety HEATING UNIT(OVIiR IM,"BTU) TOTAL: OC
CM,,Section 2553200
\ ❑Yes EI No VENTILATION PAN(SINGLE RESID) w
ISSUANCE'DATE
Will theapplicantorfutum uildingmit cupint meaquiprnaloraeviceswhichem
BOIIA?R-COMP(3)IF OR 100,000 BI U)
Iwzardoas an summations as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10y"BTU) 1983
Oman.? T�
11 Ye, ❑No NEW RFSIDIN'1'IAL MECH—SQ.FI'. o
r�gt�
1 nave read be Safety
Coa..matrons%5505.255 3 ander Chapter 6.95 of he
ifthe
buil ingHealthdo&Safely Cale.Sections 25505,25533 and 25534. I understand Inas Ur
ifthebuildingamsnot comically
a,,whave astunt,that itnt. once,ior. to notify the ! Y
occupant of the rcyuircmcnta which most he met point.issuance of e Ccnifiule of
Occupat,cy.
Owner or authorized agent Dam TOTAL: ISSUEDBY:
OFFICE