24880 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINON ILDING-ELECTRICAL PERMIT NO. /1 �I HHO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT'IDENTIFICATION LLI
DING ADDRESS: SANITARY NO, ONSUBMITTALDATE
3 as P 4 OL ct (�/� UNIT# IAT#
OW ERS NAME: PHONE: CONTRACTOR'S NAMELIC NO:
fel ktws,It b
e T u_/ w IK d 31 N/c conTROL a
ARCIII'I ECT/BNGINEER: LIC NO: ADD t'S Ela C.lGNr 9 ayv(J of
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB SUCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I< RIV pN
Cyy Iherehy affirm lam license)under ACTOProvisions DECL DECLARATION
9(commcncingwith
FJO2[- Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
t�WM full force anJef(ec,. v"'9� *3 IS-qUOT02WAMPS
FZ,Vi e4isv�Cinn
m Stn Due Q4'��Y\ Commctor 202-IIIW AMPS SQ.FL I'LOOR AREA $/SQ,FT.
F,Z ARCIIITIiUl-S DECLARATION
Z O OVER IWBAMPS
m— 1 understood my plmts shall be used as public records.
O!—D
F m F W SIGNS ELECTRICAL
QXYI.ittnIeProfessional
C d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOiW,U 1 hereby affirm than I an exempt from the Cosions Cs License law for the
W 3 a y which ing rcas.n.(ren,In 7U31 5,Busll".sitand w,dation Code:Any city or county TEMP.METER OR POLE INST.
!,ISO C which,equina n permit m umslrucl,ohm,improve,JenuJl It file
repair any s.ucmre
oc,TS toil.,is,move,alsofe 'rcsilan licant for such uo file asi road statement POWER DEVICES
poor qto pp pract g
�m�0 chat he 9(comsncing with Sectiotion n
70M)the of
Divisionns 3 of the Bu Contractors Licand nsePro Law(ChapterCode)
SWIMMING POOL ELECTRIC
aaoC 9(commencing with Section]000)ofDivisionJof the Rosiness and Professions Code) / ATION
W=4 car that he is exempt therefrom azul the basis for the alleged exemption,An 11 f
w p gylPaiono OUTLETS-SWITCHES-FIXTURES /P
ZQ Section than
five
any applicantfor aPermit subjects the applicant toacivil penalty of o
not mom than Evc hundred dollars(b5 W). NEWRESIDEN'I'IALELECTR S .Fr.
� � ❑ othe wrk,adthestperty,e is notmployecsw hhwed forsale(Sec.uanpensiness _SQ.FF. .S '1'VI'Ii CONS'1'RUCI'ION
ywill do r... ,heswcmrcis not intendedor offered for sale(Sec.]044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
progeny w M1n builds or improves thereon,and who dwas such work Mmsel f or dnough his
ownemployares,provided that such improvements manse inendedoroffered forsale.If, OCC.GROUP RFS.UNIT'S
however,the building or improvement is sold within one yeaofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did nor build or improve for purpose of
L] 1.as owner ofthe progeny.am exclusively contracting with licensed comracmrslo QTY. PLUMBING PERMIT FEE FLooO ZONE APN
construe the pecten(Sec.70411.Business and Professions Corse:)The Csometurs
License Lawdoesnotapply to an ownerofpropcny who builds.,improves thereon,and PERMIT ISSUANCE.
who tomato forsuch projects with acontacmr(s)llcenad pmsuanuo the Con.acm''s
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICH UTSIDE FF;ES
SANITARY YN
\ Owner Dam RECEIPT
DRAINS-FLOOR.ROOF.AREA.GOND.
WORKMAN COMPENSATION DECLARATIONSCHOOL TAX Y N
❑ IheCompenaffirm othat Insurancve a e ora campe comenuosaf(Scsua.or aan)whichcan,of FIXTDRE$-PER TRAP RECEIPfp
Works Compensationorlerthis ermit,camped copy,bcrrof(Sec.38W,Lab C)which PARK FEE Y N
covers ell emplgee's under this pemtil. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION IliliS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is hereby famished.
❑ Cerified copy is filed with the city inspection division. GREASEANDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERSGREASETRAP SOILS ME
COMPENSATION INSURANCE.
(This section need not be completed ifthep mnit is fomne hundred dollars EUM) SEWER-SANITARY-STORM EA.20OFU ENERGY EEE
or less.)
I testy that in the performance of the work for which his permit is issued,I shall WATER HEAT ER WIVE NT/1i1.1icl'R
not employ any person in any manner so as to become subject to the Workers' PAID
Compeneaionlawsof Califomia. Date WATERSY$TEMTREATING Date Receipt
O z Applicant
z O NOTICE T'O APPLICANT:If,uftermaking this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. T AL:
r% become subject to the Workers ComrnLaborption provisions of the Lan Cole.youreasl
N forthwith comply with sue provisions or this permit sholI be deemed revoked. BUILDING ME
LIJ� �_
I] CONSTRUCTION LENDING AGENCY SIi15hfIC FEE
a z Iherebyaffiren that the.is.comwetion lendingagcney fortis Performance of TO ELECTRIC FEE
U O IM1e wonkfar which this permit is issued(Sea 3099,Civ.C.)
Lender's Name O PLUMBING ME
F Leader's Address QTY. MECHANICAL PERMIT FEE
U 1 certify that I have read This application and stat Thal the move Iaformmion is MECHANICAL
�" DJ correct.l agree to comply with all city and county ordinances and state laws alaing to PERMIT'ISSUANCE
buildiagcoastruction.and hereby audit representatives ofebariy to enter upon the CONSTRUCITO T
U z above-mentioned property for inspection purposes. ALTERORADDTOMECU
(Wa)agree to save,indemnify snit keep harmless the City of Cupertino against
Iimilities,mil,mems,costs andexpenses which gmym any way accrueagure said City AIR HANDLING UNIT(TO 10,000 CFM)
in co—q-no of 11 granting of dd-gamut.
�I / AIR HANDLING UNIT(OVER 10,000 CFM)
ngnatmenf Applicant/Commcmr ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT G 0100,000 BTU) Data Receipt#
Will theapplicant or future building occupant al a or handle M1eardoue macri.1 TAI
us defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety HEATING UNIT(OVER 100000 141 U)
Code,Section 25532(.)] VENTILATION FAN(SINGLE RISID)
❑Yes ❑No
ISSUANCE DA'Z'E
Will dues licant or future building occu Luxe t or devices which emit BOILER-COMP(3nP OR IW.(Mp BTU) A f
pP B pan equipment /1
haeardoue air conaminans as dcfned by the Buy Ama Air Quality Management BOILER-CDMP(DVER 100,000 IOU)
istricR ��qw
Cl Yes ❑No NEW RF,SIDENTIAL MECII. SQ.FT. AFAR 19Z
I hahazardous ve read the V
materials requirements under Chapter 6.95 of the i T �l
Cdlfomia Health&Safety Cade.Sections 25505,25533 and 25534. 1 understand that Ur
if the building does not currently have a tenant.that it is my responsibilitya notify the VUrrri 1 Il#v
capon,of the requiremems which must od at prior to issuance of a Certificate of
Occupancy. \S{ A-
Owner snnth oriud agent Data TO pAL: ISSUED BY: \J 1/1`[x-/�j1/X)
OFFICE