24587 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO r LULLG.EII KICAL PERMIT NO,
PLUMBING ETI
BUILDING DIVISION APPLICATION/PERMIT BUILD[SapR(JEcr IDENTIFICATION 24587
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNITN LOT#
OWNtiRS NAME: I'IIONIi: CONTRA OR'S NAME: - `C p'3_
S k1.4 q (a— / to ✓ /C N/c CONTROL#
Ak HITECf/ENGINF,ER:
LIC NO: ADDRESS. ❑
CONTACT: PHONE: I;JJ K BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El 0
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-k1iSi DIiNTIAL TOB DESCRIPTION
Or<Z I hereby,olTtmnhm l an licensed undcrprovisionsofCbupmr 9(commeadog with
¢)CC Section 900)of Division 3ofthe Businessand Prnfcssions CNe,and my license is in PANELS
=mb full forec and of t.
F-zw License Class �'�3 # aL5 97S UPT02MAMPS f.l
Date�omredor�� 301-1000 AMPS SQ.FT.FL R AREA 5/SQ.FT.
"coFyz ARCHITECTS DECLARATION OVER IOf10 AMPS I
ZO OZ�!2 71 1 understand my plans shall be used as public records. C '
E ce F w SIGNS ELECTRICAL C
<�m�a Licensed Professional OWNER"BU ILDER DECLARATION SPECIAL CIRCUIT]MISC.
C4'O LtJ 1 brief,affirm that 1 at,exempt from the Conlowl-,License Law for the
following reascn.(Section 0031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INS']'.
which cipires a Permit o construct,aleq improve.demolish.m epair any swcmre
CVS$ prior to its issuance,also requires the applicant for such Permit o filep mnt
signed stateePOWER DEVICESE,W a p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
aXoW 9(commencing with Section 900)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ts' or that he is exempt mertrom and the basis for the alleged i An violation f
W_rn p ge exemption. ylpairno OUTLETS-SWITCIIIS-IIXTURIS
F Z Q Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of 50 -
t mom than five theMhundred dollars(5500).
EspNEW RESIDENTIAL ELfiCB _SQ.FT. STORIES ]'YI'Ii CONS'1'RUCf10N
1rFo n❑ 1,mownerofthepmpeny,ormyemployeeswith wages asthcirsolecompensation,
pW,L3°,°_ will dothewark,andlhe'he C cislot is Li,ame Law does
apply 91 M4,Business
and Professions CWc:The Conuucmrs License Low dn:x not apply m un owner of
pmpeny who builds or impmves Iherton,and who does wch work himsel f m Ihrrugh his
employees,providN that suchimprovements me oat intend&oruffcmA forsale.
If, OCC GROUP RES.UNITS
however,the building or impravemem is sold withinane yearofcompletion.the owner- TOTAL:
builder will have the burden of proving that be did not build or improve for purpam of
le')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[I1.asownerofthe property.nmexdusively<onaaming with license&contractors to
orarua the arjat(Sec.7IH4,Business and Professions Code;)'Hte Contractors PERMIT ISSUANCE
License Lawdess otapply loan ownerofpropeny who builds or improves thereon,and !
who cortmets for such projects with acontmctor(s)licensed pursuant to the Convectors
Uccn.c Law. ALTER-DRAIN&VFN'I'-WATER(EA) FEE SUMMARY
❑ I um exempt under Sec. N&P C for Ihis reason OUTSIDE FRES
BACK FLOW PROTECT.DEVICE SANITARY YN
OwnerData RLCBIPT p
DRAINS-FLOOR,EDGE.AREA.COND.
WORKMAN COMPENSATION DECLARATIONSCHOOLTAX Y N
❑ Ihcreby afErtn thailhav<u<enifi<meofconsem to serif-insurt.ora anifi<mc of FlXTVRES-PER TRAY RECEIPT#
Workers Compensation Insumace or aceniBN copy theteof(Sec.380.Lab C.)which PARK FEE Y N
RECLIPI p
coversaIle yy de ti pc t. GAS-EA.SYSTEM-I INC.4 OUTLETS
Policy p 4 UTy 7 BUILDING DIVISION FEES
- Company (r. GAS-EA.SYSTEM-OVER 4(EA) PLANCIILCK FEE
.❑ CenifiNcopyiahcMryfumishN.
Certified copy is fileA with the city inspection Jivisinn GREASEINDUS'I RL WAS]E IN TERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP - SOILS FEB
COMPENSATION INSURANCE
(This sectionnecd not beexmpletN ifthe permit is furore hundred dollars(S10) SEWER-SANITARY-STORM EA.20FT. ENERGY FEE
orlcss.) a�tqe
Icenify that in the peRotmance o(the work for which this permit is issaN.l shall WATER HEATER W/VLNDELEC1R 5• W
not employ any person in any manner so as to became subject to the Workers' PAID
Compcusationfawsof Califomia. Dale WATER SYSTEM/1'RGTING Dole Receipt#
p z Applicant
z � NOTICE 10APPLICANT:If.after making this Certificate ofExemption,you should NEW RESIDENTIAL,PLMIL—SQ.Fl. 10TAI.;
tr lin became subject oche Worker',Compensation provisions oflho Labor Code,you must BUILDING FEE 7 forthwithcomply with such Frosts.....or this permit shall he deemed revoked.
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that mem is a consvuction lending agency for the peHormance of
U o the work for which this p.if is i.suoil(See 309].Civ.C.) TOTAL: r S� ELECTRIC FEE
Lender's Name PLUMBING FEE
L,
F-i Leaders Address QTY. MECHANICAL PERMIT FEF.
U I certify that I have read this application and state that the above information is MECHANICAL.FEE
correct.I agree to comply with all city and county ordinances and state laws relating to FERMI r ISSUANCE
F" buildingcanebuetion,and hereby:mthmlae representatives til'his eitymenter upon he CONSTRUCTIONTAX
U2 Door mentioned property for inx(tcetion purposes. ALT ER OR ADD TO MFCH.
(We)....c rosase,indemnify and keep females,ales,the City of Cupertino agalna
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING ON I'1'(TO IO.WCFM)
quence of the ranting f
Ihis .unit.
AIR HANDLING UNIT(OVER 10.000 CFM)
azure of Applicam(Contmctor Dam EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI"1'00 101,000 B'10) Date Reccipt#
W ill the applicant or lmum building occupant sure nr handle hazmduus material TOTAL;
as deli tied by the Cupertino MunicipalCode,Chance,9.12.and the l health and Safety HEATING UNI'1'(OVER 1(10.100 BTU)
Civic,Section 25532(0)! VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE'DATB♦
Will the applicant orfutum buildingeceiranuaa
t eeiuipmelndmi
evices which et BORER-COMP(3HPOR10.000BTU) �+ Y J
®
hamrdm,air comaminants as defined by the Bay Acte Air Quality Management BOILER 10.000 BTU)District, FEB 9 1993
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.F1'.
I have read the hamoloux materials requirements under Chapter 6.95 of the CITY I V tI, �uP,C
California Health&Safety Cndc,Sections 25505.25533 and unders
25534. 1 tand mol nL'
If the building drex nal curmndy have summit,that it is my.expansibility to nmify the
occupant of the requirements which run M mel prior to issuance of a Certificate of
Occupancy.
Owner lir audmrimd agent - Date TOTAL: ISSUED BY:
OFFICE