24780 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
F0WN;S,WA1vIE
OF CUPERTINO BUILDING-F,LECTRICAL PERMITNO. ,.a 0
APPLICATION/PERMIT PLUMBING,-MECHANICAL 'LJ
DING DIVISION BUILDING PROJE<TIDENITFICA'1'1ON
,AaDDDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
) ONI'1'p LOT# �7 � 7-T T/
: PHONE: CONTRACTOR'S NAME, LIC NO: �'•
-!'�r"•A// /aT//"`�� NIC CONTROL p
i ARCHITECT/ENGINEER: LIC NO: ADDRESS:
COP'TAGT: PHONE: BUILDING PLRMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUAfB MfiCII
PFRMIEl El F-1'1'ISSUANCE fL�7j-
LICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pC2 Iherebyaffimn that lamlarensed underprovisaons of Chap¢r9(commencingwith (1 ��
W00 Section 7000)of Division 3 of the Business and Professions Cade,and my license is in PANELS I///1✓5
full force and effect.
U U UP TO 200 AMPS
d,Z ly hlcomc Class Lic.p
,<-=y Dare Conmucmr 201-IOW AMPS Q S FT.IFLOOR AREA $/SQ.Pf.
ZOyZ ARCHITECPS DECLARATION OVER IWO AMPS
OZ-0 Iundervmnd my plans shall be used us public records. F I `p ap\Ill A p E D IN F,u,Em SIGNS ELECTRICAL IEL�
Q $j LittnxJ Professian#I
zyc'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT(MISC. " Ips+ I
XOy V 1 hereby from Aha 1 am exempt from the Convaztors License Law for the G O M V EA
W 3 a rFit following reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INSA'.
I:7 u 0 G which requires a Femur to construct,alter,improve,demolish,or repair any structure w
�W}510 its issuance,alsone the licant forsuch permit.filensi meJ.amnncnt POWER DEVICES DA�
prior quires pp pe b
Iy IY<O than he is licensed puraaannothe provisaom'ol'Ihc Cnnnicor 's License Law(Chapter
e.XOC 9(commencing with Section 7000)of Division 3 ofthc Business and Professions Code) SWIMMING POOL ELECT RIC VAI.HATION
u•
or he is exempt therefrom and the basis for the allegedAn 1 t f
u1'Z� P he Yvmaiono OUTLETS-SWITCHES-FIXTURES
FZa Smrion703L56y ve hmy undred
lours P$5OOr
rmit subjects the applicant maciyil penalty of
trye�own rorthendreJdollars yempl
K F_o �'Lasownemfthe progeny,ormyemployttswith wages as lheirsolecompensation, NEW RCSIDFJ TIAL ELECI'Ii SQ,DI'. STORIES TYP[CONSTRUCTION
will do he work,and the oruaurc isnot intended oroffered for sale(Sec.70 ,Business
and Professions Coda The Contractor's License Law does not apply n)an owner of
property wholomidi or improves thefeon,and w1hndoaasuch wink himself..nhroughhis
Jed thmsuahim t Yt dW nroffeW forsale.If. OCC.GROUP RES.UNI'I'S
amp the
provemensamne men
howcer ,will have
burden
of improvementishewithiniot build oimproeiforon,purthepose of TOTAL:
builder will have the buNen of proving thin he did not buil)m improve for purpose m(
Elas I, rofnhe progeny.amendusivdyconlracting with licensed contmcmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u
omsum the project(See 7014.Business and Professions Codes ATe Contractors '
License Law Joey notapplyntmowncrofprogeny whobuilds mrimprmva thereon.and PERMIT ISSUANCE
who onion, such projectss�iI ammmenn licensed pursuant to the Contractors M:1'IiR-DRAIN&VENT-WATF,R(FA) FEE SUMMARY
License L
❑
1. rte under B&P C for this reason BACK FLOW PROTECT.DEVICE OU'T'SIDE FEES
SANDARY Y N
Owner Date RECEIPT»
DRAINS-FLOOR.ROOF.AREA,GOND.
WORK.GAN COMPENSATION DECLARATION SCHOOL TAX V N
❑ m'Co Compensation
cnifcaeof comenurcof(Sec.38 o,Lab C)
)caich FI%TURFS-PER TRAP RLCLIPTN
• Workers Compenaatinn lnsurancemacenineJ ropy thereof(Scc.3800,Lab C.)which PARK FF.F, YN
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Py# BUILDING DIVISION FEES
Compact' GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenlGcd copy is hereby famished.
❑ Cenifted copy is riled with the city inspection division. GREASFANDUSARL WAS TE IN]ERCEPTOR GRADING FEE
CERA IFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIISME
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forms hundred dollars ISIW) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE
I cert. .... In nhc p in mynodua the work in ecomehi.bc,l is theWI shall Wn'Hift HEATER W/VIiNT/ELECfR
nut employ any person in any m .a la become subject m IM1c Warkars' PAID
Compensation Laws of California. Dae s WAI'M SYSTEM/I'RHA'1'ING Date Recdptp
O Z Applicant
z 0 NOTICE TO APPLICANT.If.after making this Cenificam of Exemption.you shouldNEW RFSIDE, IAL PLMIU SQ.FT. TOTAL:
F (/I become subject to the Workers Compensation pmvisiona of the labor Code,you must FE
� ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING E
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm thin there is a consumnion lending agency for the performance of TOTAL: �.•`� ELFC7rRICFEE
We wmk for which lbh lw•rmit is issued(Sce.3OrG,Civ.G)
Lender's Name
Lender's Address IMECHANICALPERMIT FEE PLUMBING FEE ,S
V 1 certify that I have mad this application and state that the above in0ammioo is MECHANICAL FEE
>' 0. correct.l agree to comply with all city and county ordinances and state laws relaing to PERMIT ISSUANCE
bnildingconswcdon,and hereby authorize representatives or this city to enter upon the CONSTRUCTION TAX
V Z aMve-menti ud open'farinspection purposes. ALTER OR ADD TO MECIL
(We) e t n Indem41yk,ep h s the City of Cupcnino againstIlubilitiee,j idgn Asa itsand ich nywayaecroeagainn-idCary AIR HANDLING UNIT(101(1,1100 CFM)
cmnsequt of • morin l.
AIR HANDLING UNIT(OVER IO,WO CFM)
Signature of App 1nUCmu for Use EXHAUST HOOD(W/DUCD
PAID
H/R,ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receapt#
Willthe applicant in future building occupam store or handle hovurJous material I IEATI NO UNIT(OVER 100,000 BTU) TOTAL: �.SO
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553211)'1 VENTILATION FAN(SINGI,H RESID)
❑Yea ❑No
F IS$UGE gNDATE
mm
Will lheapplicanrfmurebuildingoccupause equipmmh
enmrdeviceswhicheBOILGR-COMP(3HP OR JOY"BTU) � /�, ll
haezrdam,air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District" FEB 19 1993
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have real the hazardous materials requirements under Chapter 6.95 of the
Cnlafamae Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that lsfTy Ur %jueth I IIIA/
if the building hon,oat eunaml,have a tenant,Ono it is my resporeibilary to notify the VII '
occupant of Ne rcyuinmen¢wM1icM1 maw be met prior m issuance of a Certificme of
Occupancy.
Owner tar auNoriud a gent Doc TOTAL: ISSUED BY: Vlvt C-
OFFICE