24549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ELECTRICAL ICA PGRMII'NO.
APPLICATION/PERMIT PLUMBING CT IDENTICAL 24549
BUILDING DIVISION I4UILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 4I
I SANITARY NO. APMCATIONNSUBMI TA)LDATF.
v LJ L)ftfA�wc� w UNITN LOT# 1/4 ion
O�y'ii[R$�.\A�: PHONE: CON'I'kACTOR'S LIC NO:
1!_3nV�
NIC CONTROLp
CHIIECI'/ENGINEEN: LIC NO: ADD ;:5: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG E�.EC•f PLUMB MECH
PERMIT ISSUANCE ID 1-1 1-111
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �'Y
nxz I hereby affirm that l am licensed under provisionsofChapter9(commencing with JOBB
DESCRIPTION
WOO Section]IXIO)of Division 3ofthc Bueincxmand Pmfes,avw Code,and my license is in PANELS
W F full force and effect. 1
F!W Licence Class Lie.# UPT020DAMPS
m=y Date Contractor unr 201-IOAMPS - S IT.FLOOR AREA $/SQ.FT.
ZOyz ARC[UI ECT'S DECLARATION OVER IINN1AMPS
Q
OZ_p I rederamndnry plamshml be used.,public records.
F re,F W SIGNS ELECTRICAL
Q W< Licenced Pndessinval D
X owu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. _ I N l
X Oa U I hereby nfl(Se that I am exempt from the Contractors Co e:Any
Law for the r /7 • 'v
W3W1 followingmason. 700L5,�usiness and Professions Code:Any city orcounty TEMP.METER OR POLE INST. J) L�/11 _.D p 0
O; which requires a permit to con.nmm,alter,improve,demolish,or repair any stmcturc 'IIVO
TER
WWJ 2 pnerio its issuance.also requires the applicant for such perrm fileasignedstatemem POWER DEVICES
ti C p that he is licensed pursuant h,the provisions of the Conuacmrx License Lew(Chapter SWIMMING FOOL ELECTRICATION
VAL
o.a�W 9(commntem,with Section 7000)of Division 3 of the Business and Prefe,eioos Corel
Lx�Jt, or that he is exempt herefrom and the basis fm the all exemption.Any violation of OUTLETSSWITCHES-FlXTURFS
FZ¢ Section 7031.5 by any applicant for a permit subjects the applicant'.a civil pointy of
�S t] not more than rove hundred dollars($500).
K_Fp ❑ 1,asowneroftheproperty.ormyemploymswith wages astheirsolecompensation, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
a3c—u will do Newons ands no Coreiactor's kende Useddsnon apply 70 f4,Business
and Professions Code:The improves
Contractor's License sew does not apply lf an owner of
pmpeny whobuilds.rimer.ves thereon.endwhndcessuch workhimsclfor Nroughhif, OCC GROUP RFS.UNITS
own employees,provided thm sue h Improvements are not i ended m offered foe role.
If,
however,Ihe IIhave the buten of
issoldhe id none yem of completion.purpose f TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
I,as ownernfthe progeny,anmxclusivelyconvnning with licensed contma.om QTY. PLUMBING PERMIT FEE F1000'/.ONE APN
0 the project(See.7044,Business and Proessiorw Code:)The Contractor's PIiRMI"1'ISSUANCE.
_ren Law does not apply to rot wmcrofpropcny who build,.rimpn,ves thereon,and
ndwtho,oaaacs for-en If jecawl thu contmdot(s)licensed pursuant o the ContmemT''e DRAFT EA
Licensc Lew. AL'I1 H ( ) FEE SUMMARY
'❑ 1 um exetnpl under Sao B&P C for this rcusnn BACK FLOW PROTECT.DEVICE OU"I SIDE FEES
SANITARY Y N
Owner Date RECEIPT p
COND.AREA,,
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR. SC11001.TAX Y N
❑ Iherebyaffirmrhatlh:tvcacenificateofconuntiomlf-iusme,oraceniGemeof FIXTURES-PER MAP RECEIPT#
Workers G,mpcosmios lnsumnce or a ecnfied icopy thereof(Sec.3800.Lab C.)which PARK FIDE V N
cover,all employcc'm under this panne. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT b
Pa1a5.# BUILDING DIVISION FEES
Company GAS-F.A.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GRIASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not be completed Him,permit is for one hundv4 dollses(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
en less.)
I certify that inlhc performanceefrhe work for which this permit is issued.l shall1Q1,y.
WATER HEATER WJVENT)ELECTR
not employ any person in any manner so as to became subject to the Workers' PAID
Compensation Lswsof California. Date WATER SYSTEM/TREATING Date Receipt#
C) Z Applicant
z NOTICE TO APPLICANT:If,.1m,making this Certificate of Exemption,you shouldNEW RLSIDF,NTIAL PLMB. SQ.FT. TOTAL:
ry become subject to the Worker's Compensation provisions of me Labor Code,you must
> forthw'aM1 comply tui th such provisions or this permit shall he dtsmed revoked. BUILDING FEE
W Q SRI'MIC-L,
( a
CONS construction
IONLENDING AGENCY
1 hereby filum That there is i sued(Sec.
Civ agency for the performance of
U z
the work I'ar which this pomtit Is"issued(Sec.JW7,Civ.Cr TOTAL: ELItC'1'RIC
Lenders Name
U" MECHANICAL PERMIT FEE PLUMBING FEE
O L) IxndIC Address
U I.I ago that 1 have read this application and state that ar aboveinformationrelating is MECHANIC P
s�" W correct.Inge mcomply with all city and ammy ordinances and sum laws relining u, 1'LRMI'1'ISSUANCF;
I"' building ttmsuugian,and herchyauthoriae represenwrivesof this cieymemer upon the CONSTR '10 l'AX a
U z above-mcmionesl property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree remove.indemnify and keep harmle„the City of Cupertino against
liabihtia,judgmems,costs and expenses which may in any way accrue against said City AIR I IANDLI NO UNIT(T010,000 CFM)
I.consequence of the gmming of this pc nit.
AIR HANDLING UNIT(OVER 10,000 CFM)
gnat' Applican mmm.r Date .,00eT HOOD(W/DUCT) PAID
HAZARDOUS MA RIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dme Rcttipt#
Will the applicant or future building occupant store m handle havrdous material TOTAL:
mes defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100.!100 BTU)
Code.Section 25532(a)? VIiM'IIAB']ON FAN(SINGLE RESIDE .fie
❑Ye, El No
ISSU 'CF,DATE
Will the applicant or future building occupant use equipment ordevices which emir BOILER-COMP DIIP OR 100,000 BTU) IP 04 111
hazardous air contaminants am defined by the Bay Area Air Quality Management [3011 ER-COMP(OVER 100.000 BTU)
D,,tnct? ca El 41992
❑YNo NEW RESIDENTIAL MECH. SQ,FT.
1 have read the hamrdnux materials requirements under Chapter 6.95 of the
Caufmnia Dewar&S.fcty Cade,Semh,na 25505,25533 mid 25534. I uaamsmrd thmr C11 Y Lite Cut,=I DIU
If the nullding does no,comedy favors rearm,Into it is my m,poneibility u,notify the
capam of the requireiecros which must be mel prior to issuance of a Certificma of
Occupancy.
Owner or authorised agcm Date TOTAL: ISSUED BY:1/
OFFICE