24851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'T'RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� ^ O C
BUILDING DIVISION BUILDINGPROJEiCTIDENTIFICAI]ON L LF v J
BUILDINGADDRMS:` SANITARY NO. APPLICATIONSUBMDTALDATE
UNIT# LOTH �12
OW SNA,{ME /1 t 1 1r /' PHOkNEC:�1 CONTRACTOR'S NAME: LIC NO:
N/C CONTROL
/IRC__HITECR3q(T,IFEG(n7�: LIC NO, ADDRESS: El
L awk,r we 94,F
CONTACT: PHONE QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L(�dA N •`I ZJ� 2�� QPF,RMII ISSUANCE
B F.C' PLUMB
LICENSED CONTRACTORS' DECLGhaperN pPPLIANCFS-RESIDENTIAL
2=z Ihereby affirm that I CENSE licensed under isDECLChapter9(commencing with T
W100 Sr,mm 7000)of Division J of the Business and Professions Code,and my license is in PANELS
yUU License
Clfull force ad effect. UP AMPS
Liccnx Class Lia#
w Q e- Date Contractor 201-1000 AMPS
)p'0N SQ.IT.FLOOR AREA E/SQ.FT.
NZ ARCHITECTS DECLARATION OVER I(XlO AMPS — w
0z—❑ 1 understand my plans shall be used as public records.
FyF; SIGNS ELECTRICAL Z
QY�': Licensed Professional
Jew A
Ecu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. X300 D
dO c. hereby by uff a that I am exempt frmothe Con racmrs License Law for the
W `y following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POIl INN('.
ON< which requires a permit to consmtm,alter,improve,demolish,or repair any structure
WY2 poor o its issuance.also requires the applicant for such pronitto file a signed statement POWER DEVICES
,=<0a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapeur
dKo4 9(wmmei,esemitharetian 1f1t10)al Division 3ohhe Business and P An,siolmi.n.1'Cade) SWIMMING POOL ELECTRIC VAI _
Section 703exempt Barrel the Permit
the appemptt to civil plation of OUIT.L IS-SWITCHES-FlXTURFS f�%(y^Jw
F L Z< Section703than
n by any applicant fora Permit subject the applicant m a civil penalty of
not more than f se bandied dollars(5500).
p ❑ I,asswncndthepmpcny,ormyentployceswiihwugesas theirsnlecompensxtidq NEW RISIDENTIAI.ELECfR SQ.FT. STORIES TYPE CONSTRUCTION
a3— will Jo the work,andthe structure is not intended m otered fonsale(See 1016,Business
and Professions Code:The Contractors License Law does not apply to an owner of
propeny'who buildsorimproves thereon.and whodoessuch work himselfonhmugh his
OCC. RES.UNITS
vert employcex,provided that such impmvemenu are not intended or nffercd for sale.If,
however,the building or improvement is sold within oneyear of completion,the owner-
builder will have the burden of proving that he did nm build or improve for purpose of
I' —
as ermhe property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
nsoua the pr lett(Sec.1046,Business and Professions Coded The Cminsclor's :� t
a-icese Law does not apply m an ownerepropeny whobuilds or improves thereon.and PERMII'ISSUANCiiIS
who contracts for such pmjttts with a convacror(s)lic<nsed pursuanuo the Convectors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am caroT under Sec. ,B&P C for this¢axon OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COST EONDECLARATION SCHOOL TAX Y N
C] Ihereby affirm that have acenificanecme cd of consenno self-inseam,orattnifcate of FlXTURFS-PER TRAP RECEIPfp
Workers'Cnnspcnsation lauhisper aanilicd copy thcmof(Sec.3X00,Lah C.)which PARK FEL Y N
ars allempinyee's under this permit r GAS EA SYS 1 .4D LT /�' RECEIPT
N
Policy R n BUI TNG (VISION ES
Company �. 'OAS- v1.I�SYSTF.h4OVET14(EA PIANCHECK FEE
❑ Certified copy is hereby famished. I lei
❑ Certified copy is filed with the eiiy inspection division. ( GREASlVlh TR -#T*li 'OR GRADING Ili AA
CERTIFICATE OF EXEMPTION FROM WORKERS' GKEAsEP9/19 SOILS IZ:� y J
COMPENSATION INSURANCE
(This section need nm be rnmpleted lTtue permit is lomne hundred dolbvs(151 W) fXIFT� I?NH Y '.E
or less.)
I certify that in the perfomtanceafuhe work forwhieh this permit is issued,I shift WATER HEATER W/VENT/F.LCCIR
not employ any person in any manner so as m become subject to the Workers' PAID
Compensation LiwsmColifomia. Date WATER SYSTEM/TREATING Date R eiptN
O z Applicant
z2 NOTICETOAI'PLICAN'I:ILaftefmukingthis Cenificuesf Hsempuion.youshould NEW RESIDENTIAI.PLMB. SQ.Ff. NOTAL.
fA become subject to the Workers Compensation Provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE `
C QSEISMIC INCE
CONSTRUCTION LENDING AGENCY
U O we
I hereby affirm performance is a commuction lending agency for the perfomnce of I) ELECTRIC FBI"
Bar work for which this permit is issued(Sec.3091,Civ,C.)
I, Lender's Name PLUMBING FEE F Lender's Address QTY. MECHANICAL PERMIT FEE V 1 certify that I have read this application and nam that the above inf rm inion is MECHANICAL FEE
>. correct.l agree to comply with all city and county ordinances and sums,laws relatingto PERMIT ISSUANCE
building consumerism,and hereby authorise representatives ofthis city to enter upon the
U z abase-mentioned n lot ins lion ALTER OR ADD TO MECH. CONSTRUCTION TAX
grope y pec keepmea.
(We)agree m save,indemnify and keep harmless the City of Cupeni against
liabilities.jud nt.cust and -which may in anyway eccrvcagainmt said City AIR HANDLING UNIT(TO 10,M)CPM)
in con elat go(th i .mit.
IZ/ AIR HANDLING UNIT(OVER 10,000 CFM)
tures Apph r Dau EXHAUST HOOD(W/DUCT)
PAID
o HEATING UNIT(TO 100.000 RTU) Dam Receipt is
HAZARDO DISCLOSURE
W ill the appliwm m future handing occupant store of handle hmnNoua material s .
as defined by the Cupenino Municipal Cole,Chapter 9.12,and the I lcahh and Sam, HEA'1'INC UNIT(OVER IOO.Ilflll BTU) ra
Cole,Section 25532(a)4 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Wllhhevpplicanunfuwrebuildingnceupanluueyuipmunt ordevieeswblcM1 emit BOILER-COMP(dTTP OR IW,OW BTU) pp�� AID
^ 1haasrdous air coramma
inis defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.(X11 BTU) r i D
DrstricC
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT.
I have read the ha,allous materials me rimments under Chapter 6.95 of the MAY 121993
Culdmaia Health At Safety Code.Sections 25505.25533 and 25534. I understand that
if the building dres not currently have a tenant,that it is my responsibility to notify the (s
cupamt of the requirements which must be met prior to issuance of a Certificate of CI 11, Ur CU tTl I
Occupancy.
Owner aremburiudagem Date T - ` ISSUED BY:
OFFICE