24640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILLU -LLECrRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 24640
BUILDING PROJECT IIIENruriCATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONNSSUBMIIyyyTTALDA'IE
UNIT# — LOTN
O NERS NAME: PHON@ NTRAC'TOR's NAME: JLV LIC NO:
^ _ , , NIC CONTROL#
A i1TEC'I'/ENGINEER: _I LI-CI NO: ADDRESS: l•` ^/
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
F �� PERMIT ISSUANCE BLDG 3.E PLUMB MUCH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL FOB DESCRIPTION
no4z I hereby affirm that l an licensed under,rovisiovs of Chepmr9(commencingwith
J400 Section'1000)ofDivision 3ofthe Business and Professions Code,and my license is in PANELS
5dE full farceandeffect.
cQQ. yl Lice CI s Lic.A a- UP TO 200 AMPS
to 7 y Dare Conran 201-1000 AMPS SQ.FT.FLOOR AREA $/$Q.FT.
ARCHITECTS DECLARATION - OVER 1000 AMPS
OZN—❑ I understand myplans shall be used as public records.
F y t"i SIGNS ELECTRICAL
Licensed Prdessioml
KK OWNER-BUILDER from
m CLARATION SPCCIAI.CIRCUIT/MISC.
O0 V 1 hereby affirm that 1 con exempt from the Commas Co A:AnLaw for the
B]3P-vFi ffollowing rceson.(stttion]B3 LS,Busincas and Professions CWe:Any
city or county TEMP.METER OR PoLE INST.
G:E:y l which requires a permit to construct,alter,improve.demolish,m m,air any structure
1;yY7 prior to its issuance,also requires the applicant for such Permit file a signed statement POWER DEVICES
yy�as a that he is licensed pursuant to the provisions of the Contractor's License law(Chapter
,a. C 9 SWIMMING POOL ELECTRIC VALUATION
DLL (commeis ixemit therefrom
a Division Sof theed exemption.
Professions Cadet)
Z- At that h7031.5 by any Applicant
from and the permitortheas the
s,xentnt to civiny l
of OUTLETS-SWITCHES-FIXTURES
Za Section ante by anydreddanlfo(epermit subjecu the applicnm toacivil penalty of V
not more than five hundred dollars($500).
'�O NEW RESIDENTIAL ELECfR _SQ.M. STORE TYPECONSTRUCTION
W m ❑ athe wok,and
f Asthei(m.compensation,
a will Bothe dons and e:rte Contractors
intended License
Law
dos not apply to 44,Business
unit Professions Code:The Cnnvame/e License Law Bros not apply to an owner of
property who bu i Ids or improves there nn,add who docs such work hi mself or through his
OCC.GROUP RFS.UNI CS
ownhoweverloyees,ping orimprovcnimpmvementsanormycarofoornf&red for ole.If,
however,illha lmema denofementissold haildethinoneyvar of completion,the purpose of T q
hda). will have the buNen of proving that he Jid not build or improve for purpose of
'sale')'
❑ bus owner of the property,umexdnsively, convening with licensed commQTY. PLUMBINGPERMIT FEEctorsto FLOOD'tONE APN
onstrua the project(sec.90Q Rusinesx And Professions Code:)The Contractor's
License Lawdresnot apply toanowneroTropeny,who builds or improves thereon,end PERMIT ISSUANCE
whocommctsforsuch projects withacolmelo(s)licensed pursuant to she Contractor's ALTER-D Ei W :R .A) s FEE SUMMARY
License law.
ES
❑ I um exempt under gee. ,B&PC for this reason BACK FLOW RO Cr.DEVICE.' I E
_ _ SANITARY Y N
Owner DateDRAINS-R F ARNA. ISN RECEIPT,
WORKMAN COMPENSATION DECIARAT10N uv u U h SCIIOOLTAX Y N
❑ I hereby affirm Nat l have ocertifcareofconsent to self-insure.or acenificateof FdX.1.U'ES-PER TRAP RECEIPT,
Worked Comp'oev�nsseaatiouunnnlncs'u�tI1atrIm{Forprr��a certified copy,thereof(Sec.3800,Lab C.)which PA FEE Y N
Povera.111ea RF_Li'/vAdErtyl1°n'[i GAS. . .SYSfF: - REC Pr#
licy# BUILDING DIV ION FEES
Company GAS-EA.SYSTEM-OVER4(FA) PLANCHECK FEE
❑ Cenifiedeopy iilumryfumished.
$,Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
- \ CERTIFICATE OF EXEMPTION FROM WORKERSGRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be,completed ifthe permit is barons,hundred dollas($100) SEWER-SANITARY-STORM FA.200FT. ENERGY FIt
or less.)
I cerifydat in the ,to..of Ne work far which this permit is issued,l shell WATER HttATER W/VENT/ELEM
not employ,any person in Any manner so As in hasome subject to the Workers PAI
Cmmpcnmtion Iowa.(California. Dam WATER SYSTEMflREATING LXDAM Receipt#
,2 Applicant
Z C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
ie f/3 become subjeeuv the Workers Compensation provisions of the l,abm Code,you most
5 forthwith comply with such provisions m this permit shall rte deemed revoked. BUILDING iF
W [� CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby af1'mn that there is a construction lending agency for the performance of
U O TOTAL: F.LECfRIC FEE
the dark for which his permit is issued Sm.3097.civ.G)
IS
D. Lendds Name
Ems'" Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L) I certify that I have read this application and state that the above information is MECHANICAL FE
corral.l agree to comply with all city and county ordinances And state laws relating to PERMIT ISSUANCE
p" buildingconstruction,and nerebyawharioreprcsemetivesof thio<iry to emerupon the CONSTRUCTION fAX
V z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to mve,indemnify and keep hamdess the City of Caper inm against
.-. habiliy"�sjudgmcroscoutsand expenses which may in any way accruengainst said City AIR HANDLING UNIT(TO 10,000 CFM)
incot�kyuucnceof t�rs ting of this permit,
(/I( f Iifn AIR HANDLING UNIT(OVER 14000 CPM)
Signmureof Appheam mmnor ate EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Da¢ Receipt#
Will the applicant or future building occupant store or handle haxadous material HEATING UNIT(OVER IW,IXIp BTU) TOTAL:
as defral by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Jsl
Code,Sation 25532(x)? s./ VENTILATION FAN(SINGLE RESID)
❑Yes No
\ BOILER-COMPCIHPOR I00,00i ISSUA DATE
Will the upplicantorfuwmbuildingoccupant useequiparentordevices whichento ,aa I1
tutu ishma air contaminants As defined by the Bay AMA Air Quality Management BOILER-COMP(OVER 1110,000 BTU)
District? �/ g3
r ❑Yes YlNo NEWRPSIDENTIALMI:CH. SQ.FT.
I have read the Inert s materials re,maremems under Chirpier 6.95 of the
Cdiform.Health&Safety Cade,Sections 25505,25533 end 25534. 1 understand that V051
ifthe building diva not currently have a tenant,that it is my responsibility to notify are Ur VUf
occupa of the require t which most l e met prior to issuance of a Cetnfice¢of ``,Sy
Y
Owner or oath ri em I TOTAL: ISSUED BY:
OFFICE