24800 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 24800
� /I H O O
APPLICATION/PERMIT PLUMBING-MECHANICAL G i.I
BUILDING DIVISION BUILDING PROJECT IDERn FICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITI'ALDATE
UNIT# LOT# .2-0) ^` e2
0 PHONE C ACTOR'S NAME: LIC NO: N/C ^CCOONTRJOL#
ARCI 111PCIDENEN�G[NNEEER: LIC NO: 8/IPIRLSS: ❑ //��
CONTACT: t/ t �.a PI10 - QTY. ELECTRIC PERMIT FEE UUILDING PERMIT INFO
�L ` BPLU B 1E 11
P[RPERMITISSUAISSUANCEIg >?
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL
LOB DESCRIPI'lON
not I herchy affirm Nat l sn+licensed under provisionsof(Chipler9(commencing with
F�00 Section70M)of Division 3 of the Business and Professions Code.and my license is in PANELS
!y 1'-11 curve and affect.
U
Liu# UP TO 200 AMPS
DatFzw ensc Cluss
m?y a¢ 1 ECrS D 201-RkYJ AMRS SU.FI'.FLOOR AREA S/,SQ.FT.
Fy/ ARCIII'1'ECI'S DI3CLARATION OVER IOW AMPS
C Z—2 I unJemonJ my plans shall be used 3x Public records.
CZ-2 IL
SIGNS F.I,ECI'RICA1. 5�
QY�; Licensed Processional
�'ei OWNER-BUILDF,R DECLARATION SPECIAL CIRCUPCIMISC.
KOaO 1 hereby affitaa chat I am exempt(roto Ne Con uccmr's License Law for the
tyl3 LL h following muwn.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F�OQ
which«arm.,a permit m concoct,31mr,improve,dent.hsh,or repair any sooaure
to its i+,mance.alsor thea Iican fm such 'I to file a.si dstatement POWER DEVICES
Prior cr 1. h pp penin gine
,,0 9(croun he islicemeJpua,tim.7heprovisionsn the Commaor's Lice nae Law sion,Cre) SWIMMING POOL FLECIRIC
11p�' 9(connnencing with Seclinn]fgNl)of Uivixion3nfthe Business cod ProfczsinnsCodq VA ON
Wim or that he is exempt therefrom and the basis tin the alleged exemption.Any violationof
FZ_Q Sectio 170315 by any apps icons far apc—it xubjecta the applicant m o civi l penalty of OUTLETS-SWI'1 CIMS-IIXTURES
I more than live hundred dollars(SSW).
�_� NEW RESIDENI'[At,ELECTS SQ.I . STORIES TYPE CONS IRUCI)ON
aKfm n❑ othewrk,andeestructure y,oro otintnded arrofwed forstbeirsec. 0,14.Bsiness
3— and dothcsime,and the he Contisnots Licnsor awdosnot apply to an wner of
and Ncy woore Cale:The ves trecmrs nd who law does not apply to an owner of
pmpcny whubuildsrrimpmves thcrton.and whodmaauchwork M1imsdforNroughhia
cmployees,pmvidedthm sucb impmvememsarenotimendMormffcrcd(rotate.IL OCG GROUP NIS.UNIT'S
however,the building or improvement is sold within one year ofcompletion,the owns- TO
builder wil I have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE
❑ I,®ownereflhepmpeny,amexclusivelycnmrmtingwithlicenttdcomraetnnto Iq.00D APN
instruct the project(Sec.7044,Business co
d Professions Code:)The Contractor's LI
I`iccnse Luwdnes not apply man owncrnf pn,pcdy whu builds mrimprovcs thcnem,and PERMIT ISSUANCE
who rommms for such pmjecs wird acon6acmr s)licensed command to the Contractor s
Liccnsc Luw. ALTER MM
DRAIN&VENT-WATER(E/id FEE SUMMARY
❑ 1 am exempt under SM. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY V N
Owner Data DRAINS-FLOOR,ROOF,AREA.COND. RECEIP #
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I bercbyaffrm that I have acenificateolcontent to self-insure.oracenlftemeof FIXTURES-PER TRAP RECEIPfp
rr
Woesi Compemm
atlon losuneeoracerifiedcopythereof(Sec.38010.Ul,CJ which PARK FRE Y N
coven dl employees under thin permit. GAS-PA.SYSTEM-1 INC.4 OUTLETS RECEIPTa
Policy# BUILDING (VISION FEDS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ME
❑ Certified copy is hereby fumislccd.
❑ Cenilied copy is fdcA wish rbc city lnspcalon division. GREASE/WDUSTRL WASTE INTERCEPTOR GRADING Viii
CERTIFICATE 017 EXEMPTION FROM WORKERS' GREASETRN' SOILS FITE
COMPENSATION INSURANCE
(This seetlooneed not becomplemd if@e permit is tomos hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE .0co+
a,Ic J SM
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELEM
not employ any person in any manner re to become subject m the Workers' PAID
Compcnuuorl�usof Califomia. Date WATER
WATER SVSTENITREATING Dae Rcoc
Q ZAPplicanr
z NOTICE TO APPLICANT:If.after making this Cenificatnof Exemption,you should NEW RESIDENTIAL PLMR. SQ.Irl'. TOTAL:
t-+ t� become subjecto the Worker's Compensation provisions of NC LuMu GMe,you must
F` Outhwilb comply with such provisions or this permit shall be deemed revoked, BUILDING FEE
F` [� CONSTRUCTION LENDING AGENCY SEISMIC Fiili
1 hereby affirm thatthere is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC FEE
Landers Name PLUMBING P
0 F- Under's Address QTY. MECHANICAL PERMIT FEE
U I rectify that I have read this application and sore had me above information is �� MECHANI ,L FRT:
correct.I agree to comply with all city and county ordinances and state laws relaing to PERMIT ISSUANCE
F- b(ZIuilding concoction,and hereby authorize mpressnueves ofthis city mentor upon the CONS UCTION TA%
U z aM vearmlioned pm,ay for inspection purposes. ALTER OR ADD TO MECIi.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmenss,costs:mdexperaes which may in any way accme against said City AIR I IANDLING UNIT(1010,000 CFM)
in....o luence nI the g.dng at Ni x pcm,il. /ate
AIR HANDLING UNH'(OVER I0.0MX1 CPM) V
Sigwmre of ApplicanVConracmr Eau pi IAUST I IOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicaat or future building occupant score es handle hszaraous mate dal HEATING UNIT(OVER 100,000 BTU) TOT L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(3)] VENTILATION PAN(SINGLE RESID) e.
❑Yes ❑No
Will Iheapplicantnrfulurc building orcupamuse equipmenmrtlevicen whi<hemit
BOILER-COMP(3HPOR 100,00013TO) UANC Uj1TE
haaarylous'air contaminants as defined by the(lay Area Air Quality Marugcmem BOILER-COMP(OVER 1(10,000 BTU)IA /�
DiOncl'I 1993
❑Yes El No NEW RESIDIiM1' L MF,CH. SV.IT. CII r V
I have read the hazardous materials requirements under Chapter 6.95 of the yr lill/'efl
California Health&Safety Code.Sections 25505,25533 and 25534. I understand Nat
Blue building does not currently have a tenant,that it is my respaasibduy m notify the
srmpant of the requirements which must be met prior to issuance of a Cer ifiwm of
Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE