24885 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY C:�1'
BUILDING
CITY OF CUPERTINOPLUMBING
-ELECT'RICAL PEUMITNO,
PIMECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTIDENTIFICATION 24885
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
D �� Dd ✓ UNIT# LO'T#
OW F:RS NAME C��ji- PIIONE: _O CONTRACTOR 9 ILIC NO: NIC CONTROLCp r—
ANCHITIiLT/ENGI EEk: LIC NO: ADDRESS:it, ❑
G Pirrr�o�v - �
CUN'JACf:N /�-I�PHON�zE: /� QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
��" OR �� d�/�D f/ PERMITISSUANCE -d0 BLDG ELLI�ECT PI.` h{EC{I
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL V � ` Ir1�1-
pCZ Iherehy affirm that l am licensed underpmvisions of Chapter9(commencing with JOB DESCRIPTION
4100 Section]WO)of Division 3 of the Businessand Poilessiona Code,andmy]]erose is in PANELS
FZy,ZW full force and effu'
y) License Lim.N ��� UP102W AMPS t
m G y Dam I Comrac� T 201-1100 AMPS
ZOt` K RCI IITECI"S DECLARATION OVER IOW AMPS SQ.17.FLOOR AREA S/SQ.IT.
O Z_C1 I understand my plans shall be used as public records.
F sot; SIGNS ELECTRICAL
d$J
Licensed Pm[eseionol
6 bar I ma-emerso t.DECLARATION SPECIAL CIRCUIT/MISC.'
W4 :i 1 hereby affirm that I am esemq from the Conmcmra License Law Ibr the
4cz.1i r"• which following reasoaerinit tocoi,.9.Business and Professions Code:Any ciryor..county TEMP.MEItR OR POLE INST.
X��2 which regnsrcs n Permit re quires due alter,Improve,demolish,or repair any structure
�}� prionoits issuance,also requires the applicant for such Permit n fie esigned sidmmenl WEN UEVICCS
C p that
9(commencing
ewd itthaSmucrion]WtheO)paro[vDislivoinsis onf3thmef tChe Business and Professions Code)
r
SWIMMING POOL ELECTRIC VALUATION
or tom he is exempt lhercfromand the break far thealleged exemption.Any vinlationof OUTLITS-SWI'I'CHHS-PIXTURCS D
G Z< Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penahy of
f S p not more than five hundred dollars(5500).
Ir�[~� ❑ I,asowneroflbeproNrly,ormyemployees with wages as 0teirsolecompensrtion, NEWRfSIDF.M'IALELECIR _SQ.FT. ISTORIES TYPE CONSTRUCTION
23- will dp the work,and the stmcmre is not imended proffered for.1.(Sm.]044,Business
and Professions Code:The Contmcmrs Littnu law does not apply to an owner of
property who builds or improves thereon.and whodoes such work himselfor through his OCC.GROUP RIS.UNITS
own emplayees,proviJod that suchimprovements are notimended muffemd forsale.If,
however,the building or improvement is sold within one yearof completion,the owner O D
builder will have the burden of that he did not build or improve for a TOTAL:
proving p p qwu of
le.).
❑ I,usnwnerof lM1e propeny,um exclusivelymmmncting with liceaseJ conmamors to QTY. PLUMBING PERMIT FEE FLOOD LONE APN
emisvuct the project(Sec.70,14,Business and Professions Code:)Tra Contrectors p R ISSUANCE
License Law does not applyto anownerofpro smy whobuildsor improves themom,and
who contracts forsuch projects with aamtmemds)Ileeosed pursuant to the Contractor's
License Law. ALTli11- RAIN&VENT'-WATER EA) FEE SUMMARY
❑ 1 amesempt under Sec. ,B&PC for this reason BACK FLO 'ROTECI'.DEVICE .SID.
5 ITARY YN
Owner DateA' RECEIITk
DRAT 5-F
WORKMAN COMPENSATION DECLARATION ,. A )ND SCHOOLTAX Y N
s:elo
❑ 1hembyaffimnhm l have a certificate ofconunt mself-insom,oracenificam of FIXTIIRFS- TRA RECEIPT#
Workern'Compenn Insurance oracenifed co _0, py thereof(Sec.3g00,huh CJ which PARK FEE V N
covers all employees under this permit. GAS-IS.S q.IND. 1' iTS .,rdT#
Policy# BUILDING DIVISION FEES
Company GAS- ASYS'1' 4( ) Pf #CHECK FEB Ss.
❑ Cert fird copy is hereby fa island.
Certified copy is filed with the city inspection division. GREA. - USTRL WASTE INT CFErrat ADING IqJ?
CHRTIF'ICATE OF EXEMPTION I:ROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE.
(This section need not be completed if Ne Permit is foronelmndooddollars(fIW) SHWER-SANITARY-slJORMEA.20D ENERGY FEE
or less.)
I certify Nath the performance of the work for which this permit is issued,]shot] WATER HEATHR W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensation Lawsrf California. Date WATERSYSI MPREATING Data Receipt#
Q Z Applicant
Z 0 NOTICE TO APPLICANT:IL after making this Ccoificate of Exemption,you should NEW NESIDEWAL PLMIL SQ,IT' 'TOTAL:
Fy become subject to the Worker's Compensation provisimrs ofrhe Labor Code,you must
W �_> forthwith comply with such provisions onhis permitshall be deemed revoked. BUILDING PER
6W. Q CONSTRUCTION LENDING AGENCY SEISMIC FEIi
1 hereby affirm thanhera is a construction,lending agency for the perfomunce of
U O the work for which this permit is issued Se.3 97,Civ.C.) TOTAL:Nvrr
ELECTRIC FCC O
Lender's Name t �� PLUMBING FEEF Lenaera rase �� QTY. MECHANICAL PERMIT
U I certify that 1 have read this application and state that the above information is S
7" a correct. l agree to nmtply with all city and county ordinances and state laws rebningm PERMITISSUANCE MECHANICAL FEE
" building construction,ondhamby amhorise representatives ofthis city to ctmerupon the p
U Z above-mentioned property for inspection puryoses. l ALTER OR ADD TO MF.CIL `OD CONSTRUCTION TAX
(We)agree m save,indemnify and keep harmless the City of Cupertino against
Iiabll0ics,Judgmcnm,c,rs1,and expenses which may lnony wayin,mi ulimastaaid City AIR HANDLING UNIT Go IO,"CFM)
in Can e of the ing of Is permit.
AIR HANDLING UNIT(OVER]O,Ilgl CFM)
lu ^ 3
ignvI ApplicunVCanvumor �/✓ Date EXIIAUS'r IIOOD(W/DIICf)
�✓ PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Wil l the applicant or fuuae building occupant store or handle hazardous material
as defined by the Cupertino M unicipal Code,Chapter 9.12,and the Ueabh and Safety HEA'T'ING ON I'J GVER 100.WO Bq'U) 'I'O"IAL: L{�.
Cade,Section 25532(x)
1:1Ycs No yENT11.AT10N FAN(SINGLE RESID)
WilHhea licuntorfmumbuildin ruse BOILL'R-COMP(3HPOR 100,000 BTU)
ISSUANCE DATE
pp goccupan equipment ord<vices whichemil
hazardous air contamirunu as defined by the Bay Area Air Quality Management BOILER-COME(OVER BELOW BTU)
Domoc,l
t ❑Yes XNo NEW RESIDENTIAL MECIL SQ,IT.
I have mad the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Core,Seatin is 25505,25533 and 25534. 1 understand that
ifthe to an,d nomaly have a tenant,that it is my responsibility to notify the
occupant, mmenu must met prior m t unm of a Certifc, of
Occupunc e
or ad agent TOTAL: ,19 1SSUI..DB It, ult s
OFFICE