24488APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECI RICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDF.N IFICA'I'ION
PERMITNO. 24488
BUILDING ADDRESS:'n
SANITARY NO.
APPLICATIONSUBMITTALDATE
/-. I
bIY /Y' UNIT# LOT#
f tom`
OWNERS NAME; PHONE:
COayTTRACfOR�S`NAMF.: .I Q'i Jt
NIC
CONTROL #
ARCHITECT/ENGINEER: LIC NO:
A'Li do Al Az _ _�Ia#n w D CaP
CONTACT: PHONE:
QTY.. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.e
(„ a R10p G—e $�
PF.RMIT'ISSUANCB
LICENSED CONTRACTOR'Svisiomof DECLARATION
I M1erebyaffDi ihatfsion ondunss and isionsimes Coar9(commencing is iM1
mine
SectimetiodefDivision3oRhe Business and Rofessiom Code, end my license is in
full farce and affiant.
License Cass Liap
APPI.IANCFS- RPSIDFNTIAL
PPNEfS
UP T02W AMPS
Sty. JOB DES�N /
w
�
'v���
Dine Cnmruaor
I�+
^ 5�9. I7. O A S/SQ. IT.
!F�p
201 - IfNq AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be ucad as public records.
OVER ION) AMPS
SIGNS ELECI
T E R�
Licamad Professional
OWNER -BUILDER
CIRCUCAL
SPECIAL CIRCUIT/MISC.
,4.(l
V
eECLARAETON
I hereby off that 1 an exempt from the Contractors License ity
fine forco the
TEMP. MCTER OR POLE INST.
following mason. (Section 7031.5, Rumness and Pro, in
oli Code: Any city or county
which requires a permit de
construct, alter, improve, demolish, or repair any structure
its e, s. re ( filtitLicense
POWER DEVICES
that hor e
mminat to the provisionsessout
licensed the Copermins
Law
9 (c he is licensed p Sectio 7the) of provisions of the Contractors License Law (Chapter
9(cnmmencing with Sermon 7") of Division3oFthe Business and Professions Cade)
orthut 7031. by
rcfromnt forpernot subjects theto Anyviocion of
anyapplicantfuru00). subjects the applicannnucivil penalty of
Section7031.5than
SWIMMING POOL ELECTRIC
VALUATIO��
OUTLETS - SWITCHES - FIXTURES
,a
t more than rvehundred dollars yempl
❑ 1,esownerofthepmperty,onnyemployeeswiN wagesestheiraolemmpcnsation,
NEW RCSIDFN'1'IAI. ELECfIt SQ. FT.
STORIES
TYPE CONSTRUCTION
will dothe work, andthe structure is not imendedoroffere4 for safe (See. 7094, Business
and Professions Cde: The Contractors Ligase Law does not apply to an owner of
property, wh,buildsmimpmves therwn,eml whmdoessuch work himeelforthrough his
employees, providedthat sac h ireprovemenD arc not i mended m offered home. If.
OC .GROUP
RFS. UNITS
TOTAL:
however. the building or improvement issmld within one yesro(completion. the owner-
builder will have Ne burden of proving thin he did not build or improve for purpose of
QTY' PLUMBING PERMIT FEE
wle.).
❑ I,mownerofthepmpeny,amexclusivelyconuactingwiNlicensedcontmcimto
FLOOD ZONE
APN
construct the project (Sec. 7044, Business and Professions CdeJ The Confr cmr's
License Lawdmornopply to annwnermproperty whobuildsmimproves thercanund
PERMITISSUANCE
who contracts formchpmjeuts with a contractors) licensed Pursuanno the Cmlmctm'e
License Law.
ALTER (FA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY N
RECEIPT#
Owner Data
DRAINS- FLOOR, ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofm sensto calf -insure, me cenifcute of
Workers Comptioution lnsurancemacenifedcopy Neremf(Sec.38W,Lab CJ which
RECF.IPf#
- FTKTURFS - PER TRAP
PARK FEE Y N
coven all employees under this permit.
Policy p
RECEIPTp
GAS - EA. SYSTEM -I INC.4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GRCASC/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE TRAP
SOILS FEC
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
Cnis section nod not be completed ifthe permit inforonehundrddollari(SIM)
orless.)
WATER HEATER W/VENT/ELECIR
I cemifydem in the performaneemfibe work far which this permit is issued. (shell
not employ any Person any manner so es a
bac reaqq t he Warriors!
wlo
penut f al omia�Dare ���'%J
ant
PAID
Date Receipt
WATER SYSTEMIDUTATING
N OpO AP NT.If. aking this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. f4.
TOTAL:
Ur
become subjectothe Worker' n1penution provisions ofthe Labor Core, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE toss""
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby offimt that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:ELECTRIC
FEE
Lenders Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that 1 have and this application end scale that the above infomation is
correct. I agree mcomply with all city and county ordinances And state laws reletiag m
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorise represenauves of this city toeroerupen the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify unit keep harmless the City of Cupertino against
liabilities,judgments,c s and expenses which may in any wayaccme ng.mo said City
AIR HANDLING UNIT (TO 10,00) CFM)
in s of th I ting ,f this permit.
H -13 -72
AIR HANDLING UNIT (OVER 10,0W CFM)
Sig IIIcore fA rlicant/C t ar Date
EXHAUST HOOD(W/DUCO
PAID
HEATING UNIT (TO IW.000 BTU)
11 DODS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant or future building occupant some or handle beam ous mashed
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER I W,000 Bllp
TOTAL:
VENTILATION FAN (SINGLE RESID)
Cala, Section 25532(.)T
CI Yes 13 No
ISSUANCE DATE
Will chanpplicanmrfuourcbuilJingoccupantuse equipmencordcviccnwhichemit
TOILER - COMP(JHPOR I00,000 BTV)
BOILER - COME (OVER I00,000 BTU)
hazardous air carnation as defined by the Bay Arca Air Quality Munugmom
DimicIT
p� ypk
IC L"k Q
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
I have read the hazardous materials aquiremencs under Chapter 695 of the
California Heohh & Safety Code, Sections 25505, 25533 and 25534. 1 undersand than
if the building does not currently have a form, thin is is my responsibility, to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
VUr�
Occupancy.
ISSUED BY:
Owner mr auchorird agent Data
TOTAL:
OFFICE