24755 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL (;-ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PING R O,-T IDENTICAL 24755
BUILDING DIVISION BUILDING PROJECT IUNNTIHICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
DMEaTCAD /T UNIT# LOT
OWNERS AME: PHONE: CONTRACTOR'S NAME: LIC NO: /
C4,F�f 7A/�1 NIC CONTROLp
RCHITECf/ENGINEER: LIC NO: ADD ° 8: ` CJ// 49
a0
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG it
LECT PLUMB MBCH
PERMIT'ISSUANCE ` El
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
p p,� Iherehy:dlirm ohmlam licensed underprovlsionsofChapnrY(commencing with JOB DESCRIPTION
yO� fulhfoae aion �nJ effawin3of the Business and Rofessions//Code,and my license is in / PANELS
<7iy License Class Lie.p W/ • UPT0200AMPS
�?y Date Contactor _ «7— 201-1000 AMPS
70yK- ARCHTECT'SDECLARATION OVER ItX11)AMPS SQ.I2 FLOOR AREA 8/SQ.IT,
CZ-0 I understand my plans shall be used as public records.
F-rn, — ' SIGNS ELECTRICAL
Licensed Professional
C yv�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUITJMISC.
XC W, 1 hereby aRirm that 1 am exempt from the Comoneasex License Lew tube
W LLOO1 following teason.(Section]031.5,Busincssand Prefe,,am,Code:Any city or county TEMP.METER OR POLE INST.
f'—y; which requires a permit to conswcl,altar,improve,demolish,or repair any structure��Y� lino.it,Lc...also requires theapplicana fursuch Permit o file.signedoseemem POWER DEVICES
tyCOp Nut he is licensed punuant to the Provisions film Comira ,'e License Law(Chvpmr
dyo f' 9(commencing with Section 7M)of Di vision 3 of the Buxuass and Professions Code) SWIMMING POOL ELECTRIC
VALUATION
W'_^y or he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
�yY Section 903 L5 by any app)iwmapplicant for u permit subjects the applicano a civil penalty of
�_�0 men norethan live hundred dellms(S500). NEW RESIDENTIAL ELF.CIR —SQ.FT.
C E_o ❑ I,asownerofNepropcny,ormyemPloyaswithwagesastheirzolewmpenution , STORIES TYPECONSIRUCTION
will Bothe work,and the structure isnot intended oroffered forsole Xce.7l ,Business
and Professions Code:The Comruclnr's License Law rues not apply to an owner of
property wbo badds or improves,hereon,and who does such work h imsel f or l hrough h is
employees,provided that such improvements amnot irmabdoroffered forxale.If, pr S OCC GROUP' RIESUNITS
however,the building or improvement is sold within one year ofcomple ern,the owner- TOTAL:
builder will Immune burden of proving that he did two build or improve for pupwse of 3t
sale.).
❑ L asowner ofthe III anexclusivefy contracting with licensed contractors to QTY. PLUMBING PERMIT FEE E1001)70NE APN
construe,the project(Sec.]DPL Business and Professions Code:)The Commerc s
License Law doesnot apply Loan owoerofprownY who builds Orimprovev thereon,and PERMIT ISSUANCES
who Contrac¢Tor.mch Projects with acnntractor(s)licensed pursuant o the Contractor's
License law. ALTER (EA)) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW "f€C iVI OUTSIDE FEES
SANITARY Y_N
Owner Dae DRAINS-PL AOR,RObIR£A:CdNB. RECEIPT.
WORKMAN COMPENSATION DECLARATION _ SCHOOL TAX Y N
m
I hereby affirthat l have a certificate delineator t,seifi
lf-insure.ora cencam of Fl%TURFS- .R TAP V RECEIPT.
orkers Compensation Insurance or a ourifiN copy ohereof(Set.3800,Lab C.)which PARK FEE Y
covers N_
4" RECEIPTY
employ } nJ�r per)pu / GAS-EA.SYSTEM-11 INC.60 S
'-Ery y
Company l' AA _ A__- a _ BUILDING DIVISION FEES
c -
❑ Ced copy is M1ereby fumisM1CA. GASA.SYS PL NCHECK ME
❑ Certified copy is fled with the city inspection division.
GREASFIINDUSTRL WASTE INTERCEPTOR GRADING WE
CERTIFICATE OF EXI:MPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATIONINSURANCE
(This section rad not becompleted ifthe permit is forme hundred dollars($Ugu SEWER-SANITARY-STORM EA.200M. ENERGY PETE
or les,)
I certify that in the peffmanarm of the work for which this permit is issued.)shall WATER HEATER W/VENT/ELECTR
not employ any person in any mower as a became subject to the Workers' PAID
z Compensnim Lawsof California. Dam so WATER SYSTEM/TRFATING
Applicant Date Receiptp
Q
z 0 NOTICE TO APPLICANT:It.afar,making his Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Worker's Compenvatmn provisions of the labor Code,you must
fonhw ith comply with such lime isions or this permit she][be damcd revoked. BUILDING PEG
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7. z I hereby affirm that Nem is a construction fending agency for the performance of
U O the ware for which his Rcrmiojpystod(See 3197,Civ.CJ TOTAL: ELECTRIC FEE 'J
Leader',Name /1//J/VC- d
U I Lenders Address�Aln/xl'lnnl`- QTY. MECHANICAL PERMIT FEF. PLUMBING FEE
I mm y that I have dead this application and state Ira the.neve information is
corer'. IugreemenmPly with all city and county mNinanees and stmelaws rdatingm PERMITISSUANCE MECHANICAL FEE
_ building construction,and hereby authorize representadvesofthis city to enmrupon,he
U z above-mentioned property for an,,, on puryoses. ALTER OR ADD TO MECIL CONSTRUCTION TAX
(We)car t save,indemnif 1 kc p M1armle a We City of Cupertino against
Ipabplities.j Is,costsand ex s whichmay in any way accmeagaiaa said City AIR HANDLING UNIT GO Ig000 CFM)
in sense the Ing of is permit.
AIR HANDLING UNIT(OVER IQUUO CFM)
union, Applican ommanr Dae EXHAUSTHOODOODUCO
PAID
HA/AR S ATERI DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Racipop
ill the applicant of mmnildin pant score nr handle M1uea dmfs material y
as defim by the Cupertino M n:pu rale.CM1apter 9.12,end the Ilealth wd Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:.JV aso
Code.Seca
❑Yes No VENTILATION FAN(SINGLE RESID)
Willduapplicantorfulumbuildin mese BOILER-COMP(3HPOR 100.(00 BTU) ISSUANCE DATE
g he Bay equipmentQualit Management p�
hazardous sir commitments;as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10(1,1X0 BTU) V A i D
District) y
❑YLC.hf..i.H.hh
s 1h No NEW RESIDENTIAL MECH. SQ.FT.
real the hazardous materials requirements under Chapter 6.95 of the FEB , 9 1993
ahh&Safety Cade,Sections 25505,25533 and 25530. 1 understand theng does nm currently have a oemm,Nat it is my responsibility oo notify the
the rcImminems which must be met prior to issuance of a Certificate ofCI I Y UY k:Uren1 nvv
honzcd agent Date TOTAL: ISSUED BY:
OFFICE