24599 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF,CUPERTINO . BUILDING-ELECTRICAL. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� / r/�
40:
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION c 4 559 YV
BUILDING ADDRESS: /� SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT If
OWNER$NAME � PHONE: C NTRACTOR'S NAME: LIC NO: NIC CONTROL#
n In Z
ARCHITF,CT/ENGINEER: LIC NO. ADDRESS: ❑
L G I V
CONTACT: PHONE: BUILDING PERMIT INFO
/.N L%yr�IIC� L �// �/�. ���(,f) QTY. ELECTRIC PERMIT FEE
C—`, ` 1 —agwc\ •01_/� -_Iv`o PERMIT ISSUANCE JiW* EL T PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'SDECLARATION APp1.IANCES-RESIDENTIAL
p00 Iherehy ufE Division
amlicensed Br randerpnes,a dProfesio Ch odea d nmecense with JOB DESCRIPTION
s00 Smlforce I1)of Dlvis onJ of he Business and Professions Code,and my license ism PANELS
aw tart force and erten. t
�Z License Class Lic.# UP To 200 AMPS L
,<a. Data Convacmr 201-IOW AMPS
ZFOrv'irZ ARCI IIT ECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0z C) I understand my plans shall be used as public records.
p=y F w SIGNS ELECTRICAL
Licensed Proverional -
K
K< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t
W'Oy F 1 hereby .f(Se IM1m 1 am exempt from the Contractors License Law for the
w 3 O m following reason.(Section 9031.5,Business and improve,
dr ions Code;Any city or county TEMP.METER OR POLE INST.
W W O7 prior
ri rM1 requires o issuance,aka
cores the,alter,improve,demolish,or repair any statement
WN<0 that be is lerroxiursuant to the
tpocohicamlohe Cr Permit rile a License
La ttahapter FEWER DEVICES
w�.00 thatbelicensedpursuantmthe provisionsof the he Buenos,
Law(Chapter
°i'e 9(,ommencingwith Scmion9W0)ofDiviaion3o[the Business and Professions Coale) SWIMMING POOL ELECTRIC VAIUAygy
wMm onhalhceasamyuherefmmond the basis fartheulleged exemption.A.yviolalion of OU9'LETS-SWITCHES- — _ l SSV
FZQ Section 9031.5 by any applicant for a demerit subjects the applicant to a civil Penalty of FIXTURES /WMY/
�= not more IM1a.five hundred dollars($500). NEW RESIDENTIAL ELECTR _SQ.PT.
� p ❑ i,axnwncr.fthc property,nrmyemployecs with wugesastheirsolerompensalion. STORIES TYPECONSTRUCfION
G will do the work,and[Ile stricture is not intended or offered for sale(See 90W4,Business
and Profesaions Code:The Contractors License Law does not apply to an owner of
property who buildsor improves thereon,and who deessuall work himselfm through his
on employees,provided that such improvementse not imendedoreffered forsale.If, OCCGROUP RES.UNITS
hoar
wever,the building or improvement is sold within one year ofcomplelion,,he owner- TOTAL
builder wil I have the burden of proving that he did not build or improve for purpose m'
sale.). . PLUMBING PERMIT
❑ Leri the ,aof th(So,.7y,umexelusivelyco Profession,
with le:)Tiircontractors lo CITY FEE PfAOD ZONE APN
onawd the does do'
(Sec.9044,Business and ywhobuild Cotler)The Goodarturs
License Law doesnolapply toUnoh.ccarpropedywhobu fictimprovice Commitand PERMIT ISSUANCE
Ld.icense ersLaw.
for such pmjeds withacommnm(s)licensed pursuant to the Contradora ALTER Law. DRAIN&veNT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. ,R&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FCC
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby infirm lhatlhaveucenificam ofconsenv...f(Snsure,ora,enil)whiah FIXTURES-PER TRAP RECEIPT#
Work.i Compensation lnturanw oraeedified copy thereof(Sec 3500,LaM1 C)whi,M1 PARK FEE Y N
POHall em a sunder RECEIPT#
Isc�ppdr is f GAS-EA.SYSTEM-1 INC.4OUTLETS BUILDING DIVISION FEES
any �G'—L MirGAS-EA.SYSTEM-OVER4(EA)
.edified copy is hereby rumished. PLANCHECK FEE
Certified copy is fled with the city inspection division. GREASEsINDUSTRL WAS'IF INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisaemlon.eed nm be completed It'he permit is torone hundred dollars($100) SEWER-SANITARY-STORM EA.200PT.
inlets.) ENERGY FEF.
1,voily that in the performance crime work for which lM1i,,permit is ivaed,l Shall WATER HEATER W/VENT/ELECTR
not employ any person In any manner so as to become subject to the Workers' PAID
z Compensation Wwsof Calffomia. Data &NEWRESIDENTIAL
EATING Date Receipt#
Q Applicant
z NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you shouldPLMB. SQ.ET. TOTALDO bco me subject m the Workers Compenmtion provisionsof the Labor Codeyon muss7 forthwith comply with such provisions or this permit shall be deemed revoked BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE.7. Z Ihereby affirm that them is o continuation lending agency for the performance of
fJO the work for which'his permit is lotted(Seo.3099,Civ.C.) TOTAL' ELECTRIC FEELenders Name
w0 UTraders Address ICAL PERMIT FEE PLUMBING FEE
1 codify that 1 have mad this application and state that the above information is
F0.Wi come(.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
Z) bulldingconmmcnao,and hereby authorize repremmativoaoflhia city m enlerupon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSPRUCTIONTAX
(Wu)aged,to sav,indemnity and keep harmless the City of Cupertino against
liabilides,judgmen -and expenses which may in any way accrue again.said City AIR HANDLING UNIT(TO IO,OIXJ CFM)
n,omequene Ili ,anti.,.'this permit.
IZ AIR HANDLING UNIT(OVER I0,000 CFM)
gnamreof Appltea I/ racmr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Receipt#
Will IM1a applicant of future building occupant score or handle haearde e,material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 D'FUt TOTAL:
Code,Section 2553200
❑Yes ❑No VENTILATION FAN(SINGLE.RESID)
Willlhealicanlor future building eceuquTi
panl useeent ordevlces which emit BOILER-COMP(3HPORID0,00ft ISSUANCE DATE
�hauNus air coninnms as defined by the BUY Arca Air Quality Mnna%,menl BOILER-COMP(OVER TEMP BTU)
Dinricf!nppmm
❑Yes ❑No NEW RESIDENTIAL SUCH. SQ.FT. � A
I have read the hazardous mamriels requirements under Chapter 6.95 of the n
C.lifomla Health&Safety
Code,Seninna 25505,25533 cod 25534. I un
that F.#
if the building fines Hol contently huven¢nanl,Ihnt it it my rcsponsibilitymnotify the n/1
Uoccupant of the requirements which must be met prior to issuance of a Cartibcate or `((�� �( Oi 9�.
ccupanca 11//r yr 1�`�<�
Owner orumhonzcA agent Da¢ TOTAL ISSUED BI .
OFFICE