24919 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECT RICAL PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 24919
BUILDING DIVISION BUILDING PROJECT WENT[FICA DON
BN DING ADDRESS: SANITARY NO. APPLI A�TIONSUBBM��ITTTALDATE
V UNIT# L(YTp 5-24
OW NF C: PItO E: ONTR CfOR'S NAME: LIC NO: rl_ 11..a�.��
NIC CONTROL#
HI '/ENGIN LIC NO'. DRSS: E
CONTACT. PHONE.: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
E PI M MEC
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL D10 C�IP�OI{.
Otez I herebyanm
ffihat l am licensed undaprovisionsofChapter9(eommencingwith r,fa��.�_7 /`r,,j'*` •Q+
[ 00❑ Section7W).f Division 3 of the Business and Ponfessio.s Code.and my license is in PANELS r
fall Armenian effect. l��sr����
pa„Zu1 License Class Lie.# UPT02MAMPS
m ��y�Iii
<y Date Contract., 201-IOW AMPS rz4DOV
Z 8„a LA
ARCHITECTS DECLARATION S G
OQ
OZ^-C 1 urWcrst.land my plane shall be used m public LA records. OVER 1000 AMPS
N(_W SIGNS ELECIRICA
Q yy��� 1.¢cnsW Professional
Sys 6 OWNER-BUILDER DECLARATION SPECIAL CIR T/MISC.
440Oa I hereby n.(m that I am exempt from the Conimm Cs License Law for the ���
txOay following rcma. onOr)0a.eeminessand eConamu CML:Anycityor for
TLMI'.MET RrPoL.INST.
riaI which mundma a permit to construct,after.improve,demolish,or repair any structure
7 P,imto its Women,also qire
u ,the applicant for such Permit in life a signed statement POWER DEVICES
W;!�QO that be is licensed pursuant t.lne Frvisinmoftbe Cmroomes License Law(Chapter
9(cninammith with Section"I"Im'Division 3ofthe Business and Professions Cede) SWIMMING ELECTRIC ' V/A-LUATION
�y or that he is exempt therefrom and the basis for the alleged exemption.Any violada of ,EL'S-SWITCH XTU 5 �{/�
�Z G Seat!..703 L5 by any applicant for.permit subjects the applicant m o dvd Dory of
� C not mom than five hundred dollars 4500). NEW RESIDENTIAL EL 5 ,FT,
C ❑ I,mownaofthepropenry,ormyemplo mwithwagesastheirsolecompenmtion. Q STORIES TYPE CONSTRUCTION
y § will do the woh,mnd mhesmict.re isnot immndMmoffe,ed formal.(San.J044,Business
.it Professim,Code:The Contractor's License Law does not apply to ua owner of
properly who builds or improves thereon,and who dos such work himselfor through his OCC.GROUP RES.UNITS
own employees,provided thatsuch improvemen,sma not intendedoroffe,W forsale.If,
however,the buildingor improvement is sold within one yesrofcampletion,amownerfi
-
buil will hove the burden of proving the he did not build.,improve fapuryoscof
,mowneroflhe prpcny,am exclusively contracting with licensed con,mmonm QTY. PLUMBING PERMIT ?_�
FIAODZONE APN
codaI ct the project(Sec.1UM4,Business and Professions Code:)The Contractor's
Livenac Law doesnot applyta annwnernf property who builds orimpmv<stherea.and PERMIT ISSUANCE
who contracts forsuchprjccts withaconvanor(s)licensed putsuent House—stmomrs ALTER-DRAIN&VENT-WATE '�EA
License Law. FEES ARY
❑ 1 am exempt underSec. ,B&P C for this reasonBACK F10W PROTECT.DEVICEY N
nen Data DRAIN#-FLOOR,ROOF,AREA, BOND — RF,CWORKMAN COMPENSATION DECLARATION I ' eH^ Y NI hereby affirm Nat l have a cenificam ofcouent tomelf-imam,or a certificate a( fa
EIXTlIRES-PLR TRAP RF.0:IPfp
Aems'C.mpensminn lmumncenraartified roPY thereat(See.JSW,Lab CJ which FEY N
covers all employee's under this permit. GAS-FA.SYSTEM.I INC.40 .TS I RE i1PT#
Policy# DINGD ISIONFEFS
CompanyCarert
❑ Cified copy is hereby fumisheJ. GAS-V.A.SYSTEM-OVER 4 BIA) PLANCHECK FEE
❑ Carofied copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE yrs•
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
phis section need not becompfetedBNe Permit is Income hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE �..�
or leis.)
I certify that in to performance of the work for which this permit is issued,l shall WATER HEATER W)VENTIELECIR
not employ any Person in any m a
s a to became subject to the Workers' PAID
Compensation Laws of Califomia. DateWATER SYSTEMIUIEA'I ING Dale Receipt
O Z Applicant '
ZQ NOTICE TO APPLICANT:ILafta making this Carificeie of Exemptimit should NEWRESIDFNTIALPLMB. SQ.FT. TOTAL:
p (q become subject the Wo6er's Compensation provisions of the Labor Code,you must
[�^ ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE ►'#
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
C� I hereby affirm that them is a conswmion lending agency for the perforce nce of 417
L) O the work for which this panni,is issued(Sea.3092,Civ.C.) T ELECTRIC FEE Z
r-m Landcfs Name PLUMBING ME
P I-ander,Adam. QTY. MECHANICAL PERMIT FEE
U I emify that 1 have sad this application and stem Out the above information is
RWi carred l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL ME
buildiallems.an.n,and hereby mahodu mpresenmtiva.f thisciry mamrupomM1a CONSTRUCTION TAX
V Z above-mentioned PmPeny for inspection purposes. ALTER OR ADD TO MSCI I.
(We)agree a save,indemnify and kap harmfen,he City of Cupertino against
liabilities.judgments,costs and expenses whichmay in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in comequ g e of the grunting of this a tit.
^ AIR HANDLING UNIT(OVER 10.010CFM)
Signet eofAVicanUCoutmct.r IDie EXHAUST HOOD W/DUCq PAID
HAZARDOUS MATERIALS cecAIS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dale Receipt#
Will the the Cuaertim,ion or Mu buplCode,Cameron.anMlehazamus lth and Safety HEATING UNIT(OVER 100,000 BTU)
al
mdefined i the Cupertino Municipal Cede,Chapter 9.12,end the fleuhh and Safety
Cede.Swoon 25532(a)^
❑Yo.t CI No VENTILATION FAN(SINGLE.RESID)
ISSUANCE DATE
Will theapplicmtmfmuabuildingwcupemuu equipmemordevireswhichemit
BOILER-COMP(3HP OR 100,00#BTU)
action air contnmunants it,defined by the Bay Arra Air Quality Management
I1 BOILER-COMP(OVER 1W,”BTU) ,
Ely. ❑I .
�Im NNEW RESIDENTIAL MECH.—SQ.FT.
I have read the his M.m materials requirements under Chapter 6.95 of Ne
California Health&Safety Cride,Sections 25505,25533 and 25534. 1 untenanted rated that
if the building des not currently have a memo,,that it is my responsibilresponsibiliresponsibility
to notify the
cupsm of the requimmats which must be mel prior to issuance of a Cenificate ofC/ as
Occupancy. //`
watern
o .ramhOrimd oga P Z9 \
I Doe TOTAL: ISSUED BY:
OFFICE