24646 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL MUBNG-ELECTMECH NIA. PERMIT NO.
APPLICATION/PERMIT vING PROD CU IDEN1 IFIC
CAL
BUILDING DIVISION BUILDING PRO.IR(TI'II1RN'I'llrfCA'1'ION 24646
BUILDING ADDRESS: 1 . , SANITARY NO. APPLICATIONSUBMHTALDATE
so" Fo W UNIT# LOT
OW :RS PU 1:: CONTRACTOR'S NAME: LIC NO: �" l
VxMW N/C CONIROL#
ARC TF.LT/ENGINHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDq ELECT PLUMB MECH
PERMIT ISSUANCE L#�`
LICENSED CONTRACTOR'S DECLARATION gppL1ANCES-RCSIDCNTIAI. JOB DESCRIPTION
I hereby affirm thin l am licensed under provisions ofChapmr 9 lcummencing with
tF�i-OSection finaciand ofcivision3of the Business and Professions Code,and mylicense isin PANELS / ft" �4"�
z Lie name and attar. V\
Fzy) Date ClassContractor—
'UP T02 AMPS
rn t y Dane Commaor 201,I"AMPS
0 FOyZ ARCHU DECLARATION DECLARAON OVER IWO AMPS SQ.FT.FLOOR ARIA SrsQ.Fr,
OZ�❑ IunJersmnJ my phms shell be used as public records.
<r.F-W SIGNS ELECTRICAL
C 5aJ Licensed Professional
WU OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MISC.
�0.0.�ddOy 1 hereby affirm that I em exempt from the Comructors License Law for the
u1'3�O`F" following reason.(Section?0315,Business and Professions Cade:Any city or county TEMP.METER OR POLL'INST.
�tn,� which rtquirts a permit m conmrvct,Wa,improve,demolish,nr rtpair any smnum
E YM prinnui¢issuance,also rtquimsthe applicant forxuchprnnino file asigned statement POWER DEVICES
y�j 00 than he is licensed pur manuo the provisions ofthe Contramen s License Law(Chapter
dM�toff 9fcnmmcreingwitb Section 9000)of Division3 ofthe Businessund Professions Code) SWIMMING POOL ELECTRIC VA I9BION
I—to or but he is exempt theretram and the basis for heulleged exemption.Any violation of OUTLETS�SWITCHES FIXB'URFS �Z
kZQ Section 7031.5 by any optician for a permit subjects the applicant a civil penalty of
O at ,rea5ow Bve hundred dollun(S5W). NEW RESIDE! ELECTR —SQ.PT.
.....
ra Zprorerty.ormy employaawithwegesaathcirsolecompensmion, STORIES TYPE CONSTRUCTION
I
I dashcwork,and thommemre istim ateralc6mafferedfinatme(Sec.7044,13minen
d Professions Cade:The Contractor's License Law does not apply to an owner of
property whobuildsor improvathercon,and whodocs suchwark himselforduough his OCC.GROUP RFS.UNITS
ownemployers,providedthatsueM1impnvld witarcnot Intendedorafrern{far own
.
however,the building mimprovement issolde didianeyearo,imr,a eortheowner- TOTAL:
builder mil l have the burden of proving that he Jid not build or improve for purpose of
la).
❑ Las owner Ornhe property,ran exdusivelycomructingwithlicenud conmcmrs t0 QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
emtsuuct the pmjat(Sm.7N4,Business and Professions Code:)The Contractor's p1iRMIT ISSUANCE
License Lew does not apply man owner o f property w ho hu i Ids or imprmes therton,and
who nmhans forsuch projects with a mmranor(s)licensed pursuant a the Comment's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C mr @is rcmnn RACK FLOW PROTECT.DEVICE O S DL SEES
SANITARY Y N
Owner Date RECEIPI'p
DRAINS-11.000..ROOF.ARCA.GOND,
WORKMAN COMPENSATION DECLARATION SCHOOL TA% Y N
❑ Ihmeby afFrm nhatihaveacenificuro of ennsem mselhirmure,nracertifiewn.fRECIAPTN
1>IXTURES-PER TRAP
Wnrkern'CompensnniOn Insurance orucenified copythereof(Sec.Jg00,IxbCJ wM1ich PARK FEL YN
emomi all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTp
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYST1?M-OVFA 4(EA) PIANCHECK FCC
❑ Ccobledcopylshcmhyfamished.
❑ Certified copy is filed with the city inspection division. GREASF/INDUSMLWAS'rl?INTERCEPJ'OR GRADING FEE
CERTIf1CATL'OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe#ambo is for one hundred Rkms(EIWI SEWER-SANITARY-STORM F.A.20OFT. ENERGY FEI?
m Ic.w.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HFA'1'ER W/VENAILECTR
not employ any person in any manner ser as to became subject no the Workers' PAID
Compensation Laws of Califamm. Date WATERSYSTEMfrREATING Date Receipt#
Z Applicant
O NOTCH TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RF.SI DENTIAL PLMIL SQ,Fr. TOTAL:
t-t En become subject to the Workers Crnnpensutio.provisions ofine Labor Code,you must
> forthwith comply with such provisions or this permit shall be dame)smoked. BUILDING FEE
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is it curromcdon leadingagency for Hite perfmaniueof TOTAL: ELECTRIC FEE
L) O the work for which this permit is issued(Sm.3097,Civ.C.)
Lenders Name
U Lenders Address QTY. MECHANICAL PERMIT FEB PLUMBING PEE
1 certify that I have read this application and state that the above inf cmmion is
W
cnrzect. Ltgrcem nmtply with all city unJ county nNinunces and amts laws relining to PL'RMIT ISSUANCE MECHANICAL FEE
k, building construction,and hereby audience representatives of Nis city memerupon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree ro save,indcmrdfy and kap h imades5 the City of Cupertino against
liabilities,judgments,castsundexpenses which may in any way accrve against said City AIR HANDLING UNIT(TO 10,000 CFM)
inceoftcgrantingof` I AIR HANDLING UNIT(OVER 10,000CPM)
'^ EXHAUST HOOD S' amrt ApplicanUConuact r ` Date PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00()BTU) Date Rcccipt#
Will the applicant or future building occupant store or handle bszardous material
as defined by the Cupertino Municipal Cole,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,OW BTU) TOTAL:
Code.Section 25532(x)? VENTILATION FAN(SINGLE RESID)
❑255 11 No
Will nhwpplicant urfmurcbuildingoceupant uxequipmenundevices which emit
BOILER-COMP(311P OR I(gOM BTU) ISSUANCE DATE
haaaalous air contaminants as defined by the Bay Arca Air Quality Management
BOILER-COMP(OVER 100.000 BTU)
sWn?
❑Yes ❑No NEW RESIDCMTIAI.MEC11, SQ,ff.
1 have read the hevaudous animists requirements under Chapter 6.95.1 the 0
CnObania Healm&Safety Code,Sectiotu 25505,25533 and 25534, l understand that DECD M921
if the building does not currently have a nemu.that it is my responsibility to notify the
aecupont of the requirements which must be met prior to issuance of a Certificate of CII r
Occupancy.
Owneror unhoriud agent Date TOTAL: ISSUED BY: V
OFFICE