24673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILD ING-ELECTRICAL PERMITNO.
PIO I
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDENTIFICATION
24673 4^73
BUILDIMhAi]DRP_SS: ,// SANITARY NO. APPLICATIONSUBMITTALDAM
b \ rr UNIT# 1.01,# —(3— c
It 13
OWN' NAME: PHONE: CONTRACI'OR'SNAME: hIC NO: N/C CONTROL#
aad=sw41 HI'I'E .NGINEER: LICNO: ADDRESS: a�
ONTACT: PHONE: QTY. ELECTRIC PhaRMIT FEE -J BUILDING PERMIT INFO
n
BLDG ELECT PLUMB MECH
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB'DFSCRINFION
p z 2 I hereby affirm that l sm licensed underMvisionso(Chapter9(commencing with
400W0 Section]000)nf Division 3 ofthe Business and Professions Code,and my license is in PANELS ,..�(
FCU License
Clfull force ndeffect. � \ 1 1
F^L W License Class Liak UP TO 2W AMP'S Q� tl'I` d tl`I
H 6 y Date Convector 201-I"AMPS
AREA ZO,z ARCHITECTS DECLARATION OVER 1000AMPS SQ.FT.FLOOR AR $/SQ.FT.
O Z—M I undersand my plans shall he medae public records,
,C4�vl SIGNS ELECTRICAL
hm<q�d , Licensed Professional
y
OWNER-BUILDER DECLARATION ! SPECIALCIRCUIT/MISC. ID
U 1 hereby affirm Nut 1 am exempt from the Contractors License law for the
tt1'31y following reason.(Section 7031.5.Business and Professions Cede:Any city or county TEMP.METER OR POLE INST.
1u�5 which requires a pcnnil to construct,alter,improve,demolish,or repair any structure
E1P� prior to itsissuance,also requires the applicant for such permitto file a signed statement POWER DEVICES
pj M�O that he is licensed pursuant to Ne provisions of the Contractors License Low(Chapter
9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUAT N
Warn onhul he is exempt and the basis for the alleged exemption.Anyviolationof s
G so
Section 9031.51, any upplicant for a Permit subjects the applicant to a civil OUTI•FTS-SWITCHES-FixTURES f
nut more than five hundred dullan($51)0), penally nT V D
_� NEW RESIDENTIAL ELF.CTR S .FT.
ro ❑ Lvownernnhepropecy,nrmyemployedswitbwagamthei(Sce.corn,Business Q STORIES TYPECONSTRUCTION
will do the work.and the structure isnot immndedor offend for sale(Sec.]tq4,Business L
and Professions Cale:The Cormselm's License Law does not apply In an owner of B P pip1
property who builds or Improves thereon,and who does such work Word for through his
owncmployers,providedthal such improvementsmanol intendedornffemd forsale.If, RES.UNITS
however,he buildingor improvement is sold within one year ofcompletion,the owner- TOTAL: �I
builder will have the burden of proving Nal he did not build or improve for purpose of U.
�
sole).
CF Lns ownernfthc property,um exclusively contracting with licensed contractors to QTY, PLUMBING PERMIT PEE �FI. qDZ fl{E APN
it the project(Sec.7044,Business and Professions Code:)The Contractors � a✓ Q/,��7
License Law does not applyto an nwnernfpropeny whobuilds arimproves lherwo,and PERMIT ISSUANCE _
who contracts(or such projects with acomactods)licensed pursuant o the Communes ALTER c Law. WATER(CA) FEE SUMMARY
❑ I i ma pt under Sec 11 A,P C for this reason BACK FLOW PROTECT.DEVICE TSIDE .:.
Owner
_ SANITARY Y N
Uam
WORKMAN 1PENSATION DECLARATION DRAINS-FLOOR,ROOF,AR[iA,CONRECEIPT#D. SCHOOL TAX YN_
,❑ Thereby off irm lhxllhuveacedificum of annsentmself-Insure,ora cenilicale of FIXTURES-PER TRAP ��ss RECEIPT#
Wakeri Compemrm,lnsunnce M incerlified copy Nereof(See.)800,Lab CJ which • VO PARK FEE Y N
covers all employ<Ca under this pcmoiv GAS-PA.SYSTEM. INC.4 OUTLETS RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(IEA) PLANCHECK FEE
❑ Certified cup,is hereby famished.
❑ Certified copy is fled with the city inspection division. GRIASRIINDU$TRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OP EXEMPTION FROM WORKERS' GRF.ASETRAP SOILS FEE
COMPENSATION INSURANCE
('Ihissection need rambecnmpletedifthe Nordin foronehundreJdollirs($100) SEWER-SANITARY.STORM FA.200F7. ENERGY FEE
ar less.)
I certify that indite performeaceofine work for which this pemtit is issued,Ishall WATER HEATER W/VENryELECTR
not employ any Pearson in any manner so as 1n become subject to the Workers' PAID
Z Compermlion Laws of California. Dam WA'T'ER SYSTEM/TREATING Uate Receipt#
Applicant
Z 0 NOTICE.TO APPLICAW.'If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(--1 U) become subject to the Workers Compensation provisions of the labor Code,you most
ai ; broloal b comply with such provisions or this pcnnil shad l hddamed revoked. BUILDING FEE Z'1
OW.. (� CONSTRUCTION LENDING AGENCY SEISMICFEE ZZ
s_s0
1 hereby affimn that Nenc is a composite.lending agency for Ne performance of 00 ELECTRIC FRE l'
U O the work which this permit is issued(Sec.309],Civ,C) TOTAL: z l
0 Indcr's Name PLUMBING FEE
Lendcr,Address - QTY, MECHANICAL PERMIT PEE nQ
I,I age that I have read Nis application tyJ state that the above information
ng is A/1
building lugrcemon,comply
and withall ytouttyand county admix state h ater.pingm PERMIT ISSUANCE _AA MECHANICAL FEE #
U' ; aboengcotioned Omand hercbyauNorixereoses. olives of Nis cirymemer upon the V V CONSTRUCTIONTAX
U 7 abw(Wa)Bred pine.indemnify End purposes. ALTER OR ADD TO MECH.
F7 be Jud
msave,indemnifyandkeep harmless the ai.eof Cupertino against
Ifabilitie-,judg ecomsand expenses
x pensawhich may in any wayaceme egainat aatd City AIR HANDLING UNIT(TO In,o00 CFM)
in�Auence of the�gr Igat�this p�ermit. '
/ ` 1-13—
/Q AIR HANDLING UNIT(OVER 10,000 CFM)
l�ana�pp��M17-menctor J`_. •JDme "IIAUSTHOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT DO 100,000 BTU) Dane Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00)BTU) TO'1'AL:� , 7S
Code,Section 25532(1)?
❑Yes 11 No LAVENTITION FAN(SINGLE BUSED) rS6
BOILER-COMP(31 In OR 100.000 BTU) ISSuA JCUDATE
WilHheeconcurdnntsag,future huiWing by
Bay
Areequa
Qualior ty an whichemit �P y� BJ��1
hauma? elr contaminants ns defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 1(10,0110 BTU)
DistricR ' 'I
❑Yes 0N NEW RESIDENT IAL MECH. SQ.FT. JAN 1 3 1993
1 haveread lire hamrdous materials requiremems under Chapter 6.95 of the av IJ
California Health as,Safety Cale,Sections 25505.25533 and 25534. 1 understand,an CI I Y Ur TiUF'en 1 uvv
if the building does not currently have a reason.that it is my respomibility to notify Me
occupant of the requirements which must he met prior to issuance of a Certificate of
Oecap:mcy.
Owner or amhosined ugcm Date TOTAL: ISSUED BY: vaCL
OFFICE