24832 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING.ELECTRICAL PERK"TND, 24832
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION:"�-
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
D 'b NA IE PHONE: C NIC CONTROL%
Cf R'SN LIC NO.
a
•\ 1 'CI'lEIvGIN LIC NO: AUD ESS: ❑
CONTACT: PHONE: •'t"' t• ,ti.. - "c%'-I BUDDING PERM]T INFO'
QTY•.'A:.;;i:y ELECTRIC PERIv1I1' �w ,j;.;
FEE, .
BLDG ELECT� PLUMB ME❑CII
♦ � PERMIT ISSUANCE � - IrGJ Urn/
LICENSEDCONTRACTOR'SDECLA TION APPLIANCES-RESIDENTIAL LOB DESCRI ON
O y.Z Iherehy affirm thmlam licensedunderprovixisms ofChupter9 commencing with "dd
-00 Sectlon7000)of Division 3 of thus
e Biness and Professions Cade.ata m
arta license is in PANELS
WU5 full forearm!effect.
<U ZJ V License Class Lic.X UP 1'0 200 AMPS
in<c. Date Contractor 201-1000 AMPS
7y SQ.Ff. OOR AR $ISQ.FT.
mZ ARCHITECTS DECLARATION OVER 1000 AMPS /� M
(Z t!', 1 understand my plans shall be used as public records. It
:yF' SIGNS ELECTRICAL ~Vl u
Y 7 j Licensed Professional _
?Y .<0 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. again
I hereby affirm that I em exempt from Ne[omicrons License law fix the LX
following mason.(Section 703 L5.Business and Professions Cade:My city or county TEMP.METER OR POLE INST.
—m< which require a permit to construes,alter,improve,demolish,or repa'u any stmcrure
jwYM prion.its issuutce,alsm requires theapplicent for such permiuo file a signedimemcm POWER DEVICES
z=p than be is licensed pursuant ro she Provisions of the Comore ms Li.Law(Chapter
-Kca` 9(commencing with Section 70001 of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
=y
or that he is exempt therefrom and th,basis far the alleged exemption.My violation of OUTLETS
=ZC Section 7031.5 by any applicant for a Permit subjects the applicrnnoarnil peany of
z�� not more than rive hundred dollars($500). NEW RESIDENTIAL ELELTR _SQ FT STORIES PECONSTRUCMOI
❑ Lasow rk,andepropeny,msandim ndeeswiNw ilforstheirsolew1,LBea mus CSI
3a_ wipe dothewmk.Cde:noCumisnmimm�drec,La ereoesnot appl(Secy
as an owner of
rntl Professions Code:Thr Contractor's License Law does not apply lf rn owns is
propertywyear,dsw improveschcteon.aodwbodousochwwk himsdfor through his OCC.GROUP RES.UNITS
cveployces,providedthat improvement
impmvememsseenot iemendedmoffend fwsale. r.
howevcq the buildingsehu den of proem is for he di in one year ofcompvc for the own of A
builder camel have the burden of Pronng that he did not boded m improve for purpose f r
IF. �4T PLUMBING PERhRTm't i..s x 'r r3, D ZON� APN
uownerafrie property.am excluxvely mouldring with lie seiconvanonto Q 'i} ' s�l`�a':"'
construct the project(Sm.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License law does sot apply ton ownerof property who builds or improves Hereon,and
License.Law.
Lhaaww..asuch Projects wiNacamranor(s)Iicrnsed Pursuannoda Convanms ALTER-DRAIN@V W
❑ I un exempt seeder Sec. ,B k P C fm this mason ..- -
BACK FLOW PROLE V 11 1 y Y N
Owner WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,R00 . TAX YE�'�X N
❑ Thembyaffumthatihaveamnificam of cormsttmno sel4insure.macenificane of RECEIPT%
." Workers'Compeasmionlrouranc orattni8 dmpythercof(Sec.3g0BLab C.)woeh I'll DATE I FEE Y N
rove.all employers am,this GAS-EA.SYSTE - .4 UTIETS RE PTX
Policy Jr BUILDING DI SION FEFS
Company GAS-EA.SYSTEM-OVFR4( ) PIANCHECK FEE O•�D
❑ Certified mpY ercby umished.
❑ Certified copy is filed wBb the city inspection division. GREASEIIN , TRL AS INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOBS FEE
COMPENSATION INSURANCE
(This acNmOned not be completed ifthepermit is forms,hundred dollars(SIM) SEWER-SA -STORM EA.2WFT. ENERGY FEE
unless.)
I modify then in rformasmo the work for which th' pa",is isaued,lidall WATER HEA W /ELECTR
nm employ aoY ryry m er�as ro bee a Ache Workeri PAID is
Z Comicaunt rl v m .aim. f ( WATER gY EATING Date Raeiptil
AO icor VV
Z NOTICE APPLICANT:IL ahtt mAing0ris Cttufmm of Exmnpurn,you.should
notst NEW RESIDE\TIAL PCMB. SQ.FT. TOTAL:
h become su empty the such
tics prmitiansofthelaborColked. must ILD GME
forthwith comply with such provisions w this pcmdm shall be deemed rooked.
y (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
:D Z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the word fm which Nis permit iaaed fS c.3097,Civ.C.)
Lenders Name x , .- a•s.::
f—' lenders Address ♦ QTY.:y,•, "7�MECHANICALPERMTT- ':I:`n••,;*� FEE-F- PLUMBING FEE
[SJ I certify Net 1 hi plication and state that the all a information is - MECHANICAL FEE
mrmct.legrte to comply wil alicily and county ordinances indicate laws.]an.,m PERMIT ISSUANCE
_ � building conssmction,rndhr ?yauthorinnepresentativesafthiscin mcntmuponthc CONS7RUCDONT
..J Z above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree m save,indemnify and keep hamdea Ne City of Cupertino agaimt
liebdinims,judgmests.costs and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO HI.000 CFM)
N eMYqueme,of the granum,of this pemdL
AIR HANDLING UNIT(OVER Io.000 CFM)
Signature of AppiicanUComncmr oe Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UN (TO 100.000 TUI Date Receipt#
Will the applicant m future building occupant store or handle hazardous material HEATING UNIT V W, IBTUI TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Hnith and Safety
Code.Section 25532(.)? VENTIfAT10.' A fig ERFSID)
❑Yes o
ISSUA E DATE
Will theapplinnt wfuture buddingoccupanmseequipmem m ile%ims whichemit BOILER-COM HP RIm'"BTU)
hvardnu.v air contaminants as defined by the Bay Arca Air Qualm'Management BOILER-C (OVER 100.(DO BTU)
District? r I D
,j ❑Yes � NEW RESIDENTIAL MECH. SQ.FT. a�'i
I see a h,.Td ,.materials"mr!,eno under Chapter 6.95 of the �(A
Inh Sefny Cod Sections 3505.25533 and 25534. I understand that R ax
nF sem curt haves mnrnt�hat it is my rePonsibilny to oddly the
uireme hich must be ren prior m issuanc of a nil caro of 'Cl/V
rW a cm Dam TOTAL: ISSUED BY�
r�nluvu
OFFICE