24526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
BUILDING-ELECT RACAL PERMIT NO.CITY OF CUPERTINO PLUMBINGMECHANICAL BUILDING DIVISION . APPLICATION/PERMIT BUILDING PROJECT IDENTIFICATION
24526 4CnC
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT#
OWNE PHONE: CONTRACTOR'S NAME.: LICN Vim/
N'1VN/C CONTROL M
CfII ECP .NGINEER: LIC NO: ADpRES �� ❑
CONTACT: PHONE: 2 BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
LDG
ELECT PLUMB VPERMIT ISSUANCE 11
LICENSED CONTRACTOR SDECLARAI'Chapt0N APPLIANCES-RESIDENTIAL _ TOB pESCRI ON
p0C Ihereby affirm Natl 3 of the
B sanderpwvislonaharsCpmr9gommencingwiN
I �+f 00 Section 70(10)e f Division 3 of the Business end Profcsei.v Cole,and my license is in PANELS
fCV� full f.rc<mJ elle UP T02m AMPS
FZ W License Class 1.(0.#
vs6yDmc C.mmct 201-IOW AMPS
ZOy� A 1TECTSD C R TION OVER 1000 AMPS �E�rIT. RA E/SQ,FT.
O Z-'❑ 1 understand my plans shall be used as public records. CC
rr4'y1uJ.4l SIGNS ELECTRICAL �S
NQ I.Iccntsed lh.fcssionel —AA � ' 1 I
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC, v
60n,tJ 1 hereby alfms has 1 von exempt from the Convectors License Inw for the
t+�'3 r-y following«mon.(Section 7031.5,Business and Professions Code:Any city.,county TEMP.METER OR POLE INST, {06
Ir 0 which requires a pe.iuo conswn,other.improve,demolish,m repair my ntus urs
ce <7 to its isaumce,alsort requires the licmt for such ito file a signed ammmem POWER DEVICES
prior qu pp permi gn
W�Mo that he is licensed pursuant o the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC s o f,' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) VALUATIOKCI,
_o, or he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTL[I'S-SWITCHES-FI%TURCS 3�0D VVr�
tKQeo
Stion]03Lmi
5 by any applicant for a pert subjects the applicant tourist[penalty.(
J% nm mre othan fisc hmdrW dollars(E5W). NEW RESIDENTIAL ELEGfR _SQ.FT.
❑ Lasowner.fthepropM,ormyemploymswiNwagesutheirs.lecompensati.n, STORIES TYPE CONSTRUCTION
y3. willduthework,and thestmcture is not intended orofferedfrrsule(Sm.70C4,Business
and Professions Code:The Commetors License Law docs not apply to an owner of
property who builds.r improves thereon,and who does such work himself or through his
cownOCC.GROUP RCS.UNITS
employm,ldingedprove improvements is sold
sarene iearoff opletiod the owner-
budder will
have
harden
improvement is sot within one year of completion,the owner- TOTAL:
builder will have Nc harden of proving that he tliJ not build or improve for purpose,of
salt.). QTY. PLUMBING PERMIT FEE
❑ nowner pmjmt(Sm.70Wtmexduss ncommminns Cride:)ncomnetmxm FL00020NE APN
.termer the project(Sec.]044,Business and Professions Cod J The Contractor's
License Law d.un.t apply man.wnerofpr.pmy whobuildsmimproves thereon,and PERMIT ISSUANCE
whorommcts f.rsuch projects with aconvvclor(s)licensed pursuant m the Contractor's pLTF.R-DRAIN&VENT-WAR fA
License Law. TTe (' ) FEE SUMMARY
❑ 1 em exempt under Sea .B&P C for Nis«awn BACK IlQW PROTECf,DEVICE OUTS .F.
SANITARY Y N
Owner Date DRAINS-f1.00R.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have a ccnificate of consent sel6ficame,ora ceNfcum of FIXTIIRFS-PCR TRAP RECEIPT
rakers C.mpenemi.n Insurance or�carifiml copy thereof(See3800,Lab C.)which PARK FEE Y N
covers all employee's under Nis permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
policy# BUIL GDIVISIO FEES
C,u9'IvorY GAS-EA.SYSTEM OVER 4(HiU PLANCHECKFEE �!
IJ❑x-Cerifed copy is hereby famished.
CenifiedmpY is filed with flue city inspection division. GREASZANDUSTRL WASTE INTERCEPTOR GRADING FE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS
COMPENSATION INSURANCE
(This aemommed not be completedHNe permit Ts forone hundroddollars(EIm) SEWER-SANITARY-STORM G.200FT. ENEft
.r less.)
I certify that in the performance of the work for which this Permit is issued.I shall WATER DEATER W/VENFDELECIR
not employ any person in any marmcr so as to become subject,In the Worker' PAID
Compenamma Lawsof Celifomia. Date WATER SYSTEM[FREATINO ate Receipt#
C) Z Applicant
z0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption.ynu should NEW RESIDENTIAL PI.MB. SQ.FI'. TAL:
LI) become subject to the Workers Compensation provisions of Ne Labor Code,ynu must
. 7 forthwith comply with such provisions or this permit shall be normal revoked. BUILDING .E
10
[SI A
CONSTRUCTION LENDING AGENCY SEISMIC E
1 hereby affimr that them is a construction lending agency for the performance of
U O TOTAL: ELECTRIC +E "t
the work for which Npermit is peit is issued(Sor.3097,Civ.CJ
lenders theme PLUMBIN 'EE
IenJera Address QTY. MECHANICAL PERMIT FEE
IC) V I certify that 1 have mad this application and state that the above information is MECHANIC .FEE
correct [agree mcomply with ill city andc.unry oNi......drmelawsrelaungm PERMITISSUANCE
F" y building construction.and he«byauNoris repmsermives mails city to enter upon the CONSTRUCI'1 NTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agror m ave,indemnify and keep harmless the Ci Cupminu against
liabilitic ' nts,conte mdexpenus which m C eagainstsi id City AIR HANDLING UNIT(TO IO,OWCFM)
sea o Ne gmmi f this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
z-
Si I / Dote• EXHAUST HOOD(W(DUCO
PAID
HAZARDOUS MAT SDISCLOSURE HEATING UNIT(M 1m,W0 B'TU) Date Reeeipsp
Will the applicant or future building occupant tore m Immune lamardous material HEATING UNIT(OVER Hat"BTU) TOT
as defined M ted Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
jW
Code,Section 2553200? VENTILATION FAN(SINGLE RMID)
❑Yes 13 No
ISSUA E DATE
Will theapplicu mrfulum buildiilicampmt use equipmentordevices whichemit BOILER-COMP(OVER 10WAm RTU) B
rardous air contaminant ax defined by the Bay Area Air Quality Management BOILER-COMP(OVCR Im,U110 BTU)
40,
prim?
L
EI Yes 11 No NEW RESIDENTIAL MECH.—SQ.FT. MAR 'I 1 �(�a�a�
1 I have mad the Incursions materials requirements under Chapter 6.95 of the K sL .L 993
I California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that L CUP if the building does not curemly have a tenant,that it is my responsibility to notify the city U CUP
occupam of the requirements which most be met prior to issuance of a Certificate of
Occupancy.
Gone,or mthori W agent Date ISSUED BY:
OFFICE