24824 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 2 /I HZ
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. LI
BUILDING.PROJECT IDENTIF'ICAT'ION
BUILDING ADDRESS SANITARY
Q ,w SANITARY NO. APPLICATION SUBMITTAL DATE
3W
O' N V UNIT# LOT# sa�/Er�VVV
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7
OWNERS NAME: PHONE: NTRACTOR'S NA LIC NO: I
11-V--
� � 1� NICCONTROL#
R HITECT/FNGINL•�E�R:e� LIC NO: ADDRESS: lw^ ❑
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CONTACT: PHONG:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
PERMIT ISSUANCE -FKT P
S
LICENSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. St JOB JOB DPSCftIPI'ION
Qwz lherebyafPomthatlemlicens undnpmvisionsofChapter9(commrncingwith
FT0p Sectioon 7")orDDivision J of the Business and Formations Code,and my license is in PANELS � r �
Q V Lfull icense�la)s�s�r� Lim,pV3A 110me and effec "? I UP TO 200 AMPS
~ 6 Date.fi(6>?L_"12_ I.
Contractor 201-1000 AMPS
F"yz ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
it
z p n— I understand my plans shall be used as public records. OVER 1000 AMPS
�_ ^
LiceruW Professiond �
SIGNS ELECTRICAL 1.2 O dt
^�
y0.'Q OWNER-BUILDER DECLARATION SPECIAL CIRCOIT/MISC.
XOaU I hereby affirm That 1 am exempt from the Co..,.,'a Licerue Law for the
W 3 W y following reason.(Section 707 1.5,Bmincss end Profasiane Cade:Any city or county TEMP.METER OR POLE INST.
v-�� which exclaims o permit m conswa,alter,improve,demolish,or repair any mucmre
priono its issuance,also requires the applicant for such Permit o file asignedatutement POWER DEVICES
m p Nm he is licensed pursuant to the Provisions of the Contrano's License Law(Chapter
Lamin 9(cammencing with Section 7")of Division 3 of the Bottom.and Profession.Code) SWIMMING POOL=- CIIUC VALUATION
�y or that he is exempt therefrom rod the basis for the alleged exemption.Any violation of ^ �� w� A
Cr
Section 7071.5 by any applicant for a permit subjects the applianuo a civil penalty of PUTLETS-SWITCHES-FIXTURESgan f` LCf
i,asoan fivehundreddollar yempl NEWRFSIDENTIALELECfR _SQ.FT. STORIES TYPECONSTRUCTION
N❑ o ❑ Luso ser ofdthesummore ion intended
theWe(Sec.7011 sines,
y3v0 willdmhewons and the he Contractor's
License
Law
dofs not apply 7046,Business
and Professions Code:The Camrereon,License Lew does not apply f an owner of
propertywho builds odmproveathernpr and who does
notintwmkh roffic or through his
own employees provided thatnuchimprovemenuare not intended arnffcad bode.If. OCC.GROUP EAM
however,The building mimprovemem is sold within one year ofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
role.).
❑ I,as owner ofthe property,amexclusively contracting with licensed contmetonm QTY, PLUMBING PERMIT FEE FLOOD ZONE
construct the project(Sec.7014,Business and Professions Code:)The Conm ams
License Lawdoes notapply roan ownerofpropcny whobuilds or improves thereon,and PERMIT ISSUANCE x.00,0011sa
whocommaN forsuch pmjmts with aconuacumid licensed pursuannothe Contractors ALTER-DRAIN&VENT-WATER EA
License Law. ( > FEE SUMMARY
❑ 1 am exanpt underSec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE O 51 .ES
SANITARY YN
Owner Date— DRAINS-FLOOR,ROOF,AREA.COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ a.,Co alfrmthatl M1ranceave is or aecateofcopytherof(Sramn,to esure,or as C.)whichffir.t.of FIXTURES-PER TRAP RF.CEIPTp
Wmkerw Compensation Insurance oruceni0ed copy Hereof(Sec,3800,Lab CJ which + PARK FEE YN
,zt..leasployasupdc' gdry. S-E.A.SYSTEM-IINCAOUTLETS BUILDING DIVISION FRES
P.my 44]]``YY �I �I aai
Company 4.�til. GAS-EA.SYSTEM-OVER 4IEA) PLANCIIECK FEE
EI CertifiN wpy ns hereby famished.
W Certified copy is filed with the city inspection division. GRFASHANDUSTRL WASTE INTERCEPTOR GRADIN E
�[ CERTIFICATE OF EXEMPTION FROM WORKERS' OR EASETRAP G+ 'u, m
COMPENSATION INSURANCE
(This section need not h completed if the permit is for one hundred dollars(SIN) SCWER-SANITARY- R -N ME I's
s.)
Y
I certify that in Cheperformance tonyaraf Ne work for which thisobjects isthe Wcthdl WATER HEATER WryP.NT/Y.LECTR
not employ nay person in any manner,m as m became object to the Workers' q
Compensation Laws o(Cetifomia. Dam WATER SYSI E!CEATIZATE to Re IfJ�
z0 Z Applicant
NOTICE TO APPLICANT:If,after making this CeniGcae of Exemption,you should NEW RESIDENT'IAL PLMB. SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must
; forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE I6 `
Q SEISMIC FEE L�'
CONSTRUCTION LENDING AGENCY
s� z 1 hereby affirm that then is a construction lending agency for the performance of
the work for wI y'c�this
permit is issued(Sec.3097,Cie.C.) TOTAL: ELECTRIC FEE � —#a
U Lender's Nmne�IO to
C F lender.Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE r
I cavity that I have read this application and state that the above information is MECHAM L BE[
tJQ
a mnrcct. degree to comply with all city end aunty oMinanca and state lewsrelatingm PERMITSSUANCE '�
buildingeonstruaiun,and hereby oathomc representatives ofthiseitybinrmrupov the CONSTRUCTION /V
V above-mrntimrcd pmpeny for inspection purposes. TR ADD'TO MECIL
(We)agree to save,indemnify and keep hmmless the City of Cupertino against
liabilities.judgmems,ennsandexpenuswhich may in any wayaccrue,.mint sdd City IR DLING UNIT(TO 10,000 CFM)
inco 'equcnce the r ting of this permit
c AIR HANDLING UNIT(OVER 1(L000 CFM)
Signature of Applicant ontracmr 5/24q� EXHAUST HOOD(W/DUCIy PAID
HAZARDOUS MATERIALS DISCLOSURE
)ojifiATING UNIT IT 100,00(IBTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous mutedel HEATING UNIT(OVER IN."DT'U) T
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Ilealth and Safety
Code,Section 25532(u)'t
'Lyes ❑No VENTILATION FAN(SINGLE RESID)
ISSTR
Will Neapplicant orfutumbuilding oaan
upmxequipmcm u or which emit BOILER-COMP(JHPOR 100,000 BTU) po
hnnadour air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP TOYER IDJX I BTU) NAY
as ���
Distrix? r+.I(�j
❑Yes )(No NEW RESIDENTIAL MELD. SQ,BT.
I have read the hozanlnus materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 2.5505,25533 and 25534.1 understand thm
if the building does not currently have a tenant,that it is my responsibility to notify the p e
ecu t of N rtqui rnta which must h ten palm to issuance of a Cenifca¢of /9l
exc a Or. NA
aa�.. .,I/1 �GL��yy7oy�JJ
Owneror rounro a nt Dam A ISSUED Bio
OFFICE rlrnv�