24532APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_OFFICE
CITY OF CUPERTINO I'luH.DCs , - ELEC'1'RICA],
APPLICATION/PERMIT rING PROD CT UDF.NTR`IC,
BUILDING DIVISION BUILDING PROJECT IUEN'TI4'ICA"ZION
PERMIT" NO.
24532
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE.
ISUNIT N LOI#
N' SNAMH: PIIONE:
CO A fOR:S NAME: LIC NO:
� /
N/C
❑
CONTROL p
1RCHII' I7ENGINEER: LIC NO:
ADDRESS:
y57 hA64W
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
[I A El
PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION
Ihemhy affirm shut lam licenxedunJerprovisiona OfChap¢r9fnmmmencing wilM1
Seaioacean)o[ Division of the Business and Professions Code, and my liccox is in
lull (nrce and a <cl.
Liccnu Clnw — LiuNo�
APPLIANCES - RESIDENTIAL
PANELS
UPI'O2W AMPS
JOB DI3CRIITION
Lt
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Datc Cnnvucmr
CHITECTS DECLARATION
IunJersdnJ my plana stall he used as public records,
201 - IOOU AMPS
SQ. FT. BOOR AREA
p
(III`^'
n II
(IVY
it
ESQ. FT.
OVER 1000 AMPS /
SIGNS ELECTRICAL
1
Licensed Promi,imal
OWNER -BUILDER DECLARATION
1 hereby affirJoe at I am exempt from the Contmem', License Law for the
following awn(Section 7031.5, Business and Professions Code: Any city or county
rt
which requires a permit to construct, alter, improve, demolish, or repair any common,
to its issuance. also requires [lie applicant for such Proud to file a signed statement
that he is licensed pursuant m the Provisions of the Contractor's License Law (Chapter
9(commencing with Section 7") of Division 3 of the Business and Professions Code)
or he is exempttherefrom and the basis for the alleged exemption. Anyviolatud of
Section 7031.5 by any applicant for apermit subjects the applicant mu civil penalty of
not more than five hundred dollar, ($500).
❑ I.mownerofthepropeny.ormyenmployeeswitlmwagesasthciunlccumpensation.
will Jothe work, and lheswcmre is not intended nra(fereJ foraale(See. 7044,Business
SPECIAL CIRCUIT/MISC. l L 1
\
TEMP. METER OR POLE INS'('. o t
POWER DEVICES DATE
SWIMMING POOL ELECTRIC L
li"LIATION
�s 0o,
✓
OIITLEfS-SWRCf1ES-FlXTURf•_S
NEWRESIDFNTIALELECIB _SQ. FT.
STORIES
TYPE: CQNSTRUCI'ION
and Professions Code: The Convector's License Law does not apply m an nwner of
propcny who bu i I Js or improves thereon, and who docs such work hi mac If or though his
employees, provided that such improvements manot imendedor offered fmLramle. I
OCC GROUT'
RI3. UNITSown
TOTAL:
however. the building orimprovemem is sold within one yearofcompletion, the owner-
builder will have the hmden of proving that he did not build or improve for Purpose of
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
sale.).
❑ I, as ownersdthe pmpeny. amexclusively contracting with licensed contmaorsto
onsnnu the project (Sec. 70,16, Business and Pmfeseinns CW J The Communes
License Law doesum apply loan ownarofpropcny who builds or improvestherwn,and
PERMIT ISSUANCE S O
whocontructs forsuch projects with scomenamor(s) licensed pursuant m the Contfadors
License Law.
❑ 1 am exempt under gee. . B & P C for this mason
FAALTER- DRAIN&VENT - WATER ()
PEE SUMMARY
BACK ROW PROTECT. DEVICE
OUTSIDI: YF_S
SANITARY YN
RECEIPTp
Owner Data
WORKMAN COMPENSATION DECLARATTON
❑ Ihereby official coal l have a certificam ofconscm to ulbinsure, or a certificate of
Workers Compensation insurance or m cenlfied copy themof(SecJB00, Lab Cd which
covers II< Y Bert L
A's hfa'p�%rm
PolicYN J-gf 4S�
DRAINS- RODEROOFARCOND.
SCHOOL, AX Y N
FIXTURRS-PER TRAPRECEIPT#
PARK FEE Y N
RECEIPTa
GAS-IiA.SYST1iM-I INC.6(IUTLETS
BUILDING DIVISION FEIS
--J^- q'7
y #(
TM
GAS - G.SYST IiM-OVER
PLANCIIECK FEE
❑ Certified copy is herehy fhd.
0 Cm
GREASUINDUS'1'RL WASTE INTERCEPTOR
GRADING PER
tthe copy is flet e ricity inspection division.
Certified with
GREASF.TRAP
SOILS FEE
CERT(FICA'YE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT,
EN17RGY FEE
(This section need not he completed ifthe permit is for one hundreddullars(SINR
Z
Z
or less.)
I certify that in the performance of (be work liar which this permit is issued, I shall
not employ any person to any manner a as ro become subject to the Workers;
Cmr,maion Lawsnf Callfmd.. Date
Applicant
NOTICE TO APPLICANT: IL after making this Carl i fcatenf Exemption. you 01muld
' WATER HEATER W/VFNT/BLECTR Is8'd
PAID
Dam Receipt#
WATER SYSTEMflREATING
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
�-s
'rte
Y
1 Q'
becomesubject to the Worker's Compensation provisions of the labor Cadt mat
fonhwlth comply withmch pn sisinns Or this permit ehallMJeamed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING FEE
SHISMIC FEE
^^
TOTAL: al.S-
ELd?CI'Ric FEE
z
U"' F
U
U Z
erformce of
(hereby affirm that Chert is aconswaian lending urgency for pm:
the work forwhlch this pc,uml is issued (Sec. 3(#)7, Civ. C.)
Landers Name
QTY. MECHANICALPERMIT FEE
PLUMBING PER
MIiCIIANICAh FEE
Leaders Address
1 certify thal 1 have mail this application and sate that the above information is
mnea.Iagme to comply wllh all city and cony oninancen and state laws relating to
bulldingcomtivaion. and hereby authorize representatives ufthis city manner upon Ne
shove -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupenino against
Emolnes,judgmems, costs and expenses which may in any way accrue against said City
PERMIT ISSUANCE
ALTER OR ADD TO MECII.
CONSTRUM ION TAX
AIR I JANGLING UNIT (TO 10,0111 CFM)
AIR I IANDLING UNIT (OVER I 0.00D CFM)
t quence of the granting of this peso u
,r'1 n
// /' %%f/ Lk--�.— 3 ib -77
of App ¢ant/COntmctor Date
EXHAUST HOOD (W/DDCIj
PAID
HEATING UNIT (TO I0L0#1 BT U)
Vitiate
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OV I1I00000 BTU)
OTAI
Will iheapplicunt or farorebuilding —cap., score or handle hamrdousmmeriul
as def old by the Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety
VENT'ILA'TION FAN (SINGLE RESID)
Cade. Section 25532(#)?
❑ Yea ❑ No
Will 1hea licantorfummbuildin tune mrdevices whicbemit
pp g«cube gmpmen
PySIJp�CE D TF.
f�1� D
BOILER-COMI'(3IIPOR IfNJ,B1IU BTU)
hazardous air comnminanw as defined by the Bay Area air Quality Management
BOILER -COMP (OVER Bq,WO BTU)
Uiumu?
AR'7
NF.W RF.SIDENTIAh MECII. SQ. FT.
❑ Yen ❑ No
1 have read the I..mnlou, m:nedaLs rcqulmnmi, under Chafer, 6.95 of the
Health & Safety Code, Sections 25505.25533 and 255]6. 1 understand that
t
cunemly have a l eshility so notify he
itf the building docs nal levant, hat it in Tmy rpousi
0%A
/J9
yll Y J
Vf L�11' Cf•I I lI VC
occupant of the requirements which most be at prior to issuance of is Cenilicale oT
Occupancy.
(\/Jj•�/��/
ISSUED BY:
Owner or uuth... ucd agent Data
TOTAL:
_OFFICE