24700 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL' PERMIT NO.
NIECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILBIN(;IROBKC7IORNTIFICA'1'LfN 24700 47OO
BUILDING ADDRESS: � SANITARY NO. APPLICATION SUBMITTAL DATE
i1, Q� OW ✓I • "A41i1'N LOT#
OWNS SNAME: PHONE: CON'1'R OR'SNAM',: LICNO:
NIC CONTROL
ARCHITECT/Et4GINEHIL I LUNG: 'ADDRESS: ❑
CONTACT: PHONE:
Q'fY. ELECTRIC PERMIT FEE ❑UILDING PERMIT INFO
OLUC I:LI'.CT PLUMB MEC"
A PBRMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES RESIDENTIAL LOB DESCRIPTION
pyZ I herebyaffrrn that l am licensed underpmvisionsofaapler9(commencingwith
uF100 Seedivir nnlof the Business and Professions Code,and my license is in PANELS '
l5ut full force and effect. �•
ayV y"j License Clans Lia# GPTD 260AMPS
Fay Data Contractor. 201-Jap S IV
zONGK ARC]IITECT'S DECLARATION OV 10 P' SO.IT.FLOOR AREA $/SQ.11r.
O Z'-'p 1 undemund my Alms shall be used as public records.
�rnFeul
5IGkS)ELtVkICAL
¢Y2j Licensed Professional
�y1Wa OWNER-BUILDER DECLARATION 5 A CIRCUIT/MISC.
.XO,F 1 herefirm by afthat 1 am exempt from the Conoamois License law for the
ul3arn following reasoe.(Section 7031.5.Business and Professions Code:Any city or countyTEMP.METER OR BI T.
f��a� which requires a permit m ttmnmct,alley,improve,demolish,or repair any swewre
Y prior m its issuunce,alsn requires the npplirml for such permit to rile n signed statement Ib D 13S
W GO that be is licensed pu...son tonic provic.mol'the Common,a License Low(Chapter
a Xo�' 9(commencing with Seaton7000)ofDivisioa3mfthe Bminessand Professions Cade) IN POOLBLE 'RIC VAWALOI�"
WM,, or that he is exempt and the basis for the alleged exemption.Any violation of V
i, ' Seentn 7031.5 by any applicant fora ,subjects then licanno o civil I71 -SWITCI IHS-FIXTURES
pemrl 1 PP penalty of
Wes nayf I.iu va an Bveda noddollms($500). -WRESIDENTIALELECUR _SQ.FI'.
W �11r-fill.. k.as thestrerty,ormyemtended oro wagcsaaectsee./tao,h miion, STORIES TYPECONSTRUCTION
d 11 ado the work,and rheiwc,ureis not imendeA.nsffereJ forsule(Sea 7044,Business
a d Professions Crude:The Contrucac,License Law does not apply m an owner of
property whohuildsor Improves thereon,and who docs such work hlnnelforthrough his -
employces,Pnrvided that such imprnvemenlsurc n.tintended onsffercd forsale.If.
OCC GROUT' RES.UNITS
however,the building or improvement is sold within one yearofcomplation,the owner- 'TOTAL:
builder will have the burden mf pmcin,,h.I he did nor build or improve for purpose of
sale.).
❑ I,as owner-ofthe propeny,am ac]usivelycontrocning with licensed conscious to QTY. PLUMBING PERMIT FEE ITOODZONIi APN
consumed the notax,(Sec.7044,Business and Professions Code:)The Contractor's
License Luwdoes nmapply manownermflopeny whobuildsm improves thenconand PERMIT A C'
whnwmrxt for tech prnJa,x wLb acomrucmr(s)liccns.d pumuonu0 the Comnectoi e
License Law. AI:TER- RAI '1' FEE SUMMARY
❑ I ten exempt under Sec. ,B&P C far this lesson BACK W TI . I SIDE FEES
as SANITARY Y N
Owner Dme RECEIPfa
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP,ARE ,C
_aL_10 12 ;U1 11 TEAX Y N
❑ Ihemby affirm rha,lhevenanificme mf consemmself-insure.ora cenificam of RECEIPT#
PI URFS-
penm,ion Insurance mracenilicJ copy,M1ercof(Sec.JSIXI,Lab C.)which ARK FE
Worlk Compensation YN
covers all employee's under this permit GAS-EA.SYSTEM.I INC. OUTLETS RECEIPT#
Policy# BUILDING DIVISION PELTS
Carolina, GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GRBASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIASETRAP SOILS FEE
COMPENSATION INSURANCE
Cnis section need no,be completed ifthe permit is formic hundred dollars(SIM) SEWER-SANITARY-STORM EA.21pFf. ENERGY FEE
or to..)
I certily that in the performance of the work for which this permit is issued,I shall WATER HEATER WNENT/ELECTR
not employ any Person in any manner so as to become subject to the WorkersPAID
Crmpcnsati.nlawsof Cvlifomis. Date WATER SYSTEMITREATFNG Dale Receipt O 2 Applicant
Z 2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMR SQ.17. TOTAL:
rEn become subject,.the Worker's Compensation provisions of the Lahr Code,you must
a forthwith comply with such provisions or this permit shall be deemed accused. BUILDING FEE st ti
W CONSTRUCTION LENDING AGENCY gLISMIC FEE
Z
g O
✓R Ihereby affirm than there is a construction lending agency for the perfommnce of
U O the work for which this permit is issued(Sec.3097,Civ.C.) 'TOTAL: ELECTRIC FEE
Pander's Name
0 U Lenders Address QTY. MECI IAN ICAL PERM IT FEE PLUMBING FEE
1 certify than I have rtad this application and sum That the above information is
W cored. l agree to comply with all city and county ordinances and state laws relatingto I'F.RMI'1'ISSUANCE MECHANICAL PER
ti>V) building construction,and hereby authorize representatives ofthis city reenter upon the CONSTRUCTION'fA%
U Z ahmvc-mentioned property for inspection pmpnes ALTER OR ADD 110 MECH.
(We)agree to save,indemnify and keep hmmless the City of Culvoina against
liabilitiea,ju t.,costs and expenses which may in any way accrue against said City AIR HANDLING ONIT(TO 10.000 CFM)
in wnseq tt ,he gmn,ing of,M1is pertni
AIR HANDLING UNIT(OVER 10.000 CPM)
oleo(Applicant/Contractor Dare EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.030 BTU) Date Receipt#
Will the apdicam nr Lane,building mccttpant atom or handle Imzartloss material
its defined by the Calamine Municipal Code,Chapter 9.12,and the Health and Safety I IIAI'ING UNIT(OVER 1 00,00,0 BTU) T
Code,Section❑Ys 1:1 No VENTILATION FAN(SINGLE RFSID)
Will Ne alspltcum or furore building weapon,use equipment or devitts which emit
BOILER-COMP(7)Ip OR 100,000 BTU) ISSUANCE DATE
nazardous air containment.u defined by,he Bay Area Air Quality Management COMPO
BOILER- ( VER 100,000 BTU)
;-ianricTl
❑Ym ❑No NI:W RESIDENTIAL MBCII. SQ.11C
I have read the hazardous materials requirements under Chapter 6.95 of the 199
Culifomia Health&Safely Cade,Section 25505,25533 and 25534.1 undcommul that
if the building dues not currently have a tenant,that it is my responsibility to notify the 3
wcapant mf the requtrs mens which..it be me,prior to issuantt of n Certificate of C! r
Occupancy. ('fir L Lljr;�J
Owner ter authorized agent Date TO'T'AL: I ISSUED BY:. !
OFFICE