24786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLEC'IRICAL PHRMIT NO. 2 4 w 6
APPLICATION/PERMIT PLUMBING-MF.CIIANICAL L 1/ yC�7{l.�/
hU1LDING DIVISION BUILDING PROJF.CJIDKN'IIFICATION
BUILDING ADDDRPSSS: e1�'(y/r SANITARY NO, APPLICATIOONN SUBM�I PIAL LATE!
2�✓ IVIVr�t �� ✓ f� • UNIT# LOTk 23 y
OWyEft�NAME� Ptj(?NE .ONTRACfOR;S NAME 1.1 0: RO —\U
A �L NIC COST
%.,CI,HTUCTfpNGINEER: LIC NO: KESS:
bl6 mow' arS � o '7.;7CI: PHONB: Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BhDC LBC PLUp/il MF.CH
PERMIT ISSUANCE:
LICENSHD CONTRAICTOR'S DECLARATION PANELAPPLIANCHS-NESIUENI'IAL JO CRIPI'ION
MCI Ihereby affirm that l am licensed under provisions ofChapler 9(commencing with
�i100 Scmian]d0lp of Dlv' n3ofthe Business dPndessinnsC and my license is in pANP.l.S
yU f force end effect. -151�
4Z Iccn�Lic.p UPl 10100 AMPS
ti<y Gc.Vomnr 201-I(100 AMPS
Z FO v`atiz CHIlECTS DECLARATION OVER 1000 AMPS Sp.FT.FLOOR AREA $/SQ.PF
O Z.pp I undershoot my plots shall he used as public records.
rh2-1 SIGNS ELECIRICAL
q j Licensed Professional
6 d'6 OWNER.BUILDIiR DECLARATION SPECIALCIRCUIT/MISC.
gxOte. 1 hereby from
that I am exempt from the Comma.,',License Law for the
I+I�+Is-tn following Mason.(Section)031.5.Business and Professions Code:Anymy memory TEMP.MLTIiR OR POLE INST.
Eta which requires o permit to construct,alter,Improv,demolish,ar re u I t
y� Pnunlnnocent POW11R DEVICES
Y0 prior toat heir licensed pursuntto ePrvisis the osocant fffic Co penniuo Liense La stammenl
�Om 9hommushcengwith Section
n70 Provisions the Contractors and Predawn Coder
d oW 9that he
exepttS«Emmen(the Division 3nftheed BusinessandProfessions Code) WIMMING POOLIlLECTRIC ^ VALUA '
ty,�y Sotto he isexempuherefromanf the periodsbjs for ects thedexempti to civil
of OUTLETS-BTS1 ` 006
�4 notmSoctiore than v anyhu applicant donlfsrrs $501). subjects the.applicammacivil penally of �j {���J
� � not more than rofhedreddollormye pl NHWRISIDIlNTIALELECTR _SQ,M'.
❑ I,ssnwnerofthepropeny.urmyemplmyeeswith wngesastheirsole compmenta n. S RI13 TYPIl CONSTRUCTION
y3_, wi 11 do the work,and the structure i x not intended or offered for sale(Sec.7044,Bmainess
and Professions Code:The Cmnvataores License law docs not apply to on owner of
property who builds or improves thereon,and who does such work himselfor through his OCC.GROUP RPS.UNITS
own employees,provided that such improvements me hot intended or offered for role.IL
however.the building or improvement is sold within oneyear ofcompletion,dwowncr- T f .
"1111-
builder will have the burden of proving that he did not build or improve for purpose of
Ie.).
❑ I,ssownerofthe pntpeny,am exclusively contracting with licrnsedconlmnors to QTY. PLUMBING PERMIT n FEE J.ONN
construct the project(Sec.7644,Business and Professions Code)'The Convector's
Licenso Lawdues nm apply to on nwnerofpropcny who builillmimproves thereon,and PBRMIT ISSUANCE!
whocontmcts forsuch projects with acomracmr(g licenscdpunuannothc Conwaors pL'R!R-DRAIN&VENT-WATER(IA)
License Law. U
❑ 1 am exempt ander Ss. ,B&P C For This reason BACK FLOW PROTECT.DEVICE Aid ID
SA
Owner Dare DRAINS-TIFLOOR,ROOF,AREA,COND, RL til
WORKMAN COMPENSATION DF.CI.ARATION SCHOOLTAX Y N
❑ therebyaffimlh:olhuve.cenificmeofennsemmxel&insure,oracenific:aeof FIXTURES-PHRTRAP RECEIPT'#
Workers Cmmpenwlinn lnsoranec«acmi0ed copy th<rcof(Sec.3800,Lab C.)which /e PARK FEH YN
covers all employee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECP.IPP p
Policy# BUILDING DIVISION FEES
Company GAS.FA.SYSTEM OVER 4(EA) PLANCHECK FUR
❑ Certified copy is hereby famished.
❑ Cenifted copy is fled with the city inspection division. GRHASFINDUSTRLWASTEINThRCEPIOR GRADING PEE
CERTIFICATE.OF PXHMPION FROM WORKERS' GREASETRAP SOILS FBE
COMPENSATION INSURANCE
(This secmnneed not becompleted ifthe permit is foram hundred victims;(SIM) SEWHR-SANI'T'ARY-STORM BA.20l FNERGY TEE
lets.)
I certify that in Else performance of the work for which this permit is based,l shall WAIBR HBATER W/VEN3'4?LEMR
nor employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws of Culifomia. Dme WATHR SYSIPM/IRHATING Date Recnpt#
Z Applicant
�y 0 NOTICE TO APPLICANT:If.after making this Cenificme of Baronial.,you should NEW RBSIDBNTIAL PLMB. SQ.R. TOTAL:
fn become subject to the Workers Compensation provisions of the Labor Cade,you must
7 m
forthwith comply with such provisions or this Permit shall be,deemed invoked. BUILDING FHL' .�
ECa CONSTRUCTION LENDING AGHNCY SBISMIC FBI,
Z I hereby affirm that there is a construction lending agency for the performance ofp �� ELECTRIC FEG
0 the work for whpermit is this perix issued(Sce.3097,Civ.CJ
Lenders Name BING FEE
0 U LenderPLUM
Lenders Address QTY. MECHANICAL PERMIT FEE
1 certify that 1 have mod this application and state that the above information is
correct. I agreem comply wiNull city and county ordinances en dsntelawsmlatingm PERMIT ISSUANCE �� MPCHANICAL FEE
�t Httilding construction,end hereby authorize representatives of thiscrymemeruprbe CONSTRUCTION TAX
U Z aba,wirmaional property for inspection pentoses ALTER OR ADD TO MUCH.
(We)agree m save,rude Ty an J ka unles�yuc-ugainxx
pertino against
Iiuhilitiea,jud arace,st dcxpcnse mh may inu 'd City AIR HANDLING UNIT(TO I6,oW CFM)
in con. ce oft odipg of t� ir. ,� w� �/ AIR HANDLING UNIT(OVHR 10,()00 CFM)
In cot ApplicanUConan or Date MHAUSTHOOD(W/OUCD PAID
HAZARDOUS KITRIALSDISCLOSURE HEATING UNI'I'('1'O IUII,INNIBTU) Care Reccipl#
Will the applicant or future building compact stare or handle hazardous material
usdeftned hythe Cupertino Mundcipal Gale,Cloper'>.12,moldw Hothh and Safety HEATING UNIT(OVER 100,000 B"1'U) T
Code,Section a)?
,Yc, El No
VBNTIIATION FAN(SINGLE RFSID)
❑Ycs
Will theapplicant orPowre building«cupant uuryuipmemordevices sOMItemil
BOII.L'R-COMP(3HP OR l(K,"BTU) ISSUANCE DATE
�Imzurdmr sic amamia moss as defined by the Bay Are.Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A 1 D
Distnn?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the harardous materials requirements under Chapter 695 of the MAR 1993
California Health&Safety Simian,Code,Sian 25505,25533 and 25534. I understand in.,
II'the building does not currently have a moral,that it is my responsibility to amity the
occupantof the requirementsrequirementswhich must be met prior to issuance of a CeniOcete of
Occupancy. C(I Y r wi-rH I�
O
Owner.,aathonMxf egem Date T I$SUEDBY:
OFFICE