24624APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
HUII.DI. G-ELECTRACAL
PLUMBING - MECHANICAL.
BUILDING PROJECT IIIENTIFICATION
PERMITNO.
i A C A
2 4 6
24624
4
BUILDING AUDRC55,
SANITARY NO.
APPLICATION SUBMITTAL DATE
Y O� �� • \�
UNI I'll
I.OTN
OW NAMC: PHONE:
CON
CTOR'SN LIC NO:
N/C
CONTROL#
I1 ARCHITECT GI%NIiER: LIC NO:
ADI
ESS:
❑
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CONTACT: � i _Pf7[)N""C UO
.ONTA`yAC Ai' 6,-1T1�,MV`
QTY.
ELECTRIC PERMIT
FEE.
BUILDING PERMIT INFO
fl� CII
.ECL' UJOB
PERMIT ISSUANCE,,
I.ICIINSCDCONIHACPOR'SDHCLARATION
Ilmrebyafliwthat/mn Iicen underpsovisionsofChapier9(commemeingwith
Section 7000)of Division 3o17the Businessand Professiuns Code, andnty license is in
APPLIANCES - RESIDEENTIAL
DESCRIPTION
PANELS
full farce and effect.
j License CI,xx Lic.#
UP TO 200 AMPS
■ ��
"{f
201 - 1000 AMPS
Dam Contractor
ARCI II'IECTS DECLARATIONOVER
I understand my plans shall be used as public records.
101111 AMPS
SQ. FT. FLUOR AREA $/SQ. FT.
M`
lb it
ai
SIGNS ELIiCIRICA sv
p License,]Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 um exempt from the Contractors License law for she
SPECIAL CIRCUIT/MIS
Lt� . �k
nq�V�/
TEMP. METER OR POLE INS .
i following reason. (Section 7031.5, Business and Professions Code: Any city or county
1 which requires a permitto coaswcs,alter,improve, demolish, Or repair any .Weturc
prior in its issuance, also requhn th"Miicatn fnrsuch penmillr fileasigned statement
'POWCN DIiVIClES
j that he is licensed pursuant n she provisions ofshe Contractors License Law (Chapter
9(cnmmencing withSection7000)ofIiviswr3 afthe Businessund PofeW.mCode)
SWIMMING POOL ELECTRIC
orthm fieNexempt derefromanJ thehavisfor Neallegedexemption. Anyviolalion of
Section 7031.5 hymnyupplic:msl'or. permit subjects the oppliannn a civil penalty of
�''y EVALUATION
tel L. 0
)) F
OUTLETS -SWITCHES -FIXTURES
b than five It dreddollars($5W).
nofthe pmpeny, onmy employes wird wages ns theirsolecampensation,
NEW RPSIUENTIALF:L[CfR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will dmtha work, and the auucoreis not imendedoroffered Porsale (Sec. ]fN4, Business
and Professions Cole: The Convector's Liccrue Law does not apply to an owner of
property whohuildsorimprovevthereon,and whodmi,tich work himselforthroughhis
ownemployers,po vided that such improve men tsmesminrandedarofferedtorsade. If.
OCC. GROUT'
RES. UNITS
however, the bnildingor improvement is sold withinaneyear o rompletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QrY,
PLUMBING PERMIT
FEE
sale,).
❑ I, as owneroflbe propeny,mm exclusivelycontracting with licensed convectors to
FLOODZONE
APN
conamet the project (Sec. 70,4, Business and Professions Code:I The Conwcwh
Lice se Law drys not apply munowneri f pmperty who builds or improv. dam no.ord
PERMIT ISSUANCE
who contracts fnrsuch projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
ALTER-DN,t.N& . A A)
FEE SUMMARY
El1 am exempt under Sce. , B & P C far this reason
BACK PLOW PRO Cf. VIC (�
IP ID : FL•
A Y Y N
RECEIPTp
Owner Dale
DRAINS - FLOOR 'A
FR
WORKMAN COMPENSATIONDECLARA7TON
❑ Ihexby affirm that lhave e arifiwsc of rnnsenno xlGinsurt, ora certificate of
Weaken CompnavOon lnsumnce nracenifMmpy thereof (See.36W,Leh C.)whichPARK
1001. T'A% Y N
RF.CEIPTN
FIXTURES-PERTRAP
FIE Y
GAS -EA.S STfiM-I
GAS - PA. SYSTEM -OVER 4(HA)E
savers ellemployee's under this permit.
Policy #
RECHIPfp
G DIVISION REFS
Company -
❑ Ccniflcd copy is hereby famished.
CRI?ASrONIIUSTBLWASTEIN"I'ERCEPOR
❑ Camfi>d copy is filed with the city inspection division.
C I ssssss
CERTIFICATE. OF EXEMPTION FROM WORKERS
GREASE TRAP
SOI FEE
Is
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY Mdl�y
(Thisaection ncedmo be completed ifthe pooh is fora. hundred dollars(8100)
or Ices)
WATER HEATER W/VENT/ELIECTR
-
I certify that in the perfamenceofthe work far whichmis pe wit is issued. I sholl
nos employ any person in any manner so as m become subject to the Workers'
PAID g
WATER SYSTIItTREAnNG
Cmademationlawsuf Culifomia. Data
Dme Rccci
Applicant
J III
iso—
NOTICE TO APPLICANT: If, after making this Cenif¢at, of Exemption, you should
NEW RESIDENTIAL PLM. SQ. FT.
become subject to the Worker's Compensation provisions of the Labor Code, you must
fnMwith comply with such provisions or ibis permit shell be domed mvnked.
BUILDING PCC
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I herehy affirm that there is a construction landing agency for the perfarmrce of
the work for which this permit is issued (Sm. 3097. Civ. C.)
Lender's Name
'1'
ELECTRIC FEE
Lendar'e Address
QI'Y.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
I certify that I have read this application and state flat the ohne information is
correct. l agree to comply with all city and county ordinance andetme laws relmingto
PERMIT ISSUANCE
building construction, and hereby authorize representatives of this city to enter upon the
shove -mentioned propeny for inspection purposes.
ALTER OR ADD TO MHCH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep hornier the City of Cupertino against
Iiabilitin'Ju Jg enes,costs and expenses which may in any way aecme against said City
AIR HANDLING UNIT (TO IB,OW CFM)
s osseyuenc Ithe granting of this permit.
/
O
AIR HANDLINGIINITIOVER IO,WOCFM)
Si entre of p ¢enVCom nr Ute I
EXHAUST HOOD(WAIUCI')
PAID
HHA'UNG UNIT (To 100. W BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt If
Will the applicant or future building occupant score or handle hazardous material
as defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
gEATINO UNIT (OVER IW,OW BTU)
T
Code, Section 25572(a)7
❑ Y. 11 No
VENG ILATION FAN (SINGLE REID)
Will da, applicant mfus a building by thenBay Amu Air Quality
azardws air contaminants us defined by the Bey Area Air Quality Management
Management
istrict.
BOILER - COMP (311P OR 1f10,000 BTU)
ISSUANCE DATE
BOILER - COMP (OVER 10
0,wo BTU)
❑ Yea ❑ No
NEW RESIDENTIAL MECIL SQ. PI',
I have mad the hazardous materials requirements under Chapter 6.95 of the
California Health & Salary Code, Sections 25505, M533 and 25534. 1 understand that
if the building does not currently have a term, that it is my maimr,dality to notify the
)
occupant of sM1e rcyuiremems which must be met prim to issurce of a Certificate of
I
aenpaneyy.
ISSUED BY:
Ownerorauthoutslagent Date
T( AL
OFFICE oilV Wt wrcrI I law