24051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Ad rem: _ 24051
r a one: A -
w t CITY OF CUPERTINO-BUILDING DIVISION
'^
Can a or Name e0 I��GY APPLICATION I PERMIT I o� � P�1 4
Amhlted/P.nglneer.
BUILDING-ELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL#
Lk.No: '
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. nn'7Q.- PERMITISSUANCE ID ❑ 1:1LICENSED CONTRACFOR'S DECLARATION
thereby effirmthal l am licensed under provisions of Chapter 9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sed1.n7000).(DWislon3 ( etBusqipewa. �nd ProtessionaCode,andmy to
license le In(u o et(ed. � /'C /T PANELS
Llmnsc ss k.# ICJ l(/
Date Contractor 4444 a IV —UP TO 200AMP-q
ARCHITECT'S ECLA TON 211-1000 AMPS
pp��uu ren O I understand my plane shall be used as public mccoda OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Fi sob� LicenxM Profeaalonal SIGNSELECTRICAL 7
LM OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
71.., I herebyallrenthat l.....pt from the Contractor's License Lw for the .r . ' .
oo fallowing reason.(Section 70315,Business and Professions Code:Any city or
O Z F: TEMP.METER OR POLE(NSC. d
P� county which tequlmapertmtromtutrud,alley Improve,demolbh,orrepalr
< anyetrua pr toibW ..Ce,aborequi theappRcantfor,uchpermitto V Ib a signed statement that he h licensed pursuant to the provision,of the POWER DEVICES
iwContract.e.Lices=.Lw(Chapter 9(mmmencing with Section i7000)of Divi- N
1n
�Oa elon3ofthe Buelnnaend Pro(emloru Code)orthel hehexempt lhercfromand SWIMMING POOL ELECTRIC UAMQR
•1 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHE&FIXTURFS
p� applicant for a permit subject/the applicant to a civil penalty of not more t ban r
$� fivWundred dollars(SM.
I,as owner of the pro,", NEW RESIDENTIAL ELFf_TR SQ ONSD4UCTION
7< p perry,or my employees with wages a their ease
ompeneatlon,wllldothe wwkand themmdure hnm(mended or offered far
O sale(Sec.7fMy Bu=9 and Prolessiom Code:The Contradole Liceme Lw
does not apply loan owner of property who builds or Improves thereon,and O
FF who docusuchworkhmustforthrough Neownemployese,provided that such f��
MU-11 ITS
Improvements are not intended oroffered for sale.lChowve
epthebuildingor DOTAL; /
Improvement bald within oneyearn(complelb theowner-bu0derwill have
t"rdenof provingthat he did not bund orimprove fwpurposco!sale.). QTY. PLUMBING PERMIT FEE _
LL�J FLOOOZONE
7,cue owner of the property,am.70ludveli Business
contracting with licensed PERMIT ISSUANCE
contractorstoroLiceneLproject(Sec.apply
to an
of property
Code:
The Contractor's I.P .thee Lw does oho apply m.n owner of property who ALTER-DRAIN k VENC-WATER(RAI
builds or Improves thereon, and who contracts(or each ptv�ecb with a
0g6t7,ctw(s)xmpt under Ser. the Contrad.r'a Lkense Lw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I w exempt under Esc. B 4 P C far this mown —'
DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y N
Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
mbbyy
M.that I have a certificate of consent to eel(-insure,or RFCFR'C M
con ml.ofW rken'Com tumlontas. nca w'certified ythemof(Sm. GAS EA.SYSTEM-(INC4 OUTLETS PARK FEE Y N
Policy
# C.) OZ�- ls.Y
Policy# DING DI N
Corona. eK IiMV GAS FA.SYSfEM'OVERd(EA) BUILDING DIVISION FEES
ed co relay GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edNed copy b flied with
tM1 tis the city Irepedion dlvlelon.
CERTIFICATE OF E(. PFION FROM WORKERS' GRRASETRAP PAID .
COMPENSATION INSURANCE
(hi.sectionnced am becomplded Bthapermlt hfneonehundred dollars SEWER-SANITARY-STORM F.A.200FC. Date Recei t#
(E100)orless.) WATER HEATER W/VENT/E.ECIR ENERGY FEE Y N
I cent em t o any Pa..he in an the work.as to be. subjecranit I.t
blued, —
I shall not employ any peswn In any manner at u to Lmme wbjed to the
Date WATER SYSTEM/TREATING PAID
Applicant ompeneaR.n Love of Callfwnla.
Z Z Applicant NEW RESIDENTIAL.PLMB. SOFT. Date Recei t#
shoulO NOTICEen APIPLit&1.tIfW.,knnkingps Cti nproisons of
Labor
F Code,you me wbjeettotco ply with
provisions per it thesLabbe TOTAL:
W
Code,adrevoet forthwith comply with ouch provisioru ortM1bperndt shall be BU E
� deemed revoked.
LIG CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there Is a construction lending agency for the perform- ELECTRIC FEE
M Z ...of the work for which this permit is heard(Sec.3097,Civ.C.) TOTAL: ELECTRIC EEE
V O 1<nder' ams '
.LL E- !.ender ddreea QTY. MECHANICAL PERMIT PEES MECf-IANICAL FEE
O W I if thatlhave read lhhapplicatbnand patethat theabove Info sdtlon
a lam d. to comply with all city and county ordinan adp telawa PERMIT ISSUANCE FEE-PAID
:
W relatl gto sail ingmnsiudlon,and Lrebyauthorl I rep ativ of fhb
F Z City eat u the above-mentlorud property for lrm 10"'t urp wi. ALTER OR ADD TO MFCH. Date RCCCI t#
V — e)a ve,indemnify an ep harmless the Cltyl (C tuna P
agai tIla II cafe, Asa hichrnayin a .arae AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL'
agai tnl n e o gr Ingo this t AIR HANDLING UNIT(OVER 10,000CrM) CONSTRUCCIONTAX
Slgmtureof Applicant/ onimdor Da EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantatom or handle haeanlous HEATING UNIT(TO 100,000 BTU) ,UGI Date RCCCI I#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOT EE�
n Yo No
Will the applicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit lu ardous air contaminants as defined by the Bay Area Air
Quality Management Mind? BOILER-COMP(311P OR 100,0(0 BTU)
Yes ❑❑No p� y pss
t.woxdtheh.! as materialsrequirements underChapter6.95of BOILER-COMP(OVER 10D,000 BTU) It_ A b D
the California Health 4 SafetyCode,Sections 25505,255)3 and 25534.I
understand that If the building don not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT �
responsibility to notify the occupant of the requirements which most be mat lf'1
prior to issuance of a Certificate of Oce,parry. 77
Owner or authorlud agent r Date GIT
ISSUEDBY:
TOTAL: -
OFFICE COPY