24618 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPPV-OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING FROG CTF ID MECHANICAL
24618
BUILDING PROJECT IHN.NI'IPII.'A'1'ION
HUILDIN��G[yADDRESS: bfrAt) SANITARY NO. AI'Iq.ICATION SUBMITTAL DATE
1,) / r 'ONI'1'll LOTH
OW SNAME:j ONE: _ 3C, CO 'SNAMF.: � / NIC CONTROL#
•ARCHITECI'rENGINIBU9: LIC NO: ADD SSS W r-' ��(� ❑
CO TACE; PHONE.:
QTY. ELECTRIC PERMIT NIiL" BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
'16 'ENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M..z Iherehyamrmlhm lam licensed underprovisionsofCM1apter9(commencing with - //'t� LOB DI:SCRIPI'ION
V00 Smawm7cothof ivismo 3ofthe Business n Pmfe Code-and my,Reenac is in PANELS y{, ,r-M� ��(]f� I)
K{vUl U full Toone and c t �1/ /V— �r IVI"I! I Il 8
T¢„ZW LicenseC s e� Lic.N s_ (.�b / j UP 9'02fX1AMPS
m?y Uate Conuanor 1('QIy/ 201-]BOB AMPS
ZOrfen'� ARCIi1TE.CTSDECLA A OI OVER 1000 AMPS SQ.FIt FLOOR AREA S/S .FT.
OZ—M Landers and any,laas,hcll beusedaapublicrtcorle.
aF; SIGNS ELEC'T'RICAL /
y=yI.i«naw rroreaamnm ® I
Mu u
OWNER-BUILDER DECLARATION SPECIAL CLRCUIT/MISC. � r�
Oa0 1 hereby affirm than I am exempt from the Gmtron.r's Littnse Law for rhe
'3kti fnllowingreuwm.(Section 7031.5.Business it Pmfienom,Code:Any city or county TEMP.METER OR POLE INSLL N.I'`It IpI
E-�mJ which requites.permit m comms
ta,alter,improve, manm
demolish,or pair anycture I;'v'!
m its issuance,also rewires they Ileum for such u.file v signedstatement MW17R DEVICES
prior q pp pmol
yaj QO 9(comthat he la liceng with Sction7hoprovisvivion the C.ntmm.ra License Law(Chapter JTE
d W!2 ' 9or t hat he is ixemit fbeefomandthe Division Soflleed exemend ProfessionsCode) SWIMMING POOL ELECTRIC p
yl_y Sectio 7131.5 by nhertfromnt for
.basis for Neallegmexemant to civiny l poolty of OUTLETS-SWITCHES-FIXTURES
tZa oul Section 7031.5 by anyvrddolltrs($50nnit subjects the applicanuo.civil penaltyof
`C 0 mol moretbnnfvahuModny,orinyemp.
❑ hasnwnerofthepropengonnyempluyecswith wageemNeirsnlecompensntion, NIiW RCSIIJEN'l1AL Ii1.liC'TR _SQ.IT. STORIES 'TYPE CONSTRUCTION
y3. will do the work andtbeswnure is not irnendedaroffemi finitude(See 7044,Busiss
and Professions Come:The Contractors License Law docs not apply to an owner M
pmpmywlm miIdsmimprovesthrom,and whodoessuch work himself(I))tough his
employmo.provided than suchimprovc vexes menet imendedta ffered beside.If, OCC.GROUPEA
however,the buildingor impmvereem is sold within one yearof completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,ssownerofthe pmpeny,mneadusivdy connactingwiNlicensm commetorsm QTY' PLUMBING PER MIT' PEE FLOOD ZONE
construct the project(Sec.7094,Business and Professions Code:)The Contractors
License Ltwd.es not apply to anowocrofproperty whobuilds orimproves therem,and PERMIT ISSUANCE
wh.e.ntraets forsueb projects with acommemr(s)Iicenaed pursuant to Contractors -
License Law. ALTER (P ) .FEESUMN
❑ 1 am exempt unJerSa. B&P C for this mason BACK FLOW PROTECT,DEVICE SANITARY OUI YOF,FF.P N
• Owner Dam RECEIPTS
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPFIJSATIONDECLARATION SCHOOL TAX Y N
1 hertby affirm than 1 have a certificate consent en.f(Smum,.r a certificate of RV11T T N
FIXTURES-I'I:R TRAP
.rkery Cnmpensmi.n tnsumncanracenlQeJ copy,therm[(Sea.9NW,lsh CJwhiaM1 PARK IT.E Y N
covers all crop the � (j�]/Or GAS-EA.SYSTEM-I INCA OUTLETS RECEIpOH
PolicyN llJit lI��WW LL.II�� s 1�Qr T I BUILDING DIVISION PIiFS
Compmr, CZ'"-&-n�ELL Ny d GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK HE
❑ Cc,tjfcd copy Isshereby furnished.
niliW copy is film with the city inspection division. GRItSEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This seeli.nnemnotbec.mpleted ifthepetmit isrmonehundrmd011am(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or hers.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person In any manner an m m become oh,,d in the Workers' PAID
Compemmianlawsof California. Date WATER SYSTEM/REATING Dale RcceiptN
Q z Applicant
zz�-I C) NOT ICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMH. SQ.PT. TOTAL:
F' CI) become subject to the Worker's Compensation provisions Of the Labor Code,you most F� BUILDING FEC 7 forthwith comply with such provisions or this permit shall be deemed revoked.
CI-) Q CONSTRUCTION LENDING AG17NCY SEISMIC FEE
z I hereby affirm than there is it consnuction lending agency for the performance of
O the work for which this permit is issued(Sm.3097.Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name O PLUMBING FEL?F Lender's Address QTY. MECHANICAL PERMIT FEE
L) 1 certily that 1 buve read this application and one that the above inf.nmmion is "
�'s d comma. Iagree Or comply with all city and county Ordinances unit state laws rtladng mPERMIT ISSUANCE 1 1 MECHANICAL FEE
.' building construction,and hereby authorize mpresenmtivesof Niscity to initiation the J / CONSTRUCTION TAX
U shove-mentioned napery for inspection purposes. ALI'17R OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupenino against
Iiibilitica,judgments,cnsts and expenses which no,inanywaymame against said City AIR HANDLING UNIT(TO IQ(XIO CFM)
In c...m, c. grantingofthia t.
e 1 ;143 AIR HANDLING UNIT(OVER IO,OLp CFM)
$rgvwrco craw ontractur ' , Yi Date EXHAUST HOOD(WNUCT)
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt p
Will,leapplicant Or(.in.buildingomitpuntamrt.,handle broarulms material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Come,Chapter 9.12,and the Health and Safety
Cale,Section 25532(u)7
Cl Yes 11 No VENT ILATTON FAN(SINGLE REBID)
Willth.applicam.rFuturebui"b"accup'"mu quipmenmrdevices whichemit
BOILER-COMP(3HP OR 1 00,000 BTU) ISSUANCE DATE
haaandnus air contaminants as defined by the Bay Area Air Quality Management
N)erdcrl BOILER.COMP(OVER 109,000 BTU) A ' D
El Yes ❑No NEW RESIDENTIAL MECII. SQ,FT.
I have rem the hazvd.m materials requirements under Chapter 6,95 of the (�Nr�
Culifomiallcalth&Safity Code,Scetions25p15,25533and25534. 1undcrsmndthat V r7 a�
Bite building does not currently have a tenant,Nm 1
at it is my responsibility notify the Clay
occupant.f the requiremenu which must 4 met prior to issuance of a Certificate of I
Occupancy. HIL.
lir
Owner m amhmixed agent Data TOTAL: ISSUED BY:
OFFICE