24490 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI RICA I. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL _24490�I Af•� �O
BUILDING DIVISION BUILDING PROJECT IDEN'I-IF'ICATION l�
d11I1.D ('j ADDNI?. :�- —/ R 11NITp pRah Let
Ldl SANITARY NO. A19I- gUHUATC
OWN PHONE: CO ]R'S�MFi: LIC NO:
(/ NIC CONTROLp
• ARCH(' CT/EIGINEER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE: QTY. ELECTRIC PERMIT 17EE BUILDING PERMIT INFO
BLDG E ECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARA'EON APPLIANCES.RFSIDENTIAI, JOB DHS§ PITON
M9z Iherebyaffirm that l nmlicesedunderpoorkinnso(Chap¢r9(commencingwith
P100 Section 7").f Division 3.fthe Business and Pmfeatinvs Code,und my license is in PANELS
yU falimarrandetTect. 1a,
C2 Licence Class Lic.p UPTG2E0AMPS
y6y Dutra Cnnlowr 201-IIXI6 AMPS
ZOat,
z - ARCHITECTS DECLARATIONOSQ.FT.FLOOR AREA $/SQ.FT.
1 undcrswnd my plans shall be useJ as public records. VER IOW AMPS
P4 . Licensed Professional SIGNS ELECTRICAL
ggN OWNER-BUILDHR DECLARATION. SPECIAL CIRCUIT/MISC.
M1 hmehy affna ihol I an esempt-from the Contractor's License Law for the
1a13Wya following reason.(Section 7031.5,Bash.avand Professions Cale:Any dtyoroounty TEMP.METER OR POLE INET.
F'n J which requires a pmmit to construct,alter.improve,demolish,or repair any strudum ,
�rW aE priorto its issuance also requires the applicant forsuch Permit to file a signedimement POWER DEVICES1LC p thin he is licenser pursuant t.the Prnvisi.nraf the Contmcmr'n License law(Chapter
6i��d Y(commencing SWIMMING POOL ELECTRIC
e ( gwith Section�0M)of Division 3 ofthe Business and Professions Calc) AL 1
or that he is exempt and the basis for the alleged exemption.Any violation of OI1TLEfS-SWITCHES-FIXT'URIiS
GSection 7031.5 by uny PPI ant for a pernin subjects the appliconnna civil penalty'(
G 0 1.....edum fivehundreddollurs($5111)). NEW RESIDENT'IAl.ELECPR _SQ.FP.
❑ odue wrk.am[epmpuctum mycmployedorofcard Amarle(Sce.70t4.Business S PE CONS'1'RUCfION
y will Prthewons and the he Couturiers
or ofwdoes not apply to an owner
of
and Professions Cale:The Contfecmrs License Law docs not apply m an owner of p T
proown enyem wyees,prvvimproves hat such improvndwhsd.=nor chwork himulfanhmugh M1is N,. .
employees,provided that such imprnvcmcrosare nm intcndedoroffencd(mama.If, IOCC.GROUP S.UNITS
h.wevegthe building.,improvement is sold within one yea,'(completion,the.wnm- - T _.ssss".
builder will have ilia burden of proving that Ire did not build or imps ove for purpose of
sole.).
❑ I,as ownerol the propcny,am exdmivdyc.mmningwith licensed c.mrnmors to Q'I Y. PLUMBING Pf?IlMPP FEF? FLOOD ZONI? APN
consumer the project(Sec.7044,Business and Professions Cn1e0 The Contractor's PERMIT ISSUANCE
1.icenm Law does not oppl y to at owne r.f progeny who bui Ids or i mpmves thereon,w d
Lraforsuch projects pursuam to the Commemr's
Licenseicense Law.w. ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em esempt under Sec. ,❑&1'C for thio rcas'n BACK FLOW PROTECT.DEVICE
SANITARY YN
• Owner Date RECEIPI'a
DRAINS-FLOOR,BOOP,AREA,GOND.
WORKMAN COMPENSATION preparing to
SCEOOLTAX Y_N
❑ em'Compensmonlhranceve a oraccaia.fcopytioosd(im.3812 ,um,or Labcertificate.)which FIXTURES-PPR TRAP RECEIPTp
W.rk<ri Compensation Insurance oracmificd copytMreaf(Sec.3gIXl,Lab C.)which PARK FEE YN
covers all employees under Nis permit GAS-EA.SYSTL'M-1 INC. OUTLETS RECEIPT M
Policy M BUILDING DIVISION FEES
y GAS-EA.SYSTEM-OVER 4IRA) PLANCHECK FEE
ni0ed copy is hereby famished.
Certified copy is filed with the city inspection division. GRFASE/INDUS'I RL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS'" GREASETRAP SOILS FEE
-
COMPFNSA'1'[ON INSURANCE
(This scaionneed oatbecompleted ifthe permit B forage hundred dallare IS IW) SEWER-SANITARY-STORM HA.200FT. ENERGY FEE
or Tess.)
I certify thin in the performance of the work for which this permit is issued,Isbell WATER HEATHS W/VENT/LI.ECTR
not employ any person in any manner sit as m become subject o the Workers' PAID
Campensmion laws'(Confucius Dam - WATER SYSTE!"b"REATING Date Receito#
Z Applicant
z0 NOTICE TO APPLICANT:If,aper making this Cenifcate of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FT. TOTAL.
Ftq became subject to the Workers C.mpcg.mtion Provisions of the labor Code,you must
� ; forthwith comply with such proviummor this Permit shell be deemed nitrated. BUILDING FEE
z CONSTRUCT ION LINDING AGENCY SEISMIC PER
I hereby affirm that there is a construction lending agency for the Performance(if
U O the work for which this Permit is issval(Sea.3097,Civ.C) TOTAL: ELECTRIC FEE
IS-0 Lender's Name PLUMBING IEE
Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 certify thin par
1 have d this application and state that the above information is MECHANICAL FEE
�" 0. caned l agree m comply with all city and county ordinances and stale laws relating to PERMIT ISSUANCE
,f•',I fA building construction,and hereby amhorimmprescrinivcsofthis city to enter upon the CONSTRUCDONTAX
U oboe-memimed property for inspection proposes. ALTER OR ADD TO MECH.
(We)agree o save,indemnify and keep harmless the Cily of Cupertino to nind
l iubi l itim,judgmentsoO matiliffensce,which may in my way accrue against sa'ICity AIR HANDLING UNIT(TO 10,000 CFM)
incense ue ice of egrumi .(this psr ti
AIR HANDLING UNIT(OVER 10.000 CPM)
S' naturr APP ' ma f EXHAUSTHOOD(W(DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE ORATING UNTT(TO IO0,0fi0 BTU) Date Receilda
Will0mapplicam or Wore building recupam spar.,handle hazanlous material 'HEATING UNIT'(OV[R IW,fI(11111'I'tl) UAL
relined by the Cupertino Municipal Cala,Chapter 9.12,and the Ileulth and Safety
Care,Section 25532m)? VENTILATION FAN(SINGLE RESID)
❑Yea ❑No
• Will air co ournmrfattue building by the Bay Arx.Air
Marini hemit
BOILER-COMP(3HP OR IW,oW BTU) ISSUANCE DATE
Cannotus air ammminams as defined by the Bay Area Air Quality Management 'BOILER IW,OW B'T'U)
Diariet, P A I
ElYev ElNo NEW RESIDENTIALMECII. SQ.FT.
s) 1 have rend the hazardlus materiels mquiremeoo under Chapter 6.95 of the
California Health Code,Sections 25505,VUG3 and 25534. 1 understand No •v Noy 13 39,2
if the building does not currently have a tenant,that it is my responsibility to notifythe C'11 /�(�
occupant of the requiremems which must he met prior to issuance of a Cenificme of 1 0t;
Occupancy. \'''��//y�k�rN�t„ t
Owncriamomo,irtd agent - Date TOTAL: ISSUED BY: VIII
OFFICE