26062APPLICANT TO FILL IN INFORMATION WITHIN REO LINES. usF Rel I POINT PEN f1N1 V
CITU OF CLPPIIBALDI 0.ELECfkl AL
HUILDING DIVISION APPLICATION/PERMIT PLUMB NUG
NUILUNPROJEfAIDENTIFICATION
PINMIINO,
26062
BUILDING ADDRESS: -
SANITARY NO.
APNLICA'1'ION SUHMOTAL DATE
L UNITp LOT#
URS E: • PHONE.S N•
RAC 'S h. LIC NO:
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CON ON,.
' RCHITECI'/ENGNEER: LIC NO:
❑
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•CONTACT : n PHONE:
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QTY. ELECTRIC PERMIT FEF.
BUILDING PERMIT INFO
R�DQ i ELECTPL M ECD
T��[\
PERMIT ISSUANCE �•
LICENSED CONTRACTOR'S pf:C1ARAT10N
mmecense with
Z Thereby of 3 of the Business
SecO full fore and e f Division 3 of the Business and l4ofessions Cod<, end my license is in
and NIfiesof Ch Code,
F full Ccm.
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
nse Cans
W License Class Lich
Dam Contractor
UP TO 201) AMPS
201 1000 AMPS
Z, ARCHITECTS DECLARATION
., 1 understand my plans shall be used as public rtcoNs.
-
/w SQ. FT. OOR AREA $/SQ. FT.
IvC_ e
A.Y�
vv
OVER 1000 AMPS
SIGNS ELECTRICAL
jal
LmensM Pmfessronal
J OWNER -BUILDER DECLARATION
1 hereby affirm that I an exempt from Ne Contractors License Law for the
SPECIAL CIRCUITIMISC. '
THMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
b following reason. (Section 7031.5. Business and Phlessions Cale: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any shucmve
odorous issuvtce,ulso requires theaPplicam forsuch pearnam Bleosignedontemem
C mat he is licensed pars ant to the provisions of me Contractors License Law (Chapter
Y 9(rommen<ing with Senium 7000)ofDivisinn3of the Business and Profession Code)
g p yvio1.1um of
N or that he is exempt therefrom and the Ends for the aIle edexem tion, An
Sectio 7031.5 by any applicant for o permit subjects Be applicant to e civil penalty of
not more than five hundred dollars ($500).
❑ I,asownerofthepropmy,ormyemploymswithwagesutheirsolecompensation.
will Jo Ihewmic and the strumureisnot intended ornffered forsole (SIN. 7044, Business
VALUATION
f L/�/vIk '+
STORIES I'YPHCONSTRUCTION
OUTLETS -SWITCHES -FIXTURES l
NEWRFSIDENT1ALELECIR_SQ.FT.
and Prolessions Code: The Contractor's License I.aw does an, apply in an owner of
property who builds or improves thereon, and who dues such work himselfor through his
own employecs,provided thosuch improvements arc not intended proffered foreale.If,
however, the builJingor improvement is sold within mayearof completion, the owner
OCC. GROUP
NIiB.0 I'I:S
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
�_
❑ ],as owner-ofthe property, am exclusively contracting with licensed contractors to
the project (See. 7(144. Business and Professions Cale:) The Contractors
QTY. PLUMBINGPERMIT V FEE
FLOOD LONE APN
Liinstruct
cense Lawdoes not apply to an ownerorpmperty whohuildsmimproves lhincon,and
PERMIT ISSUANCE �/
who contructs foramb projects with ucontrackuhs) licensed pursuant lathe Cormal
Liccme Law. -
❑ 1 am exempt undw 9w. , B & P C fpr this reason
ALTER-DRAIN&VENT-WATER (LA) i�
Flim^SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE
)I:
SANITARY Y
Owner Doc
DRAINS - FLOOR, ROOF,AREA, GOND.
_N_
RECEII.1'#
IWORKMAN COMPENSATION UECIARA'I ION
❑ Iherehy el'firm mutlhnveacertifwm ufonsennnsal[-insure, nrucertifieme n[
Workers'Compmsoninn lnsmm�ceoraamifi.J copy thcrcof (Sea.9g00, huh CJ which
covers ellempinyee'n under this permit
Policy #
SCHOOLTAX Y__N_
RhCISIPI'#
Irl%T TRA
PARK PI3Itt Y
RECEIPT '#
GAS- EA. SYSTEM4 INCAOU ETS
BUILDING DIVISION FIATS
- Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
ertified copy is heed
AIC❑ Certified copy is filed with the city inspection division '
with the cit.
GREASEIINDUSTRLWASTEINTERCE R
GRADING RTF.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRI?ASETRAP
SOILS FEE
This section need not be completed ifine permit is for one hundred dollars ($1
or less)
SEWER-SANITARY-STORMEA.2 FT.
ENERGY FEE
I cmify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers'
Compensation Lawsnf Califomia. Date
Applicant
WATER VEATF. ENTIELE
WATER S EAT
-
PAID
Dae Receiptp
NOTICE TO APPLICANT: If.mer making this Cenificae of Exemption, yn.should
become subject to the Workers Compensation provisions of the Labor Cale, you must
forthwith Comply with such provisions of this Permit be deemed resulted.
NEW RFSI TAI B Q. FT.
TO'1'A1.
BUILDING FEE �r
CONSTRUCTION LENDING AGENCY
I hereby affirm that there i... onstruction leoling agency for the performance of
the work for whichmis permit is issued( Sec. 3097, Civ. C.)
Lenders Name
SEISMIC FEE O
�^
ELECTRIC FEE
PLUMBING FEE �•
Lenders Address
I certify tbut 1 have call this application and stere than Be shove informminn is
QTY. P ECHANICAL PE IT - -FEE
PERMIT ISS CF. /
MECHANICAL. IEE
correct. Iagrcemcomply wird all city and aunty ordinances and state laws relating to
buildingeonstruction, and hereby aohoncemprexenualives of this city nu enter upon the
above-mentioned pial for inspection purposes.
(We) agree to save, indemnify end keep harmless the City of Cope/I nn against
m finhouience flhe osmad fifth, either. which may inany wvyegra#en
nepneex,pudgofine ling ofmi •!//v'
ALTER OR ADD TO
AIR HANDLING UNIT (TO 10,000 CFM)
CONSTRUCTION TAX
-
AIR HANDLING UNIT (OVER Ig000 CFM)
Sig tore of Applice ntmmpr Dam
EXHAUST HOOD(W/DUC i
PAID
HEYI INO UNIT (T) BILL" BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Intonational maedal
Dam Receipt p
T
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health lard Safety
Code, Section 25532(a)?
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID) -
❑Yes 11 No
Will theeppli<anmrfuwrc huilJingoxcupanl use equipment prJevias which emit
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
haammus air containment es defined by the Bay Arc. Air Quality Management
District?
BOILER - COMP (OVER 100,(100 BTU)
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. PT.
I have read the hazardous maenulx requirements under Chapter 6.95 of the
California Health & Safety Codq Seeders 25505, 25533 and 25534. 1 understood that
1�
F A I
if the building does not currently have u union, that it is lily ra,hosibility to notify the
ocapanu lir the requirements which must Ila men prior m Issuance ol'a Certificate of
Occupancy.
'
FE
Y:
Owner or authonved agent pate
ISSUED
OFFICE - —' wrg17111tl(/
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