S 1448APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN, ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL. vl:y 41 F NO.
R1448UII.mNc DIVISION APPLICATION/PERMIT a ar PLUMB NG J
P MECHANIC rennN..
❑ Consultant Fees
1 hueby affirm the' I am licensed under provisions.1Chapter 9 (commencing
in tell��Z wlln5e nuccard0)of Dtvicsnn3 o[tnc Businers and Professions Cmee, and my license is
2UVLicene a Class d eRea
Liprayse Class lie#
Lal Dna TSConDECLARATION RARCatt lea T'S DECLARATION
jI uneerswnd my plans shall h useJ rs public encores
F" O Licensed Empire satonal
"j
OWNERBUILDERDECLARATION
W
Q1 hereby affirm that 1 am exempt from the Cmdre,d r'x License Law far the
W U following rase.. (Section 7031,5, Business and Professions Code: Any pity nrcoumy
LW� which requires a permit in construct, alle , improve, demolish, or repair any ehuclure
ny
,rem f.,isicarmer,also esquire, the epplicant for such permit to file a signed imposed
L� that ho is licansed pursuant tothe provisions of the Contractor's License Law (Chapter 9
Yds that he is exempt
it tSection and flf basis
for
orthe rged exe and on. Any
y vi Cedel or
y o y thin he is exempt therefrom end the basis far the alleged exemption Any violation of
a,,,n 98315 by hundred
delta,orepermit subjects the nppliwnt lnucivil penalty of
not more than five hunereA dalton (SSIXO.
e ewuULha property, nrmyemployeeswithwagesred ertheirsale wm.Hersi ios
H ad will dolheworkC de The Cureisne , Li d... Law due, ., apply a air Business
^ m and Professions Cada The Conditioner, License law dues nm apply to owner of
hpro,seryis own who build, or improves thereon, and who Boca such work nedohimself or through
his awn employeese provided that such improvements me nm iyeareed or offered for
sale If, however,thebuilding orimprovement iesold within one year nrcp...a for the
poer-bnuder, win have Inc Women of proving that he pia not mild at Improve 0npar-
sc of sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
omtmct the pu dd (Sob. 7144, Business sad Professions Cale:) The Contractors Li-
nen Law does not apply to an owner of prapeny who hones or improves thereon and QTY.
who contracts for such projects with a conaector(s) licensed pursuant to the Contractor's
License Law.
I ton exempt under Sec. .B& P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affmm under penalty ofpepury one of the following deda ntlons:
❑ Ihnveand will mrinminu CerttOram o[Conewuoself-inxurcfisWnrker9Compcn-
katon, ie pbu ieod for Ey Section 3788 of the Labor CMe, far the pc,fammnce of the
risk for which (his penao is i,muL
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3980 of the labor Cnde for the peRennance or the work for whidt this permitlstsumd.
%My Wor nm i In. cern' dPolicy number ore:
mw an
/ Carries: n Policy No.:
/// CF.RTIF ATE OP E%EMPTION PROM WORKERS'
COMPENSATION INSURANCE
(This section need rat be completed if the permit is fnrone hundred dolhm ($ 100)
mless.)
1 parity that in theperf rracroeof Ihu work for which this permit is issued, ],hall
tact employ any person in any manner so as to become subject to the Worker,' Compen-
C,7$ saticn Lnw,of California. Data
Applicant
h NOTICE TO APPLICANT: If, atter making this Certificate of Exenrytien, yon should
7 hamWilsubjecttothe,mhp........ safien provisions of the Loner Codc, you moat
� fimhwith u�mply with such provisions or anis permif.ehall he deemed revoked.
Q
CONS "[RUCTION LENDING AGENCY
U Q I hereby affirm that there,, n cm68ucliou leading agency for the perfonmtnceof
w P fheWeak for which this peon, is ;soul(Soe. 3097. Civ. C.)
Q U Larded,NameLender', Address
Ifyln,Ihave roadth. ppl t d state that the Move information is
ti pal din rect, l agirce to comply with all city and county ordinances and state laws relating to QTY
L% Z building consibration, and hereby autherve repessentallves of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamdcss the City of Culwvino against
liabilities, jndgmenfs wets and expense, may In any way ,come against said City
onsegnence of lh rating of"is
p
APPLICANT UNI 5"fANUs A LI. COMPLY WITH ALL 101 -POINT
SOURCI3 REG TIONS, i/t Int
Will IM1/Rppllcant or future building occupant store nr handle hazardous maferail
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Ctdo, Section 25532(a)? ,.
DYes ❑No
Will the applicant Ur future building cncvpnnt use equipment or devices which
emir hazardous air_cnnmmiments as defined by the Bay Area Air Quality Management
Disvict?
❑Yes ❑No
1 have read the hazardous mallards requirements under Chapter 6.95 of the Cali-
fornia Health & Safety Cede, Sections 25505, 25533 and 25534. 1 usdestend that it nhc
building does not urrently have a tenant, that it is my responsibility ut sonify the ocuup ce
of the requirements which must tin per prior o issuance of Cenlficano a] Occupancy.
EI.ECTRIC PER
PERMIT ISSUANCE
APPLIANCES - RESIDEN"I'I Al.
PANELS
UP DO 200 AMPS
[ Y
(Inixal)
OVER Main AMPS '
SIGNS ELECTRICAL.
SPECIAL CIRCUPOMISC.
TEMP. METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQ Up
ALFER- DRAIN & VENT- WAFER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS 'FLOOR, ROOF, AREA, COND.
FIXTURES-PERTRAP
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSl HM-0VF.R 4 (F.A)
GREASEANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FE
WATER HEAL Ek W/VENT/ELECPR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RISIDEN'LIAL PUMP SQ. PT.
j1 MECHANICAL PERMIT . `
PERMIT ISSUANCE
ALTER OR ADD'ro MEGI P. '
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/IIUCf) .
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (SNP OR 100,000BTU)
BOILER -COMP (OVER 100,000 RTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, FT.
bit V
FEE
COMMERCIAL:
❑NEW BLDG/ADDITION ❑DEMOLI PION
❑TENANT FOOD VRVICE
IMPROVEMEN VRVIT
❑ OTHER
SQ, FT. FLOOR AREA - S/SQ. bdr.
VALUATION
1®
GRADING
SOILS FEE
PAID
Dale Receipt W
BUILIIING FEE
FEE SEISMIC FI:F.
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEF.
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID -
Date keceiptM
ISSUED BY:
ISSUANCE DATE
BUILDING PERMIT INFO
PI ELECT _DMB MECH
E:1
JOB JOB DESCRI ION
RESIDENTIAL,
❑ SFDWL ❑ KITCHEN REMODEL
❑ ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT - ESTRUM URAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS '
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
FEE
COMMERCIAL:
❑NEW BLDG/ADDITION ❑DEMOLI PION
❑TENANT FOOD VRVICE
IMPROVEMEN VRVIT
❑ OTHER
SQ, FT. FLOOR AREA - S/SQ. bdr.
VALUATION
1®
GRADING
SOILS FEE
PAID
Dale Receipt W
BUILIIING FEE
FEE SEISMIC FI:F.
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEF.
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID -
Date keceiptM
ISSUED BY:
ISSUANCE DATE