30650APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL. PERMITNO. 3 O 6 C O
BICAL
UILDING DIVISION APPLICATION/PERMIT n PLDMBwro o—sro—o —ir— J �j
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirdoor ot 1 am licensed under provisions of Chapter 9 (commencing
Q00h S
with 7M))of Division 3 ofthe Business and Pmfessinm Codamd my license is
in full force and effect.
<UUU� Licenu Class Lic,M
�<47 Dow - Contractor
�+ ARCHITECT'S D17CLARATION
2 O � Z 1 understood my plans shall be used as public records
02-
[r
4,
!j Licensed Profensinnn -
Y% OWNER BUILDER DECLARATION
yy C Q I hereby affirm that 1 an exempt from the Contractee. License Law for the
pd 0.V following res... (Section 903 I.S. Busim.r, and Pmfawtons Code: Any city or coamy
YY1I a 1z,�rs which requires a permit to construct, alae improve. demolish, or repair any structure
F❑2,�OQ� poor to its issuance. also requires the applicant for such permino file o signed statement
om
mat he is licensed pmmut the pmvisimr. ofma Cnnorar, s lice... Law (Chapter 9
(commencing with Section 7")of Division 3 of Ne Business and Pmfcomis Code)or
that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
iemR. section 7031.5 by any applicant for .permit .objects the applicant to. civil penalty of
44F11 Z D, not mote than live hundred dollars (8500).
p=O ❑ I, m ownerof Ne pmpcny, or my employees with wages as their sole compensation,
ss55LL will dothewons Code: s o Contractors
Liens or Law
dos ..lappa JB44, Business
W and Professions Code: The Convectors License Luo does not apply to if owner of
progeny who builds or sided chit,
such i, pr who rices such work himself or through
his own employees, pnilding that such improvements ore not intended or altered for
sale. r- however,thebuilding or improvement is sold within one year of completion, the
wnenvuilJer will have the burden of proving that he did not build or improve for pur-
ppof soled
as of .
owner the pmpeny, am exclusively convicting with licensed contractors to
comm the Project (Sec. 70LI, Business and professions Code:) The Contractors Li-
cense Law aces not apply to an owner of property who builds or improves thereon, and QTY,
who contracts fm such projects th a eontmetor(s) licensed pursuant o the Contractors
Lirense Law.
1 am exct}pt under Tc. B & P C for In, Jeaeon
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPT0200AMPS
WORKER'SICOMPENSATION DECLARATION
re yallirm under penalty of perjury one of the fiJlnwing Acdxratinns:
thosee d BE mainmina Cenificmeo(Consenuoxlf-insure for Workers Compete
sotion, as pro it
for by Section 37M of the Labor Code, for the performance of the
work for which this Perth is issuW.
❑ 1 have and will maimxin Workers Compensation Insurance, as requited by Section
3700 of Ne Lahr Code, fur the petformsncc.f the work for which this Permit is issual.
My Workers Conspenandun Imumme carie, and Policy number arc:
Cartier. Policy Nu.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not be completed if the permit is forms, hundred dollars (8100)
or less.)
1 sonify that in the performance of the work for which this permit is issunl, l shall
not employ any Person in any manner so as to volume subject to the Workers Cmnpen-
Q Z sation Laws of California. Date
7 O Applicant
GNOTICE TO APPLICANT: If, after boiling aking this Certificate of Exemption, you should
a^ become subject to the Waders Compensation provisions of the Labor Code, you most
{TJ G f^nhwi n comply with such provisions or this permit shall he deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
U O work
which
thi th:nmi,i there is ed ES..i30 loading agency for the performance of
iA (-' the work for which this permit is issued (Sec. 3097, Civ. CJ -
O U Lender. Name
0. Lenders 1 ceedress
y since that 1 have read thirty and applicationanddime that the shove information is
W correct 1 agree to comply with ell city end county ordinances and stun laws relating to QTY.
U 7�. abovengeunstmctiomonJ hereby nuttionzerpowas. moves of this cirymenter ummthc
above- (We)
Wei age propene for inspection proposes.
(We)agmento casts indemnifyendkeep harmless wh CityraCupertinoagu(nx'
liabilities,judgments,coos and expenses which may in any way .sere against said City
in consequence of the granting of this perr^it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicatiVConvector Data
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupant store or handle hazmdous material
as defied by the Cupertino Municipal Code, Chapter 9.12, and the Ibmlth and Safety
Code, Section 25532(x)'!
C] Yes C] No
Will the applicant ar future building occupant use equipment or devices which
emit luxamo ma nit contaminants as defined by the Bay A. Air Quality Management
District?
Cl Yes No
I base recd its, houndro s matenals requirements under Chaplet 6.95 of the Cali.
(,arm Health & Safety Code, Sections 25505. 25533 and 25534. 1 understand that if he
building does am currently have a tenant that it is my responsibility to n lify the accupent
of the requirements which must be met poor to issuance of a Cerific:ue of Occupancy.
SIGNS ELECTRICAL
SPECIAL CIRCUITNISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC SWIMMING POOL ELECTRIC /C
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQET.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER IEA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROUP, AREA, COND.
VENTURES - PER TRAP
GAS - EA. SYSIP.M-I INC. 4 OUTLETS
GAS- PA. SYSTEM OVER 4 (EA)
GREASIVINDUSTRI, WASTE INTERCEPTOR
GREASETRAP
SEWER -SAN I'TARY-STOW EA. 2001-7.
WATER HEATER WNENTIELECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD(WIDUCD
HEATING UNIT TO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VEN IELATION PAN (SINGLE RESIDE
BOILER - COMP QHP OR 100,0110 BTU)
BOILER -COMP (OVER 100,000111U)
AIR CONDITIONER
NEW RMIDENTIAL MUCH. SQ. ET
TOTAL:
OFFICE
FEE
11
LN
BUILDING PERMIT INFO
I�LDD�G ELECT PLUMB MECI
L� ❑ ❑ ❑
JOB DESCRI V PION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
[I PLUMBING RE -PIPE
❑M1.11.11 -UNIT
El STRUCTURAL
MODIFICATION
El INTERIOR
[3 CHIMNEY REPAIR
IMPROVEMENT
TOTAL:
❑ BATH REMODEUREPAIR ❑ DEMOLITION
C OTHE�-rh,�:_?t
BUILDING FEE 1�
FEE
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLITION
El TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ, Fr. FLOOR AREA VSQ. FT.
PAI®
FEE OCT 3 1996
Gift
�2,00avess�
PLANCHECK FEE a—
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
1 t ecciptIt
TOTAL:
BUILDING FEE 1�
FEE
SEISMIC FP.P.
4— N_tliadl
ELECTRIC FEE Ef
PLUMBING FEE
MECHANICAL
CONSTRUCTION AX
HOUSINGMITIG TIONFEE
PAID
Data ReceiptM