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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECRICAL
APPLICATION/PERMIT PLUMBINf,-MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDENTIFICA'I'IQN
PIiRMff NO.
/� O .f
G o 1
BUILDINC„ADDJtESS:
SANITARY NO.
AP PLICATIONSUBMI17ALDATE
{/{/f�l//l''.�Cyy//11 UNIT O LOT#
CONTR fOR;S NA LIC NO:
NUC
❑
CONTROL
ARCHITECT/ENGINIBIR: LIC NO:
ADDRESS:
CONTACT: PHONE: ly
QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT Is UMB 13"PERMIT
ISSUANCE
1:1 El
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed underprovisionso(Chapter9 (commencingwiN
APPLIANCES - RESIDIENTIAL
JOB DESCRIPTION
fall(a 7a)0) effect. 3 of the Business orad Profeuions Cade, and my license is in
full dome and etTect,
PANELS
1 -
License Class LI<.M
UPT02W AMPS
W
Date Cor
gal - 1(KKI AMPS
ARCHITECTSownaw,c..adDECLARATION
1 undersmnA my plans xhall he used m puhlic rcc.rJs.
OVIER I" AMPS
SQ. FT. FLOOR AREA
Sm. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that I am exempt from the Contractors License Low for the
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit to concoct, alter, improve, demolish, or repair any swaare
prarto its issuance, also requires the applicantfar such Permit to file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Commemer's License Law (Chapter
9(commeacing wilh Seellon7000).f Division Jul tbo Business and I'mroWurs Code)
SWIMMING POOL ELECTRIC
VALUATION -
orthathuisexempllbercfrnmantlthebmixfortheallegedexemption. Any vialeiao of
Section 7031.5 by any applicant for a permit subjects the applicator no a civil Penalty of
pUI'LETS- SWITCHES - FIXTURES
ot re than five hundred dollars (f5W).
raftheproperty.ormyemployecs with wagesmtheiraolewmperosution,
NEW RFSIDENTIALELECR S .PT.
Q
STORIES
TYPE CONSTRUCTION
'Idothework,..the.vaaureisnotintendedoroffetedforule(Sec.7W,Business
d Professions Cade: The Cmunscror's License Law docs not apply to an owner of
p pony whobuildsor improvesthereon,and who does such workhimselforthroughhis
wnempl.yees,pro. dedfloasuchimprovemcm arc natimendedoroffercJ fnrxale. If,
OCC. GROUP
RLS. UNITS
however, the building or improvement is sold within one yearofcampletion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
QTY. PLUMBING PERMIT FEE
sale.).
❑ I,asownerofthepropeny,amexclusivelyconimmingwithlicrosedconm torsm
FLOOD ZONE
APN
connote, the project (Sec. 7044, Business and Professions Cade:) The Commcmr's
License Lawdoeanot apply manownerafpmpany whobuildsorimprovesthereomend
PERMIT ISSUANCE
whacontmets forsuch projects withacontmemr(s) licensed pursuant o the Contractor's
License Law.
ALTER (EA) )
FEESUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DFVICE
OLD'SIDI: FEE
Owner Date
DRAINS-ILO<1R,ROOF. AREACOND.
. .
SANITARY YN
RECEIPTM
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have ocenificateofcomsenttouif-insure, oracenificamo'
Workers Comas sono, insurance ora certified copy thereof(Sea. 3800,106 C.) which
SCHOOLTAX Y N
RECEIPTN
FIXTURES - PER TRAP
PARK FEE Y N
covers all employee's under this permit.
Policy g
GAS - FA. SYSTEM -I INC. OUTLETS
RECEIPT M
BUILDING DIVISION FEES
Company
16AS - F.A. SYSTEM -OVER 4 (RA)
PIANCHECK FEE
❑ Certified copy is hereby famished.
GRIEASEWNDUSTRLWAS'1'17 IN'TERCEPT'OR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATEOFEXEMPTION FROM KERS'
COMPFNSATION INSURA E
GREASETRAP
SOILS FETE
SEWER - SANITARY - TORM EA. 200FT.
ENERGY PEE
(This section necd not be comp let ed iDhe permit' for one hundred dollar (fl W)
or lem.l
:e.,I
WATER HEATER W/V '/ELECTR
I certify that in the perfm thewmk for hich this permit is issued, ishall
not employ any person in any manner so as m me subject at the Wo ars'
PAID
WATER SYSTEM/TREA ING
Compensationlawsaf Califomia. Date
Applicant
Dam ReceiptIf
NOTICE TO APPLICANT: If, after mekingthis Cer ficama xcon on n
NEW RE ALP B. SQ.IT.
TOTAL:
become subject to the Workers Compensation provi ons of .e od , ore must
forthwith comply with such provisions or this permit hall revoked.
BUILDING FEE
/�
SEISMIC FEE
CONSTRUCTION LENDINGAGENC
I hereby affirm that is a construction lendi g agency the peffomwnc f
the work for which this Permit is issued (Sec. 3097, is. C.)
Lenders Name
T
ELECTRIC PER
Lenders Address
QTY. MECHANICAL PERMIT FEE,
PLUMBING p -E LAo--
I certify that 1 have read this application and si ate that the above information is
rrect. lagreemmmplywithallciry and countyo 'ounces and emm lew.mletin,
PERMIT ISSUANCE.
MECHANICAL FEE
bmidin,counshuai.n, and hereby aoNoriu rep,.,.. es oDhisciry m asters aCONSTRUCTION
above-mentioned property for inspection purposes.
AMER OR ADD TO MECH.
TAX
(We) agree to save, indemnify and kap harmless penin. agot.,
'
liabilities,judgmermr.msandexKmcx which may in any waysccmeagainst said City
AIR HANDLING UNIT (TO IQOW CFM)
ire oni a cc.f the granting of this permit.
AIR HANDLING UNIT (OVER IQ000 CIM)
Sia read Applicant/Camwtnr ate
EXHq AUST HOOD(W/DUC
PAID
HEATING UNIT CTO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt N
Willshe applicant or future building oecupam score or handle heurdous materiel
m defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
OTA
Cale, Section 25532(uI1
13 Yea 1:1 No
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (311POR 100,000 BTU)
ISSUANCE DATE
Wilhhee listen arfuwre buiidin cu roue mrdeviceewM1ich emit
kkp=PP hoc pan q
Joos air c.nlarttinlmts as defined by the Bey AreaAir A'v Quality Management
inrin?
pOILER- COMP(OVER I00,000 BTU)
❑Yes 0 N
NEW RESIDENTIAL MCCH. SQ.FT.
I have read the houNeus materials requireme us under Chapter 6.95 of the
California Health & Safety Cade, Sections 25505, 25533 total 1 undersmnd dou
if the building does not currently have a tenant, that it is my responsibility to notify the
f
Oe uIsant othe requir amms which must he met prior to issuance of a C... licate of
fT,r 'ss ur 1
�IN
pansy.
V
ISSUED BY:
Owner or autbmixed.gem Dam
TOTAL:
OFFICE