27266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM PROJECT
BUILDING PROJKCT IBF.NTIFICATION
BUILDIN�DRESS: Soy. UNIT LOTH SANITARY NO, AP PLLIICATIONSUBMfITALDATE
OWNERSNAME: PHONE: CO R' M LIC NO: �•—�
I a W IN
&CAy �+SfR�cTge�7�IVONIC
CONTROL#
+'IIIUECT/ENGINEER: LIC NO: A gFSS: ^' �YI a//YV
// ❑ \J
CONTACT: PHONE: r BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
B ELECT PLUMB MIECH
PERMIT ISSUANCE ❑
LICENSED CONTRode,a S onsidCATION pppLIANCES-RESIDENTIAL. JOB DESCRIPTION
pal, Ihuoby a[BrliCONGRACTOR'SDE DECLARATION
(commencing with
LL100 Section"LBW)of Division3 of the Businessd Professions Code,and my license is in PANELS
t< Litenfall reeand effect 9�.� 61o7`0 UP T02IX)AMP3
FQ.ZW License Classas_at Lic.#_ t
my Dole Cdrttractdr 201-1000 AMPS `
2OcoZ ARCHITECT'S DECLARATION SQ.FT.FLOOR A EA $/SQ.FT.
O Z I understand my plans shall be used as public records. OVER 1000 AMPS 2 1�_.I,�r
"44
y � Licensed Professional SIGNS ELECTRICAL 1 �—` t
V OWNER-BUILDER DECLARATION SPECIAL CIRCUIWMISC. l•
DMF+ 1 hereby afrom that 1 am exempt from the Commends License Low for the
LL P,C,m fallowing rensoa(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLP.INST.
f� which requires a permit to construct,alter,improve,demolish,or repair any awmure
prior to its issuance,also requires the applicant fusuch permit to file asigned statement POWER DEVICES
ul O that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter
d0.o� 9(commencing with Section]000)of Division 3ofthe Bminessanl Professions Code) SWIMMING POOL ELECTRIC VALUATION
W^y or that he is exempt herefrem and the basis for the alleged exemption.Any violation of51 w
Q Section 7031.5 by any applicant for a permit subjects the applicant td acivil pevlry of OUTLETS-SWITCHES-FIXTURES 6
mnot more than five hundred dollars FEW). NEWRESIDENTIALELECTR SQ.FT. STORIE TYPE CONSTRUCTION
❑ I,the wnerafthepropeny,ermyemployees withwagesastheirsec. 0FI,Business
p, andwfiP the work,andtCusic he Contractor's
Licenseraded Law
red does not
apply to an Business
and Professions Code:The CdnOectn,License Law does not apply lf an owner of
pmpertywhobuild idmpnrvesthereon,andwhodoessuchwdedoruelferthrnughhl, OCC.GROUP RES.UNITS
ownemployeesilding ri improvement
is
within
Irtaofcoroffered the o e.If,
however,the buildingorden of proving
is sot within one year of completion,the owner,
builder will have the burden of Thor he did not build or improve for f T L. tie
proving p purposed
ale.).
❑ 1,as ownerof the propeny,amexclusively contracting with licensed contractors be QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
daemon the project(Sec.9fW4,Bust feestons Code:)The Contractors
Licetne LawddesnotapplY to anowi of propenyw ilds orimpmves thereon,and PERMIT ISSUANCE
whocontmetsfursuehprojeetswlth eonvactor(s)licereed Dd the Connotations ALTER (PA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. B&P C formas BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner pate RECEIPT#
WORK N COMPENSATION DECLARATION DRAINS-FLOOR,ROOF ,GOND. SCHOOLTAX Y N
I hereby affirm that have a certificate of contend toself-insure,or a certificate of RECEIPT#
reed,Cientsmationl�imau acntifiedcopythereof I've,3800,Lab CJ which FlXTURES-PER p PARK FEE Y N
covers all employee's u ler this permit. GAS .SYSTEM-1 INC.40UTLITTS RE IPI'#
Policy# BUILDI ISION PEES
Company GAS-EA.SYSTF VE (EA) PLANCHECK FEE
❑ Certified copy is erehy famished.
❑ Cenifledcdpyis tied with the tidy ton. ORGSEANDUSTRL INTERCEPTO GRADING FE
CERTI CATEOFEXEMPTI OM WORKERS' ORES SOILS
g.
COMPENSATIONI S RANCE
(Thissectian need atteoompletedlfthcpermhisforone neddollara(5100) SEWER TARY- ORM EA.200PT. Y E I *26A
ar lei
I certify that lathe rfermanceofthewmkforwh' Nispermilisissued,Ishall WATER H RW/V /ELECTR, -
not employ my person i any mamter so as to come subject to the Workers' PA
Compensation Lawsof Cali min. Dade ATERSYSTEMITREATING Do Reei
Q Z Applicant
z NOTICE TO APPLICANT:If,a ing this Certificate of Exemption,you should NEVRESIDENTIAL PLM . SQ.IT. TOTAL:
F-' y becomeeubject to the Worker's Compensation provisions of the LaborCWe,you must
Forthwith comply with such provisions ar this permit shall be deemed revoked. BUILDI# FEE
Z CONSTRUCTION LENDING AGENCY , SEIS EEE
I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELE TRIC FEE
U O the work far which this pump is issued(Sec.3097,Civ.CJ
Lender's Name 0PLU GING FEE O U Lenders Address QTY. MECHANICAL PERMIT FEE
1 certify that I have read this application and state that the above information is
>s LTI corecd.l Teem comply with all city aM county ordinances and slam laws rclming to PERMIT ISSUANCE MUCH ICALFEE
F-i building d married,and hereby authorizereprese ativesof thiscitymenterupdnthe CONSMION TAX
U 7. above-m t t ed propeny for inspec a'.. orALTER OR ADD TO MECH.
(We) e to save,indemnify o epless the City of C,mm against
Ilabilities,j it ex
ments. shandexpe w a in#myveayac e am said City AI LADLING UNIT(TO 10,000 CFM)
in nset are ofthegranting n rmil
` IR HANDLING UNIT(OVER 10,000 CFM)
ignaLicti candComra r Dm EXH STIIOOD(W/DUCn
PAID
HAZARD MATERIALSDISCLOSURE
HGTING UNIT(TO 100,00D BTU) Date R �ipt#
Will the applicant unbalance wilding occupant store or handle hazardous mmeriN
it as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Crile,Section 25532m)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,1100 BTU) PAN- ATE
Will theapplicamorfuwre buildingoccupantuseequipmentordevices which emit I-6 jq% _
rdoue air contaminants as defined by the Bay Area AG Quality Management BOILER-COMP(OVER 100,000 BTU) T�8r 1J
ieC ^1I l 01
❑Yes El No NEW RESIDLNTIAL MECH.—SQ.IT. V LUNEHIINU
I have red the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534, I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant df the requirements which must be met prior to issuance of a Certificate of
Occupancy. 1 0
Owner or authorized agent Dam TOT L: ISSUED BY:
OFFICE