27620 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES•USE BALL POINT PEN ONLY
infinit,D( -ELECTRICAL PERMITNO.
CITY OF CUPERTINO PLUMBING,-MECHANICAL 6 O
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMTITAL DATE
_ �J �j NITM LOT#
OW ' S E: a e.3 ti CONT CTOR'S AM LIC NO:
2 NC CONTROL#
WFG111TEGT/LNGINR: LIC NO: ADD SS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
' ALDG ELECT LUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTORS ionsofDECLARATION APPLIANCES-RESIDENTIAL JpB DESCRIPTION
O 00 I hereby affimUhat l an licensed11mic.and
(co mmencing with �/
V400 W E Section force and)e f Division 3.f Me Business end Professions Code,and my license is in PANELS O
FCS faillnse Clndeffect UPT02MAMPS
F 2 W License Close Lic.N -
rnQy DateContractor201-1IXq AMPS
1—y SQ.PT.FLOOR AREA $/SQ.FT.
2O y ARCHITECTS DECLARATION OVER 1000 AMPS
p Z,.Q I understand my plans shall be used as public records.
yS ELECTRICAL
Licensed Professional
�aC
OWNER-BUILDER DECLARATION SPECIAL RCUIT/MISC.
O a U I hereby affirm that I em exempt from the Comments Li se Use for the
W 31+-rFir following reason.(Section 7031.5,Business and Professions Cod Any city or county TEMP.METER POLE(NST.
�.Q] which requirest,permit reconstruct,alter,improve,demolish r repair any swnure
�} to its issuance,also the applicant forsuch file a signedstatement POWER DEVIC S _
prior requires pp PeroLa
µ( Q p that he is licensed pursuant to the provisions of the the B or'sesu Licence Lew(Chapter
P-e.oPl 9(commencing with sermon]OOo)ofDivision Sof the mess end Pm slog Code) SWIMMING OL ELECTRIC VALUATION
uxl=to or that he is exempttherebrOm and the basis for the all ed exemption.Any anon.,
tz} Section7031.5byanyapplicemfurapermitsubje theapplicantmuc t alt,of L ITCHES-
FIXTURES
not more than fee hundred dollars($500).
o ❑ Lasowneroftheproperty,ormyemploy swithwagesasthe I pen tion, NEW FdVTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
will do the work,andthesnacmre is not int edorofferedforsale(8e s
and Professions Code:The Com met ' icense Lew does n p m am v s
pmpenywhobuildsorina,menthe n,andwhodcessuch selforthro his OCC.GROUP RES.UNITS
own employees,providedthat such i rovementsiumnotin nde offered Ie.If,
however,the building orimprovement soldwit ns m bfcoo eowner-
builder will have the burden of proving at he did t buor r improv purpose of TOTAL:
sale.).
❑ Lasownerofthepropeny,mmexcluai Iyommuct ithlionvedommormrato 0Y. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business a Professic)The ContractualPERMIT ISSUANCE
Licence Lawdoesnmapply rn un uwner Ofprope whobuils o proves thereon, d
License Laww..
whornmrafor such projects wiMaconracmHe 'tensed pu u ¢m Ne Com ALTER-DRAIN&VENT-WATER EAU FEE SUMMARY
'❑ I an exempt underScc. B&P Cfort a reason BACK FLOW PROTECr.DEVICE OUT IDE
SANITARY Y N
Owner Q.m DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT# -
WORKMANCOMPENSATIONDECLA SCHOOL TAX YN
I hereby affirm that l have a certificate ofconsem to self-insum,or a onfireate of FIXTURES-PER TRAP RECEIPT#
orkersCompensation Insurance or acertifted copy therenf(Sce.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT a
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCljl FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE THAT SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is bounce hundred dollars($100) SEWER-SANITARY-STORM EA.20(1 ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner eo as in become subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTEM/TREATING Date Receipt#
0 z Applicant
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW REST IAL PLMIL SQ.FT. TOTAL:
�+ cii7i become subject o the Workets Compensation Provisions of the Labor Code,you must
forthwith comply with such provisions a this pemdt shall be deemed revoked 4a
BUILDING FEE
L>a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of ELECTRIC FEE
O Me work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Nome
u" Lender's AduressQTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have read this application and state that the above information is MECHANICAL FEE
correct PERMITISSUANCE
(agree mcormply with all city anJ county aminances end state laws relatingm
building construction,and hereby amhoriurepresentatives affix city to enter uponthe CONSTRUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liab0 ie judgmems,cmo,and expenses ich insnywayaccruea ai'r id City AIR HANDLING UNIT GO 10,0W CFM)
in co Dance oft cgmaf o 'is it.
Z AIR HANDLING UNIT(OVER Igaro CFM)
ig APPIiv. Cmmm EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOMI E HEATING UNIT(TO 100,0!10 BTU) Date Receipt#
Will the applicant or future building occupant store or fill, hazardous material HEATING UNIT(OVER 100,00!1 BTU) TO L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(e)?
0Yes El No VENTILATION PAN(SINGLE RESID)
SSN�F15A
Will Meapplicnntor futurebuildingmccupentuseequipmenwrdevicea whichemit BOILER-COMP(3HP OR I[D,f1008N) V
IrF
hi,arardous air communion,as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) �e _
nen?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. I�'GF /199S
1 have read the hamrdous materials requirements under Chapter 6.95 of the LurL
California Health&Safety Code,Sections 25505,25533 and 25534. I undemtmtd that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Cenificme of
Occupancy.
Owner or authoneed agent Date TOTAL: ISSUED BY:
OFFICE