26041 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 ECTRICAI PERMIT No. r� O
APPLICATION/PERMIT PLUMBING-MFICIIANICAL G
BUILDING DIVISION - BUILDING PROJHC'TIOUNTIFICATION
BD41
ILDINGADDRE$$: /) / \ SANITARY NO. APPLICATIONSUBMITTALDATE
9 le Lk) UNIT# LOTH
OW � SNAME: PHONE: CO R CfOR'B NAME: LIC SN/C CONTROL#
CH.TECT/ENGINF.P I LIC NO: ADDRESS; ❑
[A 416 Al-
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRIPf1 N
pmZ Iherebaffirthe
Ynt l emnsedund
liceerprovisionsafa.pteri?Emomencing wish
Fa100e Seminn90110io'Divisio Sof Business and Pmfessiom Code,and my liceme is In PANES 1 -
tt�U fu 11 force and c ect
pQ.,ZW License Clan ic.# � UP TO 200AMP$
an=ti Date Contractor 201-1000 AMPS
ZOD ARCHITECTSDECLARATION e;- OVER IOOOAMPS SQ.FT.FLOOR AREA $/TQ.FT.
OZ-0 I understand my plans shell be used ss public records.
r,4�: SIGNS ELECTRICAL
�k 2 Licensed Professional
yec OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
XO�F L hereby afros Chet I am exempt from the Contractors License Law for she I a ■
W a m fallowing mama.(Section 7031.5,Business arslProfessions Code:My city or county TEMP.METER OR POLE INST.
which requires a Permit to consmoct,alter,improve,demolish,or repair any audio,
�t'try��'}� Prior to its issuance,also rc9uirea the applicant(orsuch permit to file.signed statement POWER DEVICES
y�'j C p0 Nat he is licensed panursuant m the provision ache Coutrecmra Licenu Law(Chaptm I
e.ELft 9(commencing wish Section 7")of Division 3 of she Business and Professions Cade) SWIMMING POOL ELECTRIC j ) pTION
^y mainmainhe is exempt therefrom end the belie for thealleged exemption.My smutionof /.S� n.
FZ_a Section 7031.5 by y applicant for a Permit subjects the applicantto a civil Penalty of OUTLETS-SWITCHES-FIXTURES 1 a//
C p
t more than five hundred dollen($500). NEW RESIDENTIALLECIR _SQ.
E
m ❑ I,ssownerofshepropeny,ormyemploy«awithwegautheirsolecampenvtion. DA ------=ORIES TYPECONSIRUCOON
a3— will Professions
Code:
no Contractor's
License
La ertd s not apply to a0,owner
and arty wh of u Code:The ttrecrora Licenu Lew alma not apply io rt rang of
property w ho bu ilds or immaves tM1ereon.and w ho alas such work hinue I f or Nrough his
cmplmyeea,pmv.,imprauemimpmvcmentsinims,car oftoroffemdfm WmeIf.n. OCC.GROUP RES.UNITS
huilder thebuildimgarimprovementu tet, within .build of completion,thepose of TOTAL:
builder will have the burden ofproving that he did trot build m improve for purpme of
❑ Lace the project
Sec.70 4.Dustlwiv and Petraotiion,Coic.)The r n..''. QTY. PLUMBING PERMIT FEE FLOOD ZONE qPN
Liman❑the project(Sec.nem Business and Pmfgabld Cade:)The COnVn.and PERMIT ISSUANCE
Lianalswdasnetapplywano aeon progenywho buildsorimpmvea Cmmcand �,.
whonse La n fmsuch projects wish a conoecrorts)licemed pursuant w the GonmactM6 FEE SUMMARY
License law. ALTER-DRAIN&VENT-WATER(EA)
❑ 1 am exempt under Sec. ,B&P C far this race.❑ BACK FLOW PROTECT.DEVICE O SID
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hercbyaffirm that l have a cenificamo(concent to self-insum.or a certificate of Fl%TURES-PER TRAP RF,CEIPT#
orken'Compensmlr
Compensation uumnttmcertified copy thereof(Sm.3800,Lab C.)which PARK FEE YN
covers
allemyylIppyyp5 oder Nis permit RECEIPT#
Policy# ^T T�I�Ina GAS-EA.SYSTEM-1 INC.6 OUTLETS
Company a BUILDING DIVISION FEES
❑ Certified co OAS-BA.SYSTCM-OVER4(PA) PLANCHECK FEE
copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE:INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection read orbs completed ifthe permit is forom hundreddollurs($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shallWATER HEATER W/VENT/ELECTR
not employ any Person in any m ss
s o to become subject to the Workers T PAID
Compensationl.wsof Califomia. Data WATP.R SYSq'EM/I'REATINO Date Receipt#
Q z Applicant
z CR NOTICE TO APPLICANT;If,toor muking this Camfimtrmf Exemption,yao.hould NEW RESIDENT IAL PLMB. SQ.FT. TOTAL:
a•� 14 become subject subjecno the Worker's Compensation provisions ofine Labor Code,you must
�i . forthwith comply with such provisions m chis permit shall be deemed revoked. BUILDING ME
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
V z Thereby affirm tour there is a construction lending agency for the performance of ^y
O or
the wk for which this permit is issued(Sec.31190,Civ.CJ TOTAL: ELECTRIC FEE sse'
Lender's Name O PLUMBING FEE F Lender'.Address QTY. MECHANICAL PERMIT FEE
U
>" I cenify that 1 have read this application and state that the above information is MECHANICAL FEE
a c tet.l ogre in comply with all city and county ordinances and state laws mlmingto PERMIT ISSUANCE
building construction,and hereby aushoneempresentatives ofthis city incineration the CONSTRUCTION TAX
U 7 above-mentioned properly for inspection purposes, ALTER OR ADD TO MECH.
�7 (We)agree to save,indemnify and keep hormless the City of Cupertino against
Iiabilisies,judgmenn,costs and expenses which may I.any wey accmeagalnsaald City AIR HANDLING UNIT(TO 10,000 CFM)
9.quencooffluittramor,of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
DataEXHAUST HOOD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Rettitax
Will the applicant or future building mcupant store or handle hassrdous material
in defineA by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100,00)BTU) TOTAL:
Code,Section 25532(.)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will thea applicant mfuwmbuildin oceu equipmen BOILER-COMP(JHP OR ItK1,IXq BTU)
ISSUANCE DATE
pp g p.m tete tordeviaswhichemit
true our emmmonann ss defined by the Bay Arca Air Quality Management BOILER-COMP(OVER HDRODOBTU) PAID
•y p B1
tda? Y- P9 V
13 Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hamrdous materials requirements under Chapter 6.95 of the FEB' =9 1994
Califomis Health&Safety Code.Sections 25505.25533 end 25534.1 understand Out
if Nebuildingdoesumcurrentlyhaveounan met itis my mrince of. tenotify the
acupant of the requiremems which must be ten prim to iuuerrce a(a Certificate of CITY OF OUNEM I I
aeapaneyy.
Owner or authonuG agate
Data TOTAL: ISSUED BY: