26438 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL n n O
BUILDING PROJECT IDENTIFICATION L 4f v
BUILDING ADDRESS: - ,O� /I' SANITARY NO. APPLICAT_ION/SSUUBIMII,TTALDATE
9 ' TM ( RS OTp �'
./� OWNERS NAME: , PHONE: CONTRACTOR'S NAME: f LIC NO: N/C ONTR—OLLp--
I"J 1
ARCHITECIDENGINEER: LIC NO: ADDRESS?/[e UI,
oNTACr: s. SN+S QTY. ELECTRIC PERMIT FEE PHONE: BUILDING PERMIT INFO
GL �o+n,ly .
un£ a1.�tC� BLD ELECT PLUMB MECH
PERMIT ISSUANCE - ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DBSCRIPI'ION
QWz I hereby affirm that l am licensed under provisions ofCTapter 9(commencing with ,
Y00 Section700)of Division Sof the Businessand Professions Code,and my license is in PANELS
yFFQF fall force and effect �. r, ��
Q'ZyV License Class Q LIaM UPT02MAMPS
in Q y Dale Carter 201-VW AMPS
'ZOoi7.] ARCHITECTS DECLARATION OVER AMPS SQ.FT.FLOOR AREA $/SQ.FT.
C Z-,0 I understand my plans shell be used as public records.
ra y F t�a SIGNS EL CTRICAL
1 Licensed Professional
g OWNER-BUILDER.the ComTION SPECIAL CI UIT/MISC.
pp,,0 U I hereby no than 1 am exempt from the Contractors License Law for the
Ixi13 Fy fallowing reason.(Seonion]03 L5.Business and professions Code:Any city or county TEMP.METER POL ST.
f� which nineties a permit.construct,alter,improve,demolish,or repair any moreem,
y}:Z prierm its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
� �p that he is licensed pureuem m the provisions of the Contractors License Law(Cl apter
d o�' 9(commencing with Section 7000)of Division 3 ofthe Business and professions Code) SWIMMING LELE IC VALUATION
or that he is exempt therefrom and the basis fm the alleged exemption.Any violation of OUTLETS WITCHES-FI URE$ .M�
F G Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of '.
e2 not more than five hundom dollars($5W).
K p ❑ I,asownerofthepropeny,ormyemployeeswithwMesmtheirsol¢compensation, NEWR IDENTIALELE _Sr r'_y" +�"�-- - osORIES TYPECONSTRUCION
yg� will do the work,and the stratum is not intendeduroffc.d for sale(Sec.9044,Bus y
and Professions Cade:The Contractors Limiest Law does not apply to an owner of
property who builds or improves thereon,and who does such work hlmselforthrough his OCC.GROUP E-N
nemployees,providedthat such improveramisare not imendedorofferedforsale.If,
however.the building m improvement is sold within one yeaof x mpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
C3).
❑ I,osownerof the progeny,amexdusivelymnnecting with licensed convecmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE
construct the project(Seo.9044,Business and Professions Coda-)no Communn's PERMIT ISSUANCE
Lice se Lawdoesnntapply to an ownerofpr,nrty who builds or improves thereon,and
Who contracts for such projects with s foaVeccor(s)licensed pursuant to the Contmetoe's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ [am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
SANITARY Y—N
—
Owner DateRECEIPT#
.
WORKMAN COMPENSATION DECLARATION -.PLOOR.ROOF,AREA,COND/ SCHOOLTAX YN
- ❑ (hereby affirm that l have a certificate ofeonsent to self-insure,or a certificate of RECEIPT#
FIXTURES- R TROW Workers Compensation lmurance ore certifed copy the�of(Sea 3800,Lab CJ which � PARK FEE Y N
covers all employee's uppG�tpis pe�L r+I - RECEIPT#
Policy# �&li -1..f -Q,(� GAS-EA.SYSTB IINC.40 'TS BUILDING DIVISION FEES
Company - ----^ -- O (
GAS-EA.SYSTEM- EA) IIII pp C{,A K
❑ Certified copy is hereby famished.^
�b Certified cup,is Eked with the city inspection division. GREASF✓INDUSTRL A TE INTERCE, QR i1 / iGRRgINQ
4L \
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP I LV' J E
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollare($100) SEWER-S TARY-STOR .200"1. E
mless.)
I certify that in the performance oflhe work for which this permit is issued,I suit][ WATER EATER W/VENT/ELE ao
not employ any person in any manner so as to became subject to the Workers' PAID
Comarmaitionl.awsof Califomia. Dare WA 9YSTEM/1'REATING Date Receipt#
z Applicant
yO 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should N RESIDENTIAL.PLMB. SQ.FT. TOTAL:
F7 .fir became subject o theWorker's Compensation provisions ofthe labor Coda --i
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz I hereby affirm that there is a construction lending agency for the performance of
O the work for which this Permit is issued(Sec.30D,Ci,C.) TOTAL: ELECTRIC FEE
Lender's Name I
OPLUMBING FEE F Lenders Address QTY. MECHANICAL PERMIT FEE
LUkI1 certify that 1 have read this application and state that the above information is
correctl agree to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE MECHANICAL PEE
building construction,andhereby autherie representatives ofthis city number upon the CONSTRUCTION TAX
U above-meed ntionproperty for inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIRH OLING UNIT(TO 10,0(q CFM)
in eanx �nt ng of Nis':&, 4/-W/Ry
L:&, AIR HAND NG UNIT(OVER 10,000 CFM
Squab fAp�edi plicmI1Q becwr� - / Date EXHAUSTH (W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT N 100.0008 ) Dao Receipt#
Will the applicant or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(O ,000 BTG) T T
Code,Section 25532019 VENTILATION PA OLE REBID)
❑Yes ❑No
ISSUANCE DATE
Will theapplicmtorfuturebuildingoaupmtuseequipmenlvrdevieeswhlchemit BOILER-CO (3HPO 10J."BTU)
hazallous air contaminants as defined by the Bay Area Air Quality Management BOILER- MP(OVER 1 1100 BTU) P A D
District? SEP 13Yes ❑No NEW R IDENTIAL MECH, SQ.FT, l�TTaA�p ����
I have read the hamrdous materials requirements under Chapter 6.95 of the ��CCP
California Health&Safety Code,Sections 25505.25533 and 25534.I understand that
tribe building does not currently have a reactor,that it is my responsibility to notify Ne r��Y L/(`
cupant of the requirements which must bead
et to issuance of a Certificate of V urrfy/
Occmoney.
QY
Owner or authod gen' Date TOTAL: ISSUED BY:
OFFICE