27304 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1. 1 •ELECTRICAL PERMFFNO.CITY OF CUPERTINO APPLICATION/PERMIT PLUMBNG MECHANICAL
BUILDING n N
/� A] O A
BUILDING PROJECT'IDENTIFICATION G J 4
BUILDING ADDRESS, SANITARY NO. APPWCATIONSUB[MUTAALLDATE
UNIT# LOT# LO�—g A
O NAME: P NE: CO CfOR'S NAM1}k�'I .ten LIC NO: 1•�•�
I 1�k-PTI(�LT �O NIC CONTROLp
RCI11TIiCf/IitJGINEE LIC NO: A I S:1 _ ❑
CONTACT PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICBNSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
ZWz Hanebydfir that l sum licensed underprovisions of CTapmr9(commenciagwith TOB DESCRIPTION
4100 Section 7").f Division 3 of the Business and Professions Code,and my license is in
F< PANELS f
ZBF fufome ands
<Z, Liccense I s 2 Lic,p UP TO 200 AMPS
y 6 n Do'sale Conuectm 201-I IXp AMPS
Z FO5,Z6 ARCIIITBLTS DE A ATION OVER 1000 AMPS SQ,FT.FLOOR AREA f/SQ.Ff.
LLL]]] 1 understand my plans shall be used as public records.
t,
- SIGNS ELECTRICAL ii
Q 7' Licensed Professional P•'
OOCC Ptr OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.ax'Oa V I hereby affirm the 1 am exempt from the Contractor's License Law for the
Ia1LLOos following reran.(Section7031.5.BusinesaundProfessions Code:Any city orcounty TEMP.METER ORMLEINST.
� ywhich requires a permit to com met,alter,improve,demolish,or repair my structure ' n/�
s prion,in issuance,slo,mrdresthe applicmt fortuch permit to flea iignedstatemem POWER DEVICES
Op the he is licensed purmanno the provisions of the Contractor's License Law(Chapter LC1� Jo
.0.o 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALIJ
Www or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCH(S-FIXTURES eft
rya Section 7031.5 by aa,.pplicantfar.permit subjects the applicant macivil penalty of
W AI] not momowthan ftvehundred
pmWM,ors(ympl NEWRESIDENTIALP.LECM —SQ.FT. STORIES TYPECONSTRUCHON
Cm ❑ othewneroftheproperry,ormyempindedorNwegesastheed (Sec.compensiiess
a3� will ProfesionsCodecs[mcmare ranoex Liana La a does not
7040.Business
and Professions Cade:The Contractor's License Lew does not apply tom owner propiof
s
ownerty mploym,provirlmpmvesth improve whoa nmchwmk himselforforandhhis
employees,providedthmsuch improvid witarcmsm cartsfdorpletiod for..c,- OCC.GROUP RES.UNITS
howeer will ave he b rden fpmem is sol he dul tone Y<m or mprove far the owner- TOTAL:
builder will have the bather of proving the he did rat build or improve for purpou of
❑ I,nowner altheprolzny,nmaxcl.tivelymounting with licensed contracmrsm QTY.. PLUMBING PERMIT FEEomw / '!,0 "Nct she project(Sec.7(004,Buan
ims and Palestinian Cade:)The Contractor's PERMIT ISSUANCE
Wcmulawdmsnot Vplytoanownerof pmp Aywhabuildsorimpmvathercan,and fs
whomnimetsforsuchprojectswithaconuacmr(s)licenudpunuanfsarhe Conwetoes
License Law. ALTER-DRAIN&VENT-WATTiR(FA) FEE SUMMARY
❑ I am exemq under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SANITARY 0 Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
]hereby affirm eat l have.certifimte ofcanunuo ulf-i....ora matif,,meof pIXTURES-PER TRAP RF.CEIPf#
'r
ken'Compensation lnwmnceor.cenifiedcopy dtereof(Sec.3800.lab CJ which PARK FEE Y—N
—
,overs e all^� RF.CF.IFf#
Policy# - t5'f'F 'b� GAS-EA.SYSTEM-IINC.401pfLETS BUILDING DIVISION FEES
rL'^Pany 7 `fepkjoj ZIl - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
,IQQ Certified copy is hereby famished.
Certified copy is fled with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not beccmpleted ifthe permit is forces hundred dollars($100) SEWER-SANITARY-STORM IA.200ET. ENERGY FEE
or less,)
I certify that in the performance of the work for which this permit is issued,10.11 WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject m he Wmrkern' PAID
Compensatioulawsof Califomia. Date WATER SYSJEM/17REATING Data Receipt
Q Z Applicant
O NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
(q become subject o the Worker's Compensation Provisions of the Labor Code,you muss
5 forthwith comply out such povkhas ar this permit shall be deemed revoked. BUILDING FEE
n-I A CONSTRUCTION LENDING AGENCY SEISMIC PEE
z 1 hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this pemtit is issued(Sec.3097.Civ.C.)
Isader's Nome
0 �. PLUMBING FEE
IsndI Address QTY. . MECHANICAL PERMIT FEE
LVkI 1 certify the[1 have mad this application and state that the above informs[ion is MECHANICAL FEE
correct.l agree tocmnply with all city and county ordinances and mate laws relating to PERMIT ISSUANCE
IA building construmon,and hereby authorlaercprcsenmtivesofthis city or enterumar the CONSTRUCTION TAX
L) z above-memioned property for inspection purposes. ALTER OR ADDTO MECH.
(We)agree to tave,indemnify and keep harmless the City of Cupmirm against
Iiabilities,judgmems.cams andexpemn which may ineny way accoe,ithonid City AIR HANDLING UNG`(TO 10,0011 CFM)
in consequcnce of the granting of this pannus.
AIR HANDLING UNIT(OVER 10.000 CEM)
Signature of Applicamt/Comuucmr Doe EXHAUST HOOD(W/DUCT) PAID
IIA2 RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) O Date Receipt#
Will she applicant orfuture building occupant store or handle haamdous materiel
as definW by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0(10 BTU) TOTAL:
Code,Serino 25532(gY
❑Yea ❑No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theepplicumorfmurc buildingoccupanmuegoipmem ordevicnwhichemit BOILER-COMP(311P OR 100,1100 BTU)
azmdwe air conmminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,000 BTU)
DisWnT
❑Yes ❑No . NEW RESIDENTIAL MECH. SQ.FT.
I have read the herardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
e requirements which the met prior m issuance of o.C�'Gear of
Y J/
wit
risedagcat ate TOTAL: -6 ISSUED BY:
OFFICE