24722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC DUCAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2
BUILDING PROJFIC'I'IDENTIFICATION
BUILDING ADDRESS � SANITARY NO. APPLICATION SUBMITTAL DATE
Grkfs UNIT# LOT
O NA E: PHONE: CONTRACT RS NAME: 1.11 NO:
QA4" -e^ �� NIC CONTROL#
Pj[R �CIIIT LT/FNGINF.ER: LIC NO: ADD :SS:
'CA WOoGaf�GC U
ONTACf: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE. �' ❑
LICENSED CONTRACTOR'S DECLARATION APPUANCFS-RESIDENTIAL JOB DESCRIPTION
QWz Ihcmbyafllon that l not licensed under potomem.fChapter9(commencing with
6100 failone000)a(Division Sof NC Business and Professions Code.and my license is in pgNBLg _ yak - - --•
FZ Uranse CtaadseC-1 0 Lic.# yug7y9 `p1rkL1��]I
IIP TO 200 AMPS
ry6y IJ /•2 Contmmo, 201-I"AMPS
Z�NZ. ARCHHECTS DECLARATION OVER 1020 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z pp 1 understand my plans she]he used as public records, r
r^Cu1 SIGNS ELECTRICAL FTEN L A
Live raed Professional
OWNER BUILDER DECLARATION SPECIAL CIRCUITAHSC.
°,J O y F I hereby vff that 1 am exempt from the Com meon''s License tow for the y J�
t�iO following feumr.(Sectlnn 7031.5,Business and Professions Code:Any city mcounty TEMP.METER OR PUL P.INST. 1
F-fS O which requires a permit to construct.alter,improve,demolish,or repair any structure D 2
ibwa7 priesto its issuance,alm requ'ues the applicant for such permit to rite a signed statement POWER DEVICES TE ai
t�COp that he is liceasedpursuanrto the provision of the Contractors License law(Chapter SWIMMING POOL ELECTRIC
aao", 9(commencing with Section Division 3 ofthe Business and Rafessions Cade) VALUATION
µ,,,q arthroheisesbyany refmmnt for a Permit
subjects
bcivil
of OUTLETS-SWITCHES-FIXTURES
aQ not mo a than 6y any for a permit subjecD the applicants a civil penalty of
of more than rofhundreddollars(Sean).
tY,Jp ❑ Lasoanteroftheproperty,o,myemployceswith wvgcsastheiraolecompematian, NEW RESIDENTIAL P.LCCfR _SQ.FT. STORIES TYPE CONSTRUCTION
a3-., will do thew.,k..d thesuuctureisnot inmalks1moffexd forxle(Sce.7034,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
Property who huildsor improves thereonand whodoesauch work himself.,throughhis OCC GROUP RFS.UNITS
own employees,provided that such i mpmvements are nut i mended or offered far role.If,
however,the buildingorimpmvemetn is sold within one yearof completion,the owner- T
builder will have the burden of proving that he did not buildorimprove for purpose of
sale.).
❑ I,usswnerufthepropcny.emexclusivelyc.ntmcting with licrnudcontmm
ctsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
emonue the project(Sec.TtHQ Business and Professions Code;)The Coruvebas PERMIT ISSUANCE
License Lawdoesnot apply to an uwnerufpmperty who builds or improves thereon,and
whocuntmms forsuch projects with acontractogs)licensed pursuant o the Comment's
Licanu law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 atm exempt u tdcr Sec. ,B&P C for this reasonD.
BACK FLOW PROTECT.DIiVICE SANITARY YN
'Owner Date DRAINS-FLOOR,ROOF. COND. RF.CEIPf#
WORKMAN COMPENSATION DECLARATION , , SCHOOLTAX YN
Od l hereby affirm that l have a certificate ofcousem to self-insure,ora certificate of FI%TIJRPS-PER TRAP RECEIPfN
'Wmkers'Cora,mmion beatmnceoracerified copythereof(Ser.3&X1,Lab CJwhich PARK ME. Y N
cavcrsall emloea's under this L RECEIPTp
p Y pcmtt GAS INCA OUTLETS
Policy It BUILDING DIVISION I7EES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cmified copy is herby famished.
❑ Certified copy is filed with the city inspection division. GREASPANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
coME,EVSATION INSURANCE
(This sunionncedrdbe completed ifthep.it is furore hundred dollars(SI0B SEWER-SANITARY-STORM EA,202PT. ENERGY FEE
or less)
Icertify that in the performance of Ne work for which this permit is issued,l shall WATER HEATER W/VENDELECTR
not<mpiny any pe n in any manner m t bjcet to the Workers PAID
benution fCelifomia. Date �`` WATER SYSTRISUMEATTNG Data Receipt#
O Z Applicant 1 T� as
ZNOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
�-t CA become subject to the Workers Compensation provisions of the Labor Code,you must
a
forthwith comply with such provisions or this Permit shall 4 deemed revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMICFEE
V1 hereby affirm that them is a construction lending agency for the performance of
O the work for which this permit is issued(See.3091.Co.C.) TOTAL: ELECTRIC FEE
Lender's Name
OF Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have read this application and state that the above information is MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and state laws relating to PFRMITISSUANCE
building construction,and hereby authorize rnmeaenmdves of this city to enter upon the CONSTRUCTION TAX
U Z above.mamboed property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabodides,judgms,ro. os sand expenus whichmv ' enywvy ec a against amd City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of the anting of Nis pcnnit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of ApplicantlContmmor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSUREhand
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the Cuurfinaart or tuicipal Cort,Cang mer9.ionizer,handl Heiddh and Srerial HEATING UNIT(OVER Iffy"BTU) TOTAL:
C defined io the Cupertino Municipal Code,Chapter 9.12,a,M the tleehh end Safety
Code,Section 23332(a)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE D
Will theepplicvmorfmurc BuildingoccupenruxaluipmemmdevicawM1ichemit BOILER-COMP(JHPOR 100,000 BTL)
jtma doua it contaminants as defined by the Bay Aran Air Quality Management BOILER-COMP(OVER 100,020 BTU)
'District?
❑Yea� ❑No NEW RESIDENTIAL MECII. SQ.PT. PAID
1 have read the hasarduus materials requirements under Chapter 6.95 of the ��� ��
9O
California Ilealth&Safety Code.Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a action,that it is my responsibility to notify the 1x793
Occupancy.
c up an of Ne reyuircmenta which must od ren prior to issuance of r Certifwte of �']��
Oceapaney.
Owner of authorised agent Date TOTAL: ISSUED BY:
OFFICE