S 1292APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PIIIyQfr�\%
"°� 1292
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
CONTACT
CONraACI'0Rs
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❑ Consultant Fees Paid by Applicant (Initial)
ORR.IatJ 4A J6r_ Aka-- 9bin• ZbS
LICENSED CONTRACT ORS DECLARATION QTY.
I hereby affirm the 1 am licensed under provisions of Chapter 9 (commencing
��z with Section WlflOpN Divi,ion3ofthe Rosiness and Professions Crile, and mylicense is
F FD
in full force and Ill.
GF U U License Class Lie. a
m a a Dae Commaor
ARCHITECTS DECI RATION
Zy z undenland my dans h II be us ssen+lEC
F Last �d Profess sna t
ne-,OWNER-BUILDER DECLARATION
tY 6 1 health, M. that I nm exrol from the Connector's License law for the
aU following reason. (Section 9131.5. Bu.vinexs and Professions Cedo: Any city nrcmtnny
Nwhich requires a permit to conamet, also improve, demolish, nr repair unY srruc:n,2
prior to its is adur e. also requires the applicant for such permtl In file a signctl nm¢mcnl
then he I, Iweased putsuanuu the pmvisinns of the Comructnr's License Law (Chapter 9
ps�QE (commencing with Swoon 70M) of Division 3 ufthe Buslnnsand Pmfessiom Cede)or
, c the he it exempt Iheretrnm soil the hums for the alleges exemption. Any violation of
pe ^SNL Section 9(131.5 by any applicant lin a Permit subject, the applicant m a civil penalty of
fLLf--] on more than five hundred dollars ($51Mp.
zC ❑ L as owner of the property, or my employees with wages as their sole compensation,
wan so the work, and he,mature is nm intended oroffered blood, (Sec. 7(PDL Business
m and Profession, Cade: The Contractor's License Low does not apply to an owner of
property who builds or improves theme, and who does such work himself or through
his own employees, Provided thin such improvements are are intended or nB'ered far
sale. If, however, the building m improvement is sold within one yearaf completion. the
owner -builder will have the burden of proving that he did not build or improve for pur-
pnm of soled.
❑ 1, s owner of the pmpony, an exclusively contracting with licensed contactors m
ensure, the project (Sec. 7044, Business and Professions CodeU Tha Contraemr's I.i-
x Law dms not apply man owner of pmperty who builds (ir improves hereon, and QTY.
who commas for such pro i with a contraennns) licensed pursuant to the Contmcmrs
License Law.
I am exempt unser Sec. . B ds P C lin this reason
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Owner Dee
WORKER'S COMPENSATION DECLARATION
I hereby affimt under penalty of perjury one of the following dalamtiom:
❑ I have and will maintain a Certificate of Consent w sed-insua for Worker's Conrpen-
satim. us Provided for by Section TINS of he I.aN,r Cole, for the performance of he
work for which this permit is issued.
CJ 1 have and will maintain Worker's Cmrmensa(inn Insurance, as required by Section
3700 of the Lbnr Code, forte perfronanee of he work fur which his Permit c issued.
My Worker's Compensation Insurance carrier and Policy number are
Carrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORK17RS'
COMPENSATION INSURANCE
(This section need not be completed ifthe pemtit is (Bron hundred dollars MUS)
or less.)
I certify hal in the pcdonnex ceofthe work for whichhis permit is issued, lshall
not employ any pernall in any manner so as to hecome subject o the Workers'Cmnpen.
amion Lawa of Gd if tonin. bate
Applicant
NOTICE TO APPLICANT: If, after making his Cerd flute of Exemption, you should
become subject to he Worker's Confessions pmvisims of he Labor Code, you must
fn fl with comply with such pmvisims or this permit shall he dented revoked.
CONSTRUCTION LEN DING AGENCY
1 hereby idlion that there is it construct inn lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
Lenders Address
I codify that I have read this application and state that the above inlinmmim is
deet. I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize repres moor ives of his city to enter upon the
abo%eemanimned properly for Inspection purposes.
We) agree to save, indemnify and keep harmless he City of Cupertino against
liahlllties,ludgnams, coa, and expcnsas which may in any way aecmc against said City
in meson ce of the granting of This permit.
APPLICANT UNDERSTANDS AND WTO. COMPLY WITH ALL NON -POINT
SO CERE(IULATI NS.
lreofApphcv Cot cmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocupam store or handle hazardous mmnrial
as defied by the Cupertino Municipal Cole, Chapter 9.12, and he Health and Safely
Cade. Section 25532(d? `���,///
❑Yes Iy No
l` Will the applicant or future building accident use equipment or devices which
Droit hazardous air constraints us defined by she Bay Aaa Air Quality Management
District?
❑Yes No
I have mad IM1e h:trardous materials requim encs under Chapter 6.95 of the Cali-
fornia Health in Safdy Cattle, Sections 2550 , 25533 and 25534. 1 unJentand that it the
huilJincJaws ml eudentlyhy acv mnnnI. th is my responsibility to notify IM1e accupam
nflM1�uireaenes wHch.nLu bearer s ^-�^ Certifambe of Qccapmcy.
ELECTRIC PERMIT FEE
P12RMI'T ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02W AMT'S
20I-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUS I'IMISC.
'TEMP. METER OR POU; INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
0dTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR
SQ Sell
❑
BUILDING PERMIT INFO
RESIDENTIAL:
❑SFDWI.
❑ KITCHEN REMODEL
❑ADDITION
0PLUMBING RE -PIPIT
❑MULTI -UNIT
[]STRUCTURAL
DRAINS -FLOOR, RfK1F,A .A, COND.
MODIFICATION
❑INTERIOR
[]CHIMNEY REPAIR
IMPROVEMENT
[ISWIMMING POOLS
❑ BATH REMODEURI?PAIR ❑ DEMOLITION
❑OTHER
BLDG/ADDITION ❑ DEMOLITION
,NT ❑FO01)SERVICE
SQ. FI'. FLOOR AREA I $ISQ. FT.
PLUMBING PERMIT FEE
PERMIT ISSUANCIi
ALTER - DRAIN k VENT'- WATER (EA)
HACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, RfK1F,A .A, COND.
gq
oIXTURIiS-1' TR
GAS -EA. SYS 401' ETS
OCC.
GAS -HA. SYSTp�sO..A
GRFSI%INDUS' SEE WAS TE IN'1'F. CEI t
GRHASETRAP _
PLANCHECK
SEWER -SANITARY -STORM HA.20i )�
WATER HEATER WNENTIFLEC IR O
WATER SYSTEMGRI!ATING
WATER SERVICE
NEW RESIDENTIAL PLMH, SQ, PT.
T'
QTY. MECHANICAL PERMIT
g
P17RMI'I ISSUANCE `
xt.T'ER OR ADD 'S MECH. ALM
a/�—
AIR HANDLING UNI'P ('f0 111,1)(X1 CFM)
AIR HANDLING UNIT (FIVER MAN) CF!sP
EXHAUST HOOD(WIDUCT)
HEATING UNIT (f0 100,00) BTU)
HEATING UNIT (OVER 110,1100 B'FU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP UHP OR I(0,Q'X) BTU)
HOILER -COMP (OVER I00,030 BTU)
AIRCONUITIONEIt (
NEWRESIDENTIALMECH. SQ. IT.
ENERGY Fl
SOILS FEF,
FEES
PAID D -
. Receipt a
BUILDING FEE
PEE SEISMIC PEE a r�
I�
PEE
yr
,ISSUANCE rDATE
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