26580 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[ARCHVITCT/EsHINEER:
ITY OF CUPERTINO I ° -ELECTRICAL PERMITNG.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26580
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
ILDING ADDRESS SANITARY NO. APPPL!ICATTIIONSUBMITTALDATE
I q 'P'L. LOTH
NERS NAME: PHONE: ONTRACIOR'SNAME: LI NO:
SUlMWL L� (yam NIC CONTROL
LIC NO: ADDRESS: b f� ❑
'I'Irl CAL A A-0r, (A AW
CONTACT: PHONE: BUILDING PERMIT INFO
Q.
ELECTRIC PERMIT PEE
.M B ELECT PLUMB MEC}f
PERMIT ISSUANCE saV pCJy,� IYp�( Ih7J`_—
LICENSEUCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL 106 DESCRIPTION
MCZ l hereby affirm that lam licensed underpmvisimatim Chapter9 momanencing with
FF10�Y0❑ Section 7")of Division 3 of the Business and Turf Code and my license is in PANELS
TUU fullforce end effect
ti4i
Do. Carl.".,
C_ssL__�_ Carl.". 1 UP T0200 AMPS
f"'v'Oi Z, �T 'R�CHITECTS DECLARATION 201-I"AMPS SQ.FT.FLOOR AREA 8/SQ.Ff.
ZO Z Com,uum1 1 understand my plans shall be used es public records. OVER 1000 AMPS
r"5d Licensed Professional SIGNS ELECTRICAL
wod< OWNER BUILDER DECLARATION SPECIAL CFRCU1T/MISC.
lid 1 hereby off.that 1 amexempt from the Conumtols License Law for the q
¢13 t1.h following reason.(Section 9031.5, In
and Professions Cade:Any city or county TEMP.METER OR POLE INST. �� 7„/-✓9
�;O which rululros o permit to consarem.alter,improve,demolish,or repwr any svucmrc 1
M2 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
qQ C) that he is licensed pursuant to the provisions of the Crntraem's License Law(Chapter
2aR 9(commencing with Section 7000)of Division 3rf the Business and Pmfasslons Code) SWIMMING POOL ELECTRIC J 2VALUATION
1y Z. Sectioor that 7031. by mpt
therefromandf the baspermit subjects thedexemant to civiny l
of OUTLETS-SWITCHES- La.f^ ,�Y3
ZY Sermon than
Sv anydreddontfs($500Litsubjects the applicant acivil penalty of FIXTURES xv
_ not moathanfreeiheproddollars yemp.
❑ I,as ownero❑hepmpeny,ormyemployeeswith wngesastheirsol¢coto
mpensation, NEW RESIDIiMfIAL ELECfR (a SQ.FT. a^Ig STORIES TYPECONSTRUCION
y will dothe work,andthe structure is not lrtterdedoroffered tbriale(Sea 70,14,Business
and Professions Code:The Contmctofs License Law data not apply to an owner of
property whobuildsorimprrves thereon,andwhodoessuch work himselfor thmughhis
owneroployers,provided i msuch improvemenmere not intendedrroffeced farsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,rhe owner- TOTAL: II
builder will have the burden ofproving that he did not build or improve for purpose of .Z D
sale.).
❑ Las ownerofthepmpedy,amexclusively contracting with licensed conuecmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the prolect(Sec.7044,Business and Professions Cade:)The Contractors
License Law does not apply to an owner ofpropeny who builds or improves thereon,and PERMIT ISSUANCE L
who commais for such projects with a contractors)Ilcensedpursoamt.doconametors I License Law. ALTER WATER(E ) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C(or this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsentto self-insure,ora cerci fcate of FIXTURES-PER TRAP RECEIPT'#
Workers Compensation Insurance or a cert tied copy thereof(Sm.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4A) PIANCHECK FEE l
[ICertified copy is hereby furnished. (E
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE A
CELL11171CATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME 1. [••
COMPENSATION INSURANCE
(This sectionneed net M completed ifthe permit is furore hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
on onlecv.) -
Icerify that in the performance of the work for which this permit is issued,I shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laevsof Culifomia. Date WATER SYSTEMTRFATING'Z
Applicant Dam Receiptp
Q NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLAID.I qq4, SQ.IT. •fig TOTAL:
tibecome subject to the Worker's Compensation provisions of the Labor Code,you must
�. > forthwith comply with such provisions of this permit shall be deemed revoked. BUILDING FEE h•Jb
W Q CONSTRUCTION LENDING AGENCY SEISMIC EEE 14.01
I hereby affirm that there is a construction lending agency for the performance of / �/
V 0 the work for which this permit is issued(Site3197,Civ.C.) TOTAL: LSU -1 ELECTRIC FEE -11�YI
benders Name Y /
Lender's Address QTY. MECHANICAL PERMIT FEEPLUMBING FEE (, S
V I certify Nat I have read this application and state that the above information is C
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCEMECHANICAL FEE
Co) building construction,and hereby authomz representatives ofthis city mcnter upon the CONSTRUCTION TAX
(„) Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acme against said City AIR HANDLING UNIT(TO 10,"CPM)
e of the granting of this permit.
(I AIR HANDLING UNIT(OVER 10,000 CFM)
Signature fAitplicarbCdjouniummDate EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Recaipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sccd 25532(¢)7
0Yes 13 Na VENTILATION FAN(SINGLE RESID)
Will theacarearntorlmua building by he
Bay equipment Quality ¢which emit
BOILER-COMP(3HP Oft 100,000 BTU) ISSUANCE DATE
.hazaNaus air contaminants as defined by the Bey Arta Air Quality Management M n r
DistrimY BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No - NEW RESIDENTIAL MECH. SQ.FT. eo 9.
I have red the hamrdous marerials requiremems under Chapter 6.95 of the OCT 12 1994
California Health&Safety Cade,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 (�
occupant of the roquiremema which most be met prior to issuance of a Certificate of Ci I)r Ur SaUfL;Y(
Occupancy.
Owner m authorized agent Date TOTAL: 7 0 ISSUED BY:
OFFICE