26940APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
rELECTRICAL
PERMIT NO.
APPLICATION/PERMIT
PLUMBING - MECHANICAL
BUILDING DIVISION
BUILBING PROJECT IOFJN'TIFICA'TION
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BUILDING ADDRESS:
SANITARY NO.
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2Y�vp PbNAZIT«
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JAPRICATIONSUBMITTALDATE
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OWNIi MF.: PHONE:
CONTRAq'OR'S NAME;Paw r�, LIC NO:
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CONTROLM
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CIIITECT/ENGINEER: LIC NO:QTY.
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CONTACT: PHONE:
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EI,ECI'RIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLU MECH
PERMIT ISSUANCE
El
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
y
JOB DESCRIPTION
I herele idl m that lam licensed underprovisions ofChapar9(co encingwilh
Session 701 of Division 3 of the Business and professions Code, and my license is in
PANELS
full a sr Cllnd effyqe'Bp 52
L' nae Cl s T—=•�
Z ' 6
UPT02MAMPS
��Yt Ate.
Gonuaclor
Contractor
201 - 1000 AMPS
-201
ARCHITECTS DECLARATION
OVER 1000 AMPS
SQ. PT. FLOOR AREA
5lSQ, FT.
I understand my piano shall heated as public raords.
SIGNS ELECTRICAL r
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIOMISC,
r1
E ® IN
I hereby affirm that I sum exempt from the Contractor's License Law for the
following reamn.(Section 9031.5, Business and Professions Cade: Any city of county
TEMP. METER OR POLE INST.
t
• t�
which regotres a Permit to construct. alter, improve, demolish, or repair any strucmrc
tl
prior to its issuance, also ma,mms the applicant for such pewit to rile a signed statement
POWER DEVICES
O
that he is licensed purauam to the provisions of the Contractors License Law (Chapter
VAL TION
9(commencing with Section 7001 of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
or Nat he is exempt herefrom and the basis for the alleged exemption. My violation of
-
Section 903 L5 by any applicant fora panto . subjects the applicant m a civil penalty of
OUTLETS - SWITCHES - flXTURES
nr more than rofthove dmpeny,ormyemp. m.
n❑ Las rofthlysimmmam
myemployestoro
nsBusiness
assth,(Sm.
NEWRESIDENTIALELECIR _SQ. FT.
STORIES
TYPECONSTRUCTION
is eed fairish, 7044,
will duthework, ande: mimnm i,
(pl,
and profession Camino,o Contractors License law does not apply lf as owner
The License Law out in an owmar of
propertywyeas, tlamimprovesth is
imRlfmthmogb his
OCC. GROUP
RES. UNITS
own cmployees,pmvitledmasuch improvements senor intendedoraffcred tarsale. If,
improvements nota tended
however, the buildingorimprovement is sold withinone yearofcompletion, the owner-
TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
.1l
❑ I, asowner o0hepmpertY•amendusivdyconuuling with licensed conuutors to
QTY.
PLUMBING PERMIT
FLOOD ZONE
APN
continues the project (See. ?044, Business and Profesaiov Code:) The Cmimar mr's
Licenselawdoesnot apply manownerofpmpery wholauildsm improvesmerma.and
PERMIT ISSUANCE.
whommoas forsuch projects withaconwctm(s) licensed pursuaat oNe Contractors
License Law.
ALTER - DRAIN & VENT - WATER (EA)
fiSANITARY
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
OUTSIDE • .FS
BACK FLOW PROTECT. DEVICE
Y N
RECEIPT«
Owner Dem
WORKMAN COMPENSATION DECLARATION
DRAINS- R.00R.ROURAREA,COND.
OOLTAX Y NI
hereby affirm that I have a certificate ofconsent to selpiruum, or a cartifieere of
FIXTURES -PER TRAP
RECEIPTp6acovCompensation
K FEE Y N
Insurance ore cernfiW copy thermf(Sec. 38M. Lob C.) which
coven all employee's under this Permit.
GAS - EA. SYSTEM -1 INC. 4 OTfII.ETS
RECEIPT «
BUILDING DIVISION FEES
Policy Is
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GRADING FEE
❑ Caddied copy is filed with the dry inspection division. GRFASEIINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP
SOILS FEE
COMPENSATION INSURANCE
fiNF.RGY FEE
(Thissection need not he remplemd if Ne permit is foronehundred dollars ($1010) SEWER - SANITARY - STORM EA. 200Ff.
or leas.)
I certify that in the performance ofthe work for which this permit is issued, l shall WATER HEATER W/VENT/ELECfR
mploy person is any manner so b t ub' o the Workers'
s'
PAID
armwee Oif onia, py
ATF S TEM/TREATING
Data Receipt
App iwnt 14, lJ
TOTAL:
NOTICE T'O'APPLICANT:1 'ng thrs mete of Exemprion.you should WRESIOLNTIAL PLMB. SQ. FT.
become subjecuo the WorkersCCC mpensminn provisieru of the Labor Cade, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
t
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
me work for which thin permit is issued (Sec. 3097, Civ, C.)
Epi
ELECTRIC FEE
Lender's Name
Lender's Address
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
1 certify Nat I have read this application and state that me above mformmian is
MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
building construction, and hereby authorise representatives of miscity reenter upon the
CONSTRUCTION TAX
above-mentioned pmpery for inspection purposes.
ALTER OR ADD TO MECE.
(Wa) agree to save, indemnify and keep hammers the City of Cupertino against
liabilities,j ments,costs wdexpenseswhirpmp a nyw accneapeirmssiiCity
AIR HANDLING UNIT (TO DIM CFM)
in con's... q tt ofmia per 1I
(./1
AIR HANDLING UNIT (OVER 10.000 CFM)
PAID
mgnmure of ApplicardVontowtoDas k EXHAUST HOOD(W/DUCO
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CM IW0J0 BTU)
Data Receipt«
TOTAL:
Will the applicant or future building occupant mom or handle honrdois material HEATING UNIT (OVER 1W,000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
ISS�Ur�sAN EDA1t7T7i
Will me applicant ortummbuildingaccupant useequipmentordeviceswhich emit
BOILER- COMP(3HPOR 10J,000 BTU)
Ir Q PJ
azardous air wmwermants as dented by the Bay A. Air Quality Management
BOILER - COMP (OVER I00,000 BTU)
❑Yes 0 N
NEW RESIDENTTALMECIL SQ. FF.
AUG 29 911%A
1 have mad the Innuendoes materials mquimmenu under Chapter &95 of the
California Health & Safety Cade, Sections 25505.25533 and 25534. 1 understand my
CI I Y yr �urcn
if the building does not currently have a Rost, Nm it is my responsibility to notify me
1.1;961
cupsnt of the requirements which must be met prior to issuaRe of a Certificate of
Occupancy.
ISSUED BY:
Owner m authorized agent Data TOTAL:
OFFICE