26306 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUI.DIN -ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
IIUII.HING /� EN3O
RFSPHOJE(lI'IDFN'riRCAITGON
BUILDINGADDS, ^ .x.+ - SANITARY 0. APPLICV111ONNSUBMITAL DATEI
o6SS UNIT# v LOT# � lL_
OWIF NA `_PVNE: CONTRACfOR'SN LIC NO:
`fTK7s N/C CONTROL#
•ARCIIITELTAMINHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE- QTY. ELECTRIC PERMIT -FCB
BLDG dLECI' PLUMB
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LAY TOB DESCR ION
pyZ Hambyaffirm thea lamlia se undapmvisionsof CTapter9(commmcingwith
Poo Section 7")of Division 3 of Ne Business and Professions Cale,and my license is in PANELS ��
full force and effect. `` �
License Class Lic.Is UPT02MAMPS 41�I
F .
Dam Contmcmr 201-IM AMPS
ZO
F sn y z ARCHITECTS DECLARATION SQ.PI'.FLOOR AREA $/SQ.FT.
r�
OZ-0 1 understand my Plans shell be used as public records. OVER 1000 AMPS
F.rn SIGNS ELELTRICAL �,50
6 � Licensed Professional
KK
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISQ
4yF�fO1 hereby affirm that 1 umc"no from the Conuucmrs license Law for the
W aOya following reason(Section 7031.5.Business and Professions Cade:Any city in county TEMP.METER OR POLE.INST.
mJ which mgoims a permit m conswea,all ,improve,demolish,m rc,ir any structure
t�tYY r�Y fmcom its icamoraulno requiree the applicant for such Permit to file a signed statement POWER DEVICES
ty 0100s that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
LULL 9(commencing with Section 7000)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUA7;Wik/
or that he is exempt therefrom and the basis for the alleged exemption.Any violation° UTLETS-SWITCHES-FIXTURES �' q 1 y Gam_
! z> Section 7031.5 by any applicant for a permit subjeas Ne appli a no a civil p alry of 1 LAC
nm mom than five hundred dollars($50M. NEW RI+SIDCNTIAL ELEGIR S .PT.
y ElI,nsownerofrheprnpeny,ormycmPloycee with wugesaztheirmlerompeasvtion, - Q STORIES T PECONSTRUMION
y $ willdmhe work,wrdtheatmoure isnm intended orofferW forurle(Sec.7044,Business
and Professions Code:The Cantmcmr's License Law does not apply m an owner of P
property who builds or improves themoa,and whodmes such work himselrm thraughles ,G O
ownemployaa.prm'idedahatsuch impmme
ventsme not intendrduroffered formle.If, CN_ . P.,
however.the building or improvement is sold within one yearo(completion,the owner- -
builder will have the buMen ofpmving that he did not build or improve for purpose of A
We.). TY. PLUMBING PERMIT i, FEB.. FLOODvZON, APN
❑ Las the pro0t(Sec.heMny.a7044, exduss and
The onuanarsto Q s
cmnswa the project(Sec owo Business and Profession Cade)The Contractor's PERMIT ISSUANCE AXE
License Lawdoesnmspply tsnithacofpapeny liense itch..improve thereon.and
whence Law.forsuch pmjecte withecon0uaor(s)licenced pursuan[tmhe Contremor'e ALTER (EA) FEESUMMARY
License Law. ( '
❑ 1 am exempt under Sec. ,B&P C for this mason BACK ROW PROTECT.DEVICE SI E
SANITARY Y_N
Owner Rate RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-BOOR,ROOF,AREA.COND. SCHOOLTAX Y_N
❑ Ibereby efOrm then lhnvicecenifteum of confenuoaelf-insure,arac,,aMc.teof �a RECEIPT#
Workets'Compmeciion Insurance ora cenified copy thercof(Sn.3800,Lab CJ which FTXTURFS-PER TRAP PARK IEE Y N
covers all employees under Nis permit. GAS-Eq.SYSTEM-] RECIi1 p
Policy It IINC.40lTILETS BUILDING DIV ION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumishM. LO
❑ CdnitieJ copy is filed with the city impecaion Division. GRFASUINDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PI?E
COMPENSATION INSURANCE all
(This section need not be completed Brim permit is for one hundred dollars($100) SEWER-SANITARY-STORM PA.2UOFT. HNERG O
ass.)
I certify that in the peRornesm, fthe walkforwhich this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to Ne Workers PAI
Z Applicant
Compensation Lawsof Culifemia. Data WATER SYSTEMTRHATING ate Receipt
Q
z NOTICE TO APPLICANT.If.after making this Ccnificam of Eaemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
e—I V) hecome subject In the Worker's Compensation Provisions of the Labor Cole,you must
lei > forthwith comply with such provisions or this permit shall he domed mvaked. BUILDING FEE ad
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE �+
I hereby affirm that hem is a construction lending agency for the performance of
V O the work for which this Permit s issued(Sec.3097,Civ.C.) TOT ELECTRIC E v ��
Landers Nume s V
OP Landers Address QTY. MECIIANI(',gL PL RMT a -,F. E PLUMBIN FEE
V 1 certify that 1 have read this application and state that the above information is `Tu"" Ea 'I`^
� 0. cormm.I same to complywithall city and county ledminces and state laws relating to PERMIT ISSUANCE 7 HEMA - is
�-' V) buildingconstrunion,and hereby audience represemstivesofthiseiry m fnaer upon the C
U 7 above-mentioned immeny for inspection purposes. ALTER OR ADD TO MECII.
G
(Will agree to save,indemnify and keep hulesf the City of CLpenino against
liubilitiev,judgmm�ta,costs endexpenseswhich rosy in any weyacmre ageinn said
City AIR HANDLING UNITOD lo,"CITE)
m in consequence of the grunting of this permit.
AIR HANDLING UNIT(OVER IU.M CFM)
Signature of ApplicanVConrracmr Date EXHAUST HOOD(W/UUCT)
PA
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO UXI BTU)
Will theit"licant or ruture building oecupont store or handle hazardous material Bi na
HEATING UNIT 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,end the Health and Safety _
Code,Section 11 25532(a)?
632(a)7 ❑No VENTILATION FAN(SINGLE RISIO) ut
Wil l the applicant or future building occupant use equipment or devices which emit
BOILER-COMP(3HP OR 100,(1IX1B IS P
hazardous air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER IOO,000B
Dislrin?
AY
❑Yes ❑No NEW RESIDENTIAL MECH. 5
-�� Qrr• urtHl IN
1 have read the harardous materials requirements under Chapter 6.95 of the 0
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 CITY UI- I
occupant of the mquirements which must he met prior to issuance of a Cenificme of
Occupancy. - e
Owner or authorized ager Dene T ISSUEDB
OFFICE