27568 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO tl ILUINh-ELECTRICAI, PERMITNO,
BUILDING DIVISION APPLICATION/PERMIT PING PROD CUIDEANICAL n 7 C C O
ItU11.U1NO PR(1JF.C1'IUEN'I'IF'1(:A'I'ION G r Jvo
.,X� SANITARY NO. APPLICATION SUBMITTAL DATE
fV9� UNITX L01'p ��� lcia
OW SN MH: „ate PHONE: LIC CONT�CfOR'S NA LIC NO: f �'
f- 11COWACT
BIC CON'l ROI.a
finCT/FNGINHFR: LIC NO: ADDRESS: ❑
: PHONE: HUILUING PERMIT INFO
Q•I'Y, IiLECTRIC PERMIT PER
BLDG PLUMB MECII
PERMITISSUANCE y�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IP
ncez I hereby affinn that l was licensed underpruvisions of CTapter9(commencingwith JOB DESCRIPTION
to 00 Section 700(pcif Division 3.f the Business end Profession,Code,and my license is in PANELS 0V�,. Poe 2
Fy-Uf' Inn force and effect.
FZLicense Class Ltc.X UPT02WAMPS
ot<N Date Ciammcrnr 201.["AMPS
7
zOyZ, ARCHITECTS DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA 5/SQ.FT.
p Z pp 1 understand my plans shell h used az public recons.
Licensed Professional SIGNS ELECTRICAL
Cry OWNPR.BUILDER DECLARATION SPECIAL CIRCUITIMISC.
OKI
0', I hereby affirm that I am exempt from the Committers License Law for the
following remon.(Section 10313,Business and Professimu Code:Any city m county TEMP.METER OR POLE WSJ.
F'�1 which reyuirea u permi,to conswmmr
ct..11w,improve,deolish, repair any structure
prior to its issuance,alsorequires the applicant for such permit to file a signed statement POWER DEVICES
C G p that he is licensed pursuant to the Provisions of the Contmcan a License Law(Chapter
0.0.0 9(commawing with Section 7W)of Division 3 of the Businesaand Prfiessions Code) SWIMMING POOL ELECTRIC VALUATION
WMM or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLEfS-SWITCI(F.S-FIXTURES
Y< Section 1031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more than file hundred dollars($500). NEW RESIDIiNTIAL ELEC'FR _SQ.FT. STORIES TYPE CONSTRUCTION
W ❑ I,osownerofthepmpeny,ormyemplmyaawith wagesmtheirsalecompertsatinn,
a3— will do the work.and the structure in not intendedoroffeml for sale(Sec.1044,Business
and Professions Code:The Committees License Law does not apply to an owner of
propcny whnbuildsorimprovestherean,and whadoea such work himsel(orthmugh his OCC.GROUP RES.UNITS
ownemployces,provided that Such improvements arc not imendedoroffereJ forsule.If,
however,the buildingor improvement is sold within one year ofcompletion,the massive owner- TOTAL:
builder will have the burden of proving that he did not build or prove fur purpose of
salt.).
❑ I,as ownerofthe property,umexclusively connecting with licensed contractors m QTY. PLUMBING IT F FI-DOD ZONE APN
construct the project(Sec.11H4,Business and Protestant,Cade:) Me ContRCtofb
Limeac Lawdoes not apply to an ownermpropeny whohuildsor imprnveadercon,end PERMIT ISSUANCfi
wlmmmtructs forsuch projects with a conrector(s)licensed puremnnn the Contractors pLTLR-Dft &VENT-WATIER E
License Law. ( FEE SUMMARY
❑ I em eumpt under Sec. B&P C for this rcawn BAC OW PROTECT.DEVICE 5 ARY OUTSIDE I'EFS
Y N
Owrur Dole RECEIPTM
AINS-FLOOR,ROOF.AR
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Thereby off thut{haveacertificate of mnsem mself-insure,ora ttnificme of R[CEIPI'X
%TURES-PERT
Workers'Cmmpcnsotion Insurance oracenifiW copy thereof(Sec.3g00,Lob C.mx1ch PARK FEE Y N
urris
Policy
re.oursidl nnployee's under Chia permit BUILDING DIVRECISION FEES
G S-EA.SY. - 1 OUTL811
Com GAS IA. SIT VER 4f s PLANCHECK FEE
[ICrit CenificJ copy is hereby famished.
❑ CeniRed copy is filed with the city inspection division. GREAS NDUSTRL STE INT•RCRPTOR GRADING WE ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE P SOILS FEE
COMPENSATION INSURANCE
(This seclionnced nm hecomplcted ilthe permit is for one hundred dollars($100) SEWER-SAN ARY-STORM IEA2W . ENERGY FEEor less.)
I cenifythm in Ne perfmmameofthe work for which this permit is issued,Ishall WATER HPATE W/VENVELEC
not employ any person in any manner so as to become subject or the Workers PAID
Z Compensatiunl.awsof CnliPomia. Data WATER SYSTEM? Date ReceiptX
Applicant
zO0 NOTICE 10 APPLICANT:ILwmr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT'. TOTAL:
N ) become subject to the Worker's Compensation Provisions of the Labor Code,you must
Fes , fonhwith comply with such provisions or this pennit.hall he demnW revoked. BUILDING PEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEF.
Uz 1 hereby offirm that there is a construction lending agency for the per(oorame of TOTAL: ELECTRIC FEE the work to,which(his permit is issued(S..3091,Civ.CJ
Lender's Name v PLUMBING FEE
O F [. tiers Address QTY. MECHANICAL PERMIT' FET.
L) I cenify that I have read this application and state that the above information is
coven.l agree to comply with all city and county oninancas and state laws relating m PERMIT ISSUANCE MECHANICAL FEB
building cmvtrvction. it hereby rowhorixe mpreeenmtives of thio city to enmr upon the
above memimod rt for inspection ALTER OR ADD TO MECH. CONSTRUCf10NTAX
V z Property i purposes.
lief agntt m save,indemnify krep harmless the City of eagcnino id City
IiuM1ilities,judg rnt costa and expert which may in anyway ecenreegaineuuid City AIR HANDLING UNIT(TO 10,000 CPM)
in nsu(uey oft � ting of his nnit.
AIR HANDLING UNIT(OVER If”CW)
S' nature mor ate EXHAUST HOOD(W/DUCD PAID
FIA o O A F. LOSURE HEATING UNIT OD UXLX10 BTU) Date Rceeipl q
Will the applicant or fumrc building occupant stow Or handle hererdous material HEATING UNIT(OVER 100,000 BT TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section x)7
Cl Yea
11 No VENTILATION FAN(SINGLE RESID)
Yes
Will Ne applicant or future building occupant use cyuipmem or Devices which emit
BOILER-COMP 0HP OR 100.000 BTU) 71 S ]N(`
VATE
hnxanlo^s air communism,as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District' 1:17
Yee ❑No NIEW RESIDENTIAL MECII. SQ.F1'. �sany' 9*
.� I have read the hazardous materials«quiremcma under Chapter 6.95 of the
uli(omia Ileolth&Sefcty Cute,Sections 25505,25533 andx25534.1understand that
tithe huilding Jcea not curtcmly hove a tenant,that it ie myy respomibility m nmify the
omupant of the requirements which must be mer prior in issuance of a Certificate of
Occupancy.
Owner or mthwited agent Data TOTAL: ISSUED BY:
OFFICE