28414APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CI'CY OF CUPERTINO 11 ILDING- ELECTRICAL
BUILDING DIVISION APPLICATIONAIERMIT PLUMBING. MECHANICAL
BUILDING PROJECT' IDENTIFICATION
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BUILDING ADDRESS:
SANITARY NO.
AP�PLIICATIONSUBMITTALDATE
' V e �e
UNI'( '# IAT#
C 2p
OWNERSNAME ♦ PHONE:
r Lem �V )- ��
CONTRACTOR'SNA l.: LIC NO:
N/C
❑
CONTROL#
AR'HITECf' INEFR: LIC NO;
ADDRESS:
A CA
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG IdArC'1' PLUMB MHCH
❑ ❑ Ii5
(�
PERMIT ISSUANCE?
LICENSF.DCONdunderOR'SUECLARATION
Iherebyaffi LICENEaliCONTRLnder OR'S DECLARATION
9fcammencing with
APPLIANCES -RIi51DENTIAL
/
TT1 `�'1 CRT
Section 7000) of Division 3 ofthe Business and Professions Code, and my license is in
PANELS
1
full6recandeffea.
License Class Lic.#
UPT02MAMPS
201 - I OW AMPS
Dom Contractor
ARCHITEC'T'S DECLARATION
I understand my plans shall be used as public records.
OVER RED AMPS
SQ. Ill. FLOOR AREA
$/SQ. ET.
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDI;R DECLARATION
SPECIAL CIRCUI'I'/MISC.
I hereby affirm that I atm exempt from the Contractor's License Law for the
TEMP. ME'IgR OR POLE INST.
fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county
which.,ai. a permit to construct, he,, improve, demolish, ar repair any stmcmre
prior to its issuance, alsorcquires the appliceal forsuch permit to Ii to,,mignon! emmmem
POWER DEVICES
that he is licensed puuuom wine provisions of the Ciourcmr's License raw (Chapter
9 (commencing with the Business and Professions Code)
?and of Division 3
SWIMMING POOL BUICIRIC
VALUATION
refromand the basis fnrtheallegedexdicaur exemption. civil psation of
mpt arefro e
Seor ction
Sodiume me applicant mecivil penaltyof
7031. by
by
OUTLETS - SWITCHES -FI%TURES
than hundred dollrs($50nniunbjects
not more than five hundred dollen ($500).
❑ hepmperry,ormyemplayeeswimwed
rompev mess
wrk,
NEW RESIDENTIAL ELEC E. S . FC.
Q
STORKS
TYPO CONSTRUCTION
lei(sale
do an a for
will dothe,iints odCode:'rho the cmreisnot s Puniness
Licc,u, La
Contractors License Law does not apply tat nn owner of
does of apply In
and Proproperty
I
who h ilsorafhe
is
Improves thereon, and who docs such work himsell ed fore ghhis
own eny whorl, provided
employees,providedthatsuchimprovementsarenas monde
OCC GROUT'
RBS. UNITS
'1'O'1'AL:
opletircd theo n r-
however, the building or improvement is hath within one yearof completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMNING PERMIT FEF,
ale.).
[I I, as owner nf the propeny,ameadnsivelycammoing with licensed contractors m
FLOOD ZONE
qPN
construct the project (Sec. 704q Business card Professions Code:) The Comocmrs
License Law does not apply manawnerofprnpeny who burdrorimpmvesthereon,and
Ik PERMIT ISSUANCE?
who contracts forsuch projects with a contrncmr(s) Ilccosedpursiam m the Contractor's
License Law.
ANTER -0RAIN&VPNP-WA'CER (EA)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT, DEVICE
'SIDE E
SANITARY Y N
RECEIPT.
Owner Dam
DRAINS- FLOOR, ROOF, AREAD.
, N
COMPENSATION DECLARATION
$CIIOOLTA% YN
❑ Thereby affirm that lhave acertificme ofennsem in self -insure, oracenificam of
Workers'Compensation Insurance ora cenilied copy therruf(Sec. 3800, Lah C.) which
RECEIPTp
FIXTURES - PER TRAP
PARK FEE Y N
Perm'
covers all employea's undenbist.
Policy #
GAS - EA. SYSTEM. INC. 4 OUTLEIS
RECEIPT#
BUILDING DIVISION FL'hS
Company
GAS - EA. SYSTEM -OVER 4 (FLA)
PLANCHECK FEE
❑ Certified copy is amen, famished.
GREASERNDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ Cenified<npy is fled wiN Nc city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP�
SOILS FEE
SEWER - SANITAR "1' M .2000
ENERGY FEE
(This section need not becompleted iffhe permit is forme hundred dollars($100)
torics")
WA'I ER BEAT'E IF.L
I certify that nthe perfcramoeof Oto worklux which mispetmit is issued, Isha11
.at employ any persm in any manner so as m become subject m the Workers'
PAID
WA R�/ERG G
Compensation Lawsof Califomia. Date
Date Receipt
Applicant
NOTICE TO APPLICANT:If, after making flus Certificate of Exemption, you should
NE ENTIALPI. SQ.FC.
TOT :
become subject the Worker's Compensation Transitions of the —Mr fide, you must
fonhwith comply with such provisions or this permit shall be deemed revoked
BUILDING FEF.
CONSTRUCTION LENDING AGENCY
SEISMIC ELK
I hereby affiant that hem is a construction lending agency for the performance of
The work for which this permit is issued (Sec. 309]. Civ. C.)
Lender's Name
ELECTRIC F
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLU
MF.Cfi L iE
I certify that 1 have read this application and sum that the above information is
comed. l agree to comply with all city and county ordinances and sou laws relating to
PERMIT ISSUANCE
building construction, and hereby authorize representatives of this city toerfer upon the
above-nfembrad prnpmy for inspection purposes.
ALTER OR ADD TO MSCIL
CONSTRUCTION T
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmenu, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO I0,a00 CFM)
in corse uencc of the ting mf this pe
AIR HANDLING UNIT (OVER 10,000 CPM)
10
gnature of ApplicunVContrma. ' Oa
E%I MUST HOOD(W/DUCp
PAID
IIIb TING UNIT (TO I00,000 BTU)
IIAZARI30US MATERIALS DISCLOSURE
Du Receipt#
Will The the Cupnt in, ertino re Code, Chapstoreor hndJle Health uhmamdal
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
HEATINGUNIT(OVER100,000BTU)
Code, Section 25532(4)?
11 Yes 13 No
VENTILATION FAN (SINGLE REBID)
WiIltMapplicamnr(uturebuildingoccupanruxequiptrtenf ardevicca whichemitp
hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
BOILER- COMP(3HPOR 100,000 BTU)
115'UANCED 'E
P B
#
BOILER -COMP (OVER 1 W,WO BTU)
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
JUL 20 Q
NEW RESIDENTIAL MECH. SQ. FI'.
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building dues nor currently have a tenant, Net it is my responsibility to notify the
occnt upaof the arNmo mems which most be met prior to issuance of a Certificate of
�'TY Liu' `ser -F
Occupancy.
ISSUED BY:
Owneraruuthorizedngcm Dam
'1'O'1'
OFFICE