24776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CAL
CITY OF CUPERTINO Nl IL11 -LLECI'RICAL PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PING RING-MEIDENTIICA 24776
I31111.IJINC I'ROJRC'T IIJKN'T119CA'TIOry
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.VATIC
of-ILSb o 1.01'# 2 �
OWNERS \M13: PHONE: CONTRACPOR'SNAMN LIC NO:
N/C COMR(lL#
ARCHITEMJENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT'INFO
Q I.Y. ELECTRIC PERMIT FEC
EI.FCI' PL M,CH
PfiRMf1'ISSUANANCE ;`�'_
I LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
GKZ I hcrcbyaffirm Nat l son licensed underpmvisionsof Chapter9(commencing with V JOR DISCRIPI'ION
+500 Section 7000)Of Division 3 ofihe Business and Professions Code,and my license is in PANELS
fail force and effect
<{U{ly License Chu, LIC.# 1311'I'02011AMPS
vFs 6vdi Date Commetor 201-1000 AMPS
Z064— ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Ff.Fl.00N ARFA $/SQ.FT.
O Z�n 1 understand my plus shall he used as public records.
220 SIGNS ELECTRICAL `<l
Licensed Professional
OWNER-BUILDER I wo BUIIAER DItthe Cou'1'ION SI'ECIAI.CIRCIJI'I'/MISC.
KO 1 hereby affirm that I am exempt From the Conuaamr's License Law far the
W,H following reason,(Section 7031.5,Business and Professions Code:Any city or county ILMI.METER OR POLE INS'1'.
���g whichrcyuismneermit applicant
plic impravech Permit
uy(maure 7
T� priormslicensed ,also requires theeprovisions
isios of the Co pentons LieaseLaJ(Cement POWER DEVICES
Iyf pO the he is licing ngWpursction 000)of isiansnf the Contractors and Pro Law(Chapter SWIMMING POOL ELECT RIC
0.ax e� 9t that
he is exempt
pt therefrom
add the
Division tef treed exemption.
ProfessionsGxle) �VALIJA'r1ONN'' M�
W4m ontion7031.5byanyrefnmmandrhebesiefortheallegedealicromn.Aiviviolation of OUTLETS-SWITCHES-FIXTURES S58
�Z< Section Than byanycxmrs F150tmit subjecB the vppliamto(civil penehy of \J
T not mart Nnn fve hundred della(($500).
K Ian ❑ I,asnwnerofNepmpeny,ormyemploytts wiNwagesesthcirsolecompensation, NEW RFSIDGYI'IAL ELECfR _SQ.PI'. g9'ORIFS l'YPE CONSTRUC'f10N
will de thework.and the sautum isnot intended(rofferedfors:de(Sec.70 ,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Li
Property whobtilchorimprnves thereon,and whereas such work himselforthroughhis OCC.GROUP RFS.UNITS
own employees,provided that such improvements arc not intended or offered!ar sine.If,
however,the buildingorimprovemem is sold within one yearn completion,iheowner- T
builder will have the burden of proving that he did not build or improve for purpose of
sole).
❑ 1,as ownerofthe property,um exclusively contracting with licensed commctorsto QTY. PLUMBINOPFRMIT FEE FLOOD ZONE APN
consumer the project(Sec.7044,Business and Professions CNet)The Cmatoxmr's PERMIT ISSIIANC
License Inw does not apply to an owner of pmperty who builds or improves thereon,serf
License mets fm such projuts with aconwetot(s)Iicensed pursuutm Ne Cnmmemrs nn p
License Law. ALTER-DRAIN 4V II I (flA) II IEC SUMMARY
❑ P am exempt under See. ,If&P C for this reason fK - '1'SID:FEES
ITA PLOWYRO'pECT- CZtl ICE - s - 1. Y YN
`weer s
Date 1 , RP:CEIPTM
DRABJS-FTOOR�ROp , �FASCON��
WORKMAN COMPENSATION DECLARATION TAX Y N_
All ❑ Ih<mhy af0mtlhetlhevee certi0wm of consent to self-insure,oracenifice¢of IIXTURE�-PER' P �0 R[CEIPI'p
Workers'Compensation Insurance or a certified ropy thereof(Sce.3800,Lab C.)which PARK FEE Y N
cnversall employee's under this permit OAS-FiA'.SY51P C.4 OIl'1'LF.TS RIiCEPPT#
Policy p BUILDING DIVISION FEES
Comparry❑ CmIRW copy is hereby famished. GAS-EA`,SYSTEM-GVER'4(EAJ d J PLANCHECK FARceci,,#
❑ Certified copy is filed with the city inspection division. GREASEBNDU$TRI-WASTEINTERCEPTOR GRADING FEECERTIMCATE OF EXEMPTION FROM WORKERS' GREASETRAPSOILS FIATCOMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM FA.20fit FEEor less.)
I certify that in the performance of the work for whiehthispc.it is issued,)shall WATER HEATER W/VENT/ELECTnom employ any person in any manner so as to become subject to the Workers' PAID
CUmpensalimLmvsofCa1,Rmia. Date WATER SYSI'17MG REATING Ilen
Q z Applicant
Z NOTICE TO APPLICANT:If,after making this Cenificatoof Exemption,youshould NEWRESIDENTIALPLMB. SQ.FE TOTAL:
aqbecomesubjemto it Workers Compensation prandsmoftheemed reNlood. must
> forthwith comply with such provisions onM1ixpmnir shale be deemed mvnkW. BUILDING FEE11 l5a
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE It
.7- z I hereby affirm that them,is a construction lending agency for the performance of
U O the work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
Leader's Nom< PLUMBING FEE
U Lender's Address QTY. MECHANICAL PERMIT FEE
W c P certify tom 1 have read this application and store thin the above information is MECHANICAL.FET?
act.l agree to comply with all city and county ordinances and stale laws relating to MEMO ISSUANCE
mildingeon(ruction and hereby authorize representatives of this city reenter upon the CONSTRUCf10N TAX
U z above-ha npurpoex ALTER OR ADD TO MECIL L
indent' 'y of Cupertino against
expenseswhic anyway.cc ag oimsts.id ly e AIR HANDLING UNIT(TO 10,0(1(1 CFM)
AIR HANDLING IJNI'r(OVER 10.000CFM)
Ore EXI IAUST HOOD(W/DUCD PAID
IIAZA OUS MA TERIAISDISCL)NO BEATING UNfT D'O 100,IX10 B1'U) Dame Receipp
Will the applicant or umrebailding oaeupunt store er handle hazudoner amriai IIIiATING UNIT(OVER POO,UIX113'1'U7
as defined by the Cupertino Maaieipnl CNe,Chnpler 9.12,and rhe Health and Safety
Code,Section 25532(a)9
•❑Yes CI No VIiNT1tAT10N PAN(SINOLP RPOID)
-
Will tair contamicam nants
building by me
nBay equipment unlit Managemenes t
BOILER-COME SHE OR 100,0011 BTU) ISSUANCED TF.
Mous air commninunrs us defined by me Bay Amu Air Quality Management BOILER-COME(OVE;R 100,000 BTU
Didmen
CI Yes ❑No NEW RESIDENTIAL MECH. SQ.lel'. PAID A ' D
I have read the hazmdous materials requirements under Chapter 6.95 of the r -��
Califomielicahh&SafetyCNe,Sectinns25505,25533and25534. Ispounderamadihm J -6
if the building does not currently have a tenant,that It is my rev bility to notify the
cc ant of the requirements which mu(ban nmr prior m issuance ofu Certificate of C��I /
Occupancy.
Owner or Bath tired agent Date TOTAL: ISSUED BY:
OFFICE