26644APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILUING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING- MECHANICAL
BUILDING PROJECI'IDEN OFICATION
PERMIT NO.
C ^ A
o 44
BUILDING ADDRF_SS: %
UNIT p LOT p
SANHARYNO.
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QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
11
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I a mby riffrat Nat I an licensed underprovisions ofChapter9 (commencingwith
Section ]W0)of Division Sof the Business and Professions Cade, and my license is in
'o`le^omc lnA efa Licp 30 �/
APPLIANCES - RESIDENTIAL.
PANELS
UP T0200AMP5
JOB DESCRIPTION
Iff
1
`
Dam es
Contractor -1,`b
201-Io00AMPS
ARCHITECTS DECLARATION
I understand my plans shall beusedud as public mcoNs.
OVER BIBB) AMPS
SQ. FT. FLOOR AREA
$RQ. FT.
SIGNS F.LECTRICA
Liccnsal R.fessionA
OWNER -BUILDER DECLARATION
I hereby iffirn that I am exempt from the Contractor's License law for the
following reason. (Section 70315, Business and Professions Code: Any city., county
which requires a pennil to ennsm<t, ulmr, improve, demolish, ar repair any slmaure
Met to its issuance, also requires the applicant for such pe,miuo file a signed statement
that M is licensed pormant to the previsionstm
of the Concmrs License Law (Chapter
9(ummmancing with Beeson t000)ofDivi.i.n3.f rbc Business and Rofessions Cole)
.r that he is exempt therefmm and the basis for the alleged exemption. Any vioiamn.f
Section 7031.5 by any applicant for a permit subjects the appficanuo a civil penalty of
not more than five heran d d00ans ($500).
❑ I,ms nerofNepropeny.ormycmplUceswithwMesastheirsoiccompensation,
will J. the work, and the structure is not intended or offered for zale (Sec. 7044, Business
snit Prnfcssinns Calc: The Commcmrs License Law does oat apply t. an owner of
pmpeny who builds.rimpr.vee thereon and whodces such work himselfor 1moughbls
ownemployees,pmviJe atsuchimprovementsv notintendedorofferedforsale. If,
howcom, the building or improvement is sold within.ne yearofmmpletion, theowner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowncroftheproorty,amexelusivelyconnactingwimlicertmdcont to to
mxwet the pmjee (Sec. 7044, Business and Professions Cade) The Conuucter's
License lrwdocs not applyto anownerofpropedy who buildsorimproves thereom.and
whocontracts for such projcds with acadeactor(s) licensed pursuant tothc Commeors
License Law.
❑ 1 am exempt under See. , B & P C for this reason
SPECIAL CIS T/MISC.
TEMP. M ROR POLE INST.
PODEVICES
SMMINGPOOLBLECTRIC
VALUATION
UTLETS -SWITCHES-FIXTURES
NEW RESIDENTIALELECTR_SQ. FT.
STORIES
TYPECONSTRUCrION
DEC. GROUP
RES. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
FLOODZONE APN
FEES MARY
PERMITISSUANCE
AL'T F:R-DRAIN&VENT-WATER FA
( )
BACK FLOW PROTECT. DEVICE
OU . .ES
SANITA Y Y N
Owner Dam
DRAINS-FLOOR,ROOF, AREA, CONE.
i1�
WORKMAN COMPENSATION DECLARATION
'❑ Ihertby affirm lhaJ heveacenificam of conxnu.self-insum.macmificate of
Wmkers'Compensminn Insurance ora certified copy lhereof(See. Jg00.lab CJ which
co.cn allem W.
Policy N cygnc' q�•
SCH X V N
RECEIPT
FIXTURES - PER TRAP /'
PA FEE \y N
RECEf N
BUIL. INGDIVISI NhLES
GAS - EA. SYSTEM.] INC. 4 OUTLETS
Companyl� '
GAS -EA. SYSTEM -OVER
PLANC EC FE
Qe
❑ nifid mEis hereby famished.
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is(Drone hundred dollars ($ IOU)
or less.)
I certify that in the performance ofthe work for which this permit is issued,I shall
not employ any person in any manner m as of become subject to the Worker%
CompcamlionlawsdC.drvmiu. Dae
Applicant
GREASIVINDUSTRL WASTE INTERCEPTOR
G :E
GREASE TRAP
SOI
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
WATER HEATER WIVENT/ELECfR
WATER SYSTEM/TREATING
Aifl
Dam ec<iptp
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
$canoe mbjmt m the Worker's Compenmfion provisi.m of the labor CWc, you must
f.nhwhh comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the pmfomumtt of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Neene
NEW RESIDENTIAL PLMB. SQ, IT.
TOTAL:
BUILDING FEE
SHISMIC FEB
'1 L I,—
ELECTRIC FEE
Lenders Address
Q"TY. MECHANICAL PERMIT FEE
PLUMBING FEE r�
I sexily that I have read this application and ,are that me above in(ormaion ix
,reell agree to comply with all city and county ordinances and state laws refuting to
building C..strucd.n, and hereby authorize repomsenmtives of this city to enter upon the
above-mentioned property for mspeeiom pugmscs.
( We) agree to save emnify and keep hamdess the City of Cupertino against
l imbililies,j. mentis and expenses which may in any way acemet aimtmid City
in rise e.f the nT rya
d'
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CTO IO,000 CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER I0.000C
Signa rc of AppmanUCuntraanr ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupsnl store or handle haurdous mammal
aedefinedbythc Cupertino Music" Code, Chapter 9.12, and the Health and Safely
Crede. Section 25532(in?
❑Ycs o
Will theapplicaator future buildingeempant useequipmem ordeviceswhich emit
hazardous air cumamiwn�d by the Bay Area Air Quality Management
Dist ct?
❑Yes
1 M1:a Health ,cad the hazardous materials 5505. 25533 under Chapter erst of hdueat
if the wilding& Safety Care,Seta smar505atitis yorspoit 34. 1ityto understand thus
it the building doesnot
mentacurrently have a sober, that it a my reapum oft. m notify the
«ecupam .f its, requirements which mus M met poor to issuance of a Certificate of
calatnay.
EXHAUST HOOD(W/DUCT)
PAID
Dam Rcceip,#
HEATING UNIT (TO I BTU)
HEATING UNIT VER 100,000 BTU)
TOTAL:
VENTILA N FAN (SINGLE RISID)
BOLI, - COMP OR I DEW, BTU)
ISSUpANC DATE
y✓ V L'1'
AUG Q p�
v((�� F! Q) 1�^4
/ s�
to
nunU
BY: i
B ILER-COMP(OVER IW,IX)O BTU)
NEW RESIDENTIAL MECH. SQ, 1.
()worn, antato sod agent Date
TOTAL: ISSUED
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