S 1324APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD NG - ELECTRICAL PEI IT NO
BUILDING DIVISION APPLICATION/PF,RMIT rl,Dmnnncc mEC'x^rvlcAbrefnx1 1 - 1324
ADDRESS ❑
-^3/o ALPed11: AA LA {/edDA
lD ` — (- Pu y�
R I ❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRAC'TOR'S DECI.AKA I]ON QTY
I hereby affirm that 1 um licensed under provisions of Chapter') (commenting
with Section 7000) of Division 3 of me Basins, end Profit,, ansCME, and my license is
in full mace one e
License Class Lia#
Ddm
Currentr
ARCIIITEC'I"S DECLARATION -
I undersand any plans ,bell be used us puhl Ic records
Licenacd Pml'essionel
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Low for the
following reason. (Section 9031.5, Business and Parnassian, Cade: Any it, or county
which requires a permit to construct, once, improve, demolish, or repair any structure
prior to its issuance, also requires mo applicant for such permit to file a,imed,....emend
that he is licenced pursuant to the provisions of We Contrach rs License Law (Chapter 9
(commencing with Scwtion]Gulp of Division Sof the Buaira, and Pro l msinns Code) or
that he is exempt mcrefroon and me basis far the alleged exemption. Any ....Intern rf
Section 90315 by any applicant ford permit subjects the applicant to a civil penally of
are mare,hun five hondrwl dollary (x500),
❑ 1, as owner of the property, or my emplh,ws with wages as their solo compensation,
will do the woe:, and the structure is not intended or offuul for sale (Sea 7044, Business
and Prnre d..d, Cede: The Cl)mmmors Live... Law urea not apply to an -ra, of
properly who hands or improves dneroon, and who rotes such work himself or through
his own enployecs, provided that such improvements are not Intended or offered for
sale. If, however the building or Improvement is sold within one year of completion, Ibe
pael) -budder will have the movica afpmving that he did no, bund or fmpmve for pa-
c rI sale.).
❑ I, as owner of the prepery, am exclusively contracting with licensed contractors to
Sumer, the uncia (Sao 91144, Brasiers, and Poefe...oma Calc:) The Connector, U-
se Las Anes not apply loan ownet (if property will) Hailes ot improves drawer. and QTY.
who carvers lorsueh prrjeen wish n...nimanr(s) licensed pursuant to the Contractor's
License La..
❑ I ant excum, under Sce. ,B& P C for this meson
Owner Der
WORKER'S COMPtiNSAI'ION DECLARATION
I hereby affirm under penalty of lwrjury one of the following dealers inns
D I have amd will mutation a Cemfcale of (7 I to self -insure lot Worker's Compcn-
salion, as provided for by Section 3900 of Ibe ].shot Code, for the performance of the
work for which this ,inal Is issued.
❑ I have and will maintain Workers Compensation Insurance, as acquired by Section
3700 of anc Label' Code, for ane pert artmnse of the work for which this Permit f, issued,
My Workers Conmensntjrn Insurance wmrier and Policy u lumme
Center: Policy Na
CE TIFIC TE OF .REMOTION FROM WOR
CI bar., SA'I'ION INSURANCF./fo
C-2 It
(Thi -c scetion reel urn bar., if Wepemit is far on t allure ($100)
al) Ica.)
I beary that in the perfonnenhe of the work for which Ibis permit is issued, l shall
not employ any person in any manner to as tu h ra men subject to the Workers' Compcn-
Z smear Lawsrf California. Dile
Q Applicant
y NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should
a�became subject to the Workers Compensation provisions of Ate Labor Code, you trust
forthwith connply with such trust does or this permit shall be deemed revoked.
0
CONSTRUCTION LENDING AGENCY
U O
herebyaffirmthe,
that there isneod(Sao 30 lending agency for the performance of
W.0 U the work for widen mix Aman fc issued (Sao 3097, civ. CJ
U Lenders Name
W Lenders Atldfea
V) 1 carrify mil 1 have with
this application county
and state ces and starve Iws o dation is
% correct, l agree to comply with all sty and county orl Lives of and Sete laws r uplin t e QTY
Uz buRmngamswdiomand farebyemhorizerepresvmmivcs of this city memer upon the
shove -mentioned propury far inspwlion putPnsec.
(We) agree to -sour. authority and kcep hamdcss me Cily oI Cu a'Ima agalnsl
liabilities.judgments, cove, and expenses which may In any way accrua against auid Ciry
nce thegranting permit.
APPLICANT UNNDERSTANDSS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
will 117e phcam or future budding«cupanlxmtcor handle Future! ... sunmeant
,as defied by the Cupertino Municipal Code, Chapter 9.12, and he Health and Salary
Code, Senior 25532(n)?
El Yes E] No
W,ll he applicom or fume handing occupant nae "impmenf or device, which
emit hazardous air contaminants as defined by the Bay Area Air Quality' Management
Divlrict,
]Ye's No
I have read the managers matendl, ove re fonts under Chapter 6.95 of the Culi-
fornic Health & Safety Code, Swfmn, 25545, 25533 and 21534.'T understand that if be
building does not currently hive n tenant, that it is my responsibility to reify the acupant
of the oquir mons which nmol be mm put to lecuanee of Coal p,me of Occupancy.
- ELECTRIC PERMIT
FEE
L \
C
JOB DESCRIPTION
RESIDENTIAL:
PERMIT ISSUANCE
NEW RESIDF.NTI41, F.LECTR
❑SFDWL
❑ADIIITION
D MULTI -UNIT
D KITCHEN REMODEL
I-] PLUMBING REPIPE
D STRUCTURAL.
APPLIANCES -RESIDENTIAL
FEE
PANELS
MODIFICATION
UP T0200AMP5
./�
Ll INTERIOR El CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
❑ RATE REMODEL/REPAIR El DF:MOI.1'TION
00THER
201-1000AMPS
OVER 1000 AMPS
SIGNS ELEC'PRICAL M
TEMP. METER OR POLE INS'I'.
COMMERCIAL:
D NEW BI DG/ADDITION [] DEMOLITION
%JeFNANT D FOODSERVICE
PROVEMENT
D OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
1TLETS- SWITCHES -FIXTURES
NEW RESIDF.NTI41, F.LECTR
SQ UL
P�RMITPERMIT ISS 'LL
AL'I'BI1-DRAIN&VF.N IVATER(F.A)
RACK FLOW PROTECT. DEVICE
,DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES -PERT RAP
GAS - BA SYS '1'HM-I INC. 4 OUTLETS
GAS - EA. SYSTEM OVER 4 NA)
GREASEANDUSTR, WAS' IF IN'I ERCEP'IOR
CREASE 'MAP
SEWER -SANITARY - STORM EA. 200 FI'.
WATER HEATER WNENT/ELECTR t
WATER SYSTEMn RIiAI'ING
WATER SERVICE
NEW RESIDENTIAL PLMU SQ. FT.
MECHANICAL PERMIT
PERMIT' ISSUANCE C
(4I.TERORADDTOMF.OH. t
AIR HANDLING UNIT(TO 10,000CFM)
AIR HANDLING UNIT (OVER 111,1100 CFM)
EXHAUST HOOD(W/DUC )
HEATING UNIT (TO 1011,0011 BTU)
BEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER -COME (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FI'.
AIDrFEE r�
eeivlTDTAL:BUILDING FEE SEISMIC F�ELECTRIC
An.
L
PLIIMBI f FEE {Q `\,
MF.CHA ICAI, ME
CONSTR 'ION TAX
HOUSING MIT TION FEE
PAID
Data
TydTW I ISSUED BY:
OFFICE
DATE,
COMMERCIAL:
D NEW BI DG/ADDITION [] DEMOLITION
%JeFNANT D FOODSERVICE
PROVEMENT
D OTHER
�2
SQ. FT. FLOOR AREA
2cq�pQ�
MAY 6 ANS'[]
$/SQ.
FEE
'Ittirl
STORIES
OCG GROUP
TYPE CONSTRU
APN
A
OUILDINO DIVISION PEES.
PLANCHECK FEE
ENERGY PEE
w
GRADING FEE
0SOILS CUP A
AIDrFEE r�
eeivlTDTAL:BUILDING FEE SEISMIC F�ELECTRIC
An.
L
PLIIMBI f FEE {Q `\,
MF.CHA ICAI, ME
CONSTR 'ION TAX
HOUSING MIT TION FEE
PAID
Data
TydTW I ISSUED BY:
OFFICE
DATE,