28297APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING...MECHANICAL,
BUILDING PROJECT HIKNTIFTCATION
PERMn'NO.
n e n
L o G 97
BUI INC, ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
// 6 I, [[�r /�
2 2 v S 7 I O S i A'vG UNIT# LOT If
O ERS NAME: PHONE:
V. Fa SA/emd
C ACIDR'S NAME: LIC NO:
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❑
CONI ROLA
RCIIITECT4iNGINF.FR: LIC NO:DR2S^
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CONTACI': - PHONE
QTY, ELECTRIC PERMIT IEE
BIIILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE.
El 1:1�# 11
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I um licensed underpmvisions ofar, pmr9 (corrro encingwith
, APPLIANCES-RE:SIDENT'[At.
JOB DESCRIPTION
PANELS
Section 71100) of Division 3 ofthe Business and Professions Code, and my license is in
full force and effect.
j License Class Lit.#
UP TO 200 AMPS
i Date Contractor
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plana shall be used as public resorts.
OVER IOW AMPS
SQ. IT. FLOOR AREA
$/SQ. I,f.
SIGNS ELECTRICAL
1 Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that I am exempt from the Contractors License Law for the
TEMP. MET ER OR POLE INS'I'+
following reasm.(Scction 7031.5, Business and Professions Code: Any city nr county
which requires a permino construct, spec improve, demolish, or repair any Co..stm
prior oils issuance, alsomquims iheapplicantforsuch pemnd to rile asigned statement
POWER DEVICES
that he is licensed pursuant to the Provisions ofthe Context License Law (Chapter
9(commencing with Section 7094 of Division 3 afthe Business and Professions Cale)
or that he isesemP therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant lot a permit subjects the applicant o a civil penalty of
SWIMMING POOL ELECT'HIC
{ ALUATIO
OlITl.l?TS-SWI'1'Ct{ES-FIXTURES
not m.. then five hundred dollars ($500).
ElI,asowneroftheprnperty,nrmyemployeeswithwageaastheirsolecompemation,
ST RIES TYPE NSTRUCTION
NFiW HESIDIiNI'IAL ELECfR _SQ. lel'.
willdo Nn
e work,and the same ure ism imendedoreffcred Future (Sec. R)44. Business
and Professions Cede: The Contractor's License law does not apply to an owner of
Property who builds or improves thereon, and who does such work hindel f or through his
nonemployees,provided Nat impmvomerreerene
G RES. UNITS
TOTAL:
ve yeareinscandedoroffeared
r.
ecomplfion, the owner.
hurt&, will building orimprovementiesold within oneyourorimprovefortheowner-
builder will hav<the M1UNen of that he did not build or int ova for
proving pr purpose of
QTY. PLUMBING PERMIT PEE
soft.).
❑ I,mownerofNopmpeny,amekclusivelyconamtingwiNlicenudcontmnorsto
LOOD ZONE
APN
c.nslmcl 1ho projrm (Sec. 70H4. Business and professions Code) The Contractor's
License Law does not apply to an owner ofproperty who builds or improves Nereon,and
PERMIT ISSUANCE
whocontnmtn formch projects with a conancior(s) licensed pnnuam to the Coundro is
License Law.
ABR-DRAIN&VINT-WATER (EA) )
IEE SUMMARY
❑ I am exempt under Sec, , B & I' C for this ream.
BACK FLOW PRGIECT. DEVICEO
SI . E s S
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR, ROOF, AREA, GOND.
SANI'T'ARY Y N
RECGIPI'#
SCHOOLTAX YN
❑ I hercbyarrirm that l have acenificateofconsenttovel6imum, oramnificateof
Worker% Compensation lnsumncearatrollied Copy thoreof(Sec. 311 Lin,CJ which
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y N
GAS - EA. SYSTEM-] INC. OUTLET'S �'
covers all employeesn.derthis permit.
Policy p
Brim" Is
BUILDING DIVISION FETES
Comryny
GAS - F.A. SYSTBM-OVER 4 TA)
PLANCHIiCK FEE
❑ Certified copy is hereby famished.
GREASPANDUSTRL WASTE INTERCEPTOR
GRADING, FEE
❑ Certified copy is fled wiN Ne city impaction division.
CF.RTIFICATEOFEXEMPI'ION FROM WORKERS'
COMPINSATTON INSURANCE
GRPASETRAP
SOILS FEE
SEWER - SANITARY - STORM HA, 20017.
ENERGY IEE
('1ldsseram aed notbecnmpletedifthepecond isforonehundreddollars($IW)
orless.)
WATER HEATER W/VENT/ELECIR
Icmify Net in Ne peA.rmance of the work forwhich Nispermit is issoed,lshall
not employ any person in any manner m as to become subject to the Workers'
PAID
Compensationlawsof Califnmia. Dam
Applicant
WATER SYSI'EMGREATING
Date Receipt#
NOTICE TO APPLICANT: IL after making his CCmficaleof Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
foohwiN Comply with such pmvisinns eathis permit sba11 be deemed revoked.
BUILDING IEC
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 hereby affirm that them is a construction lending agency for the permor once of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Leader', Name
ELECTRIC FEE
Lender, Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read this application and state that the above information is
correct, I agree to comply with all city and county ordinances and emm laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby amhmire representativesofthis city to enter upon the
above-mentioned prepeny for inspection purposes.
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities ,InJgi ms,cosomal expesee whichmay inany way accrueagainst said City
AIH HANDLING UNIT ('f0lf1,lKK1 CFM)
inronuquenc 'the granting of this
ground.,
AIR HANDLING UNIT (OVER IO.gIO CFM)
SignatureIApplicamVCCnntrecor Date
EXHAUSTHOOD(W/DUCT)
PAID
HEATING UNIT (TO IW,IKKI BTU)
I IAZARDOUS MAI FRIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle humrdous material
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Flealth and Safety
HEATING UNIT (OVER IW,Igq RTU)T'
L:
CMC, Senior 25532(a)'1
❑ Yea ❑ No
VENTILATION FAN (SINGLE RESID)
Will Nit Corcanmrms . defir d by the Bay equ Air Quality Mandl hemit
h tontals air ambnminrmts as defined by the Bay Areas Air Quality Management
BOILER- COMP (311P OR IW,000 BTU)
# SIU/xNCEDATE
CJJ
U� 02 i)
BOILER - COMP(OVER 100,000 BTU)
❑Yes 11 No
I have read Om humrdous materials requirements under Chapter 6.95 of the
California Health & Safety Cale, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my reafamor ility to notify the
occupant of the requirements which must he met prior to issuance ofit Ceoifcate of
A/! L6 :%
��
y yr `ser 1i
Q
NEW RESIDI'NfIAI. MECH.-SQ. Fr.
Occupancy.
ISSUED BI^v(
Owneror nmhnriuJ agent Date
TOTAL:
OFFICE