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26890 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILD NG-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICA'f1/0NrJkBDB�MITTAL DATE L UNIT# LOT it �yq� OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO: /P413 N/C CONTROL# �ARCHI'fF.CT/ENGINEER: LIC NO: SS: ❑ CONTACT:to NRC E- PHONE: LDa BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE ECFJ� 29b-3 BLDG ELFPLU B M l PERMIT ISSUANCE �. LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Tf OCZ Ihereby effDivisrm chat l am licensedinssand irofesion,Coder 9(eommenting with O SCRIPTION 566 Section,and of Division3 of the Business and Professions Code,and mylicense is in PANELS U� full force and effect ZW License Clss Lic.# or -7� UP T0200 AMPS un, F y Z A CHITECf 5 DECLARATION SQ. 201-1000 AMPS SQ:PT.FLOOR AREA 8/SQ.FT. Z C m^ 1 OVER 1000 AMPS CZ-0 understand my plans shell be used as public records. SIGNS ELECTRICAL 6�Y ,"Ij Lmensed Prnfeasional a'C OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ndOyF 1 hereby affirm fim I am exempt from the Connacmrx License Lew for the 3 p y following reason.(Rection]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. m which requiras a N.it to construct.alter,Improve,demolish,m repair any structure C�� priorroits issuance,also requires the epplicam fmsuch paaniuo file asigned statement POWER DEVICESI� � I� yI CC) that be is licensed pursuant the provisions of the Coarraoors License Low(Chapmr 0 9(commencig with Section 9000)of Division 3 ofthe Businea%dX..'smaas Code) SWIMMING POOL ELECTRIC -�, / —) I1( I UATION y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of d J V �� J >Y• Sedion]031.51, any applicant forapermit subjects Ne applicanuou civil penalty of OUTLETS-SWITCHES-FIXTURES u J cnot more then rve hundred douara(8500). ❑ I,asownemfthepmpny,ormyemployeeswithwagesastheirsoleemNnsatim, kNEWRMIDFRENTIAL ELECSQ.1� '''E 01 will do the wmk,and the structure isnorintended oroffered forsale(Sm.7044,Business and Pmfessiona Code:The Contractors License Law does nt apply to an owner of propertywhobuildsorimproves themon,and who does such workhimw1forthrough his ownemployces,providedthatsuchimprovements menotinteaded oroffered formle.IL OCC.GROUPhowever,the building or improvement is sold within oneyearofcompletion,the owner. builder will have the burden offirming that he did not build or improve for purpose of L:sale.).❑ I,as ownerofthe property,amexclusively contracting with licensed convectors to LUMBING PERMIT FEE FLOODZONEconstruct the project(Sec.]M4,Business and Professions Code:)The Contractor's License Lawdoesnotapply man ownerofpmpertywhobuilds orimproves thereon,andANCE rx salt whocomracts forsuch projects with acontractorud licensed pursuant tothe Contractor'a License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY ❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICEtNDOUTSIDE FEES SANITARY Y N Owner Date RECEIPT# WORKMAN COMPENSATION DECLARATION ISnRES FLOOR,ROOF,AREA,CSCHOOL TAX YN ❑ Ihereby affimthat l have a certificate ofconsenno self-insure,,r a certificate of -PER TRAP RECEIPT#Worken'Compesmion Insurance or acenlFed copy theeof(Se.3800,Lab CJ whih PARK FEE Ycoven all employee's undenhis permit. SYSTEM.I INC.4 OUTLRECEIPT# Policy n - BUILDING DIVISION FEESCompany SYSTEM-OVER4(EA) PLANCHECK FEE ❑ Cenifedo pyish byP mish d.❑ Certified copy is filed with the city inspection division. NDUSTRL WASTE INTERGRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' RAPSOILS FEE COMPENSATION INSURANCE(Thisscetmmiuod not becompleted ifthe permit is for one hundred dollars(SIDE ANITARY-STORM RA. ENERGY FEE orle loss.) I,amify that in the performanceofthe work for whichthis permit is issued,l shell WATER HEATER W/VENT/ELECTR not employ any person in any manner so as to become subject to the Workers' PAID Compensation Laws of California. Date WATER SYSTEMG71EATING Z Det; eipt# O NOTICE Applicant N come su O APPLICANT:Whork If,Compensation this Certificate to of Exemption e,youshould NEW RESIDENTIAL PLMB. SQ.PT. TAL: H H Iscomesubjectm the Workers Comns or this provisions,Rhe Leben Code,you must tiforthwith comply with such provisions,r this permit shall be deemed revoked. BUILDING E CONSTRUCTION LENDING AGENCY SETS IC ^a z I hereby affirm that there is a construction lending agency for the performance of L) O the work for which this permit is issued(Sec.309],Civ.C.) TAL: ELE FE t� Lendera Name Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE I certify than 1 have read this application and state that the above information is comet.I agree to comply with all city and county ordinances and state laws relatingo, PERMIT ISSUANCE MECHANICAL building cmasmuction,and hereby authorize representatives of this city m enter upon the V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION AX (We)agree m save,indemnify and keep harmless the City of Caperton,against Iiabilities,judgments,csts andexperacs whichmay in any way secrueagainst said City AIR HANDLING UNIT(TO 10.000 CFM) mxsequenceofthegram of this#omit. _I n I AIR HANDLING UNIT(OVER 10,000 CFM) gmmreo Appliwn onto Date•'�l� EXHAUST HOOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dale Receipt# Will the applicant or future building occupant score or bandle hazardous material as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) L Code,Section 25532(e)9........,,,,{{8g 11 Yea 6- VENTILATION FAN(SINGLE RESID) Will thcapplicant orfuturebuildingmcupant useegoipmBOILER-COMP SHP OR 100,000 BTU) ISSU NCE DATE entordevicce whichemit sI� hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,"BTU) P A Q District+ yS �[ ❑Yes pLNo NEW RESIDENTIAL MECH, SQ,FT. Lboildm, read the hazardous materials requirements under Chapter 6.95 of the AUG 181994 ealth&Safety Code,Sections 25505,25533 and 25534.1 understand that g does not ci mently have a tenant,that it is my responsibility to notify the Gil Y the requhemems which must be met Prior to issuance of a Certificate ofUr {#ul'trl thorized agent Date T ` ISSUED BY: OFFICE