27834 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC FRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 278341
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS:lb N , //�� SANITARY NO. APPWCATION SUBMITTAL DATE
{��c' UNIT# LOTH
OWNERS NAME: PHO : CONTRA R' E: LIC NO: bLJ'
\` NICCONTROL# ,
ARCHITECT/ENGINEER: LIC NO: ADDRFS ❑
L� CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOi DESCRIPTION
Oy�Z Iherebyaffirm thatlam licensed under provisionsofChapter9(commencing with
UE for70W)of Division 3of the Business and Professions Code,and my license is in PANELS �
C U fall full force and effect.
<z License Class Lic.ra UPTO200AMPS
y?N Date Contractor 20_1 _15M-1EAMPS
O8
^77 - ARCHITECT'S DECLARATION OVER IWO AMPS SQ.FT.FLOOR AREA E/SQ.IT.
I understand my plans shall be used as public records.
y SIGNS ELECTRICAL
License)Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aF 1 hereby affirm(Se that I am exempt from the Gonion Ce License Law for the
followrequirMason.aperittoc03L0. t,Businessand Professions Co de:Any city structure TEMP.METER OR POLE INST.
�,n; which requires issuance,permit re conswch alma improve,demolish,or repair any srmnure
N� Phatheur is lcensedpotestor to the
thevisiosocant ftheor Cotracch tostto filease La statement POWER DEVICES
that he is nci ng w pmsusnuo the provisions n 3.f Contractor's License Law(Chapter
e l+. 9(cummeneing with Section 901Mp of 0ivielan3ophe Business and Rofaesions Code) SWIMMING POOL ELECTRIC VALUATION
y❑y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
F Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars(9500).p NEW RESIDENTIAL ELECTR SQ.FT.❑ I,asownerofthepmprty,ormyemploymswithwagesastheirsolecompensation, Q STORIES TYPE CONSTRUCTION
will do the work.and the structure isnotintended oroffered forsale(See.7044,Business
and Professions Code:The Contractor'a License Law does not apply to an owner of
propenywhobuildsorimpmvesthereon,andwhodcessuchworkhimselfoahroughhis OCC.GROUP RES UNITS
ownemployees,provided that such improvements are notintendedmoffeved frrsale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,am exclusivelycounceing with licensedconnaetore to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pmjeet(Sec.7014,Business and Professions Code)The Contractors
License Law does not apply merommurofpropany whobuildsorimprovesthereogand PERMIT ISSUANCE
who contracts forsuchprojems with ammunitions)licensed paramount the Contactors ALTER EA
License Law. ( ) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason Ot1T ES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner - Date DRAINS FLOORROOF,AREA.COND. RECEIPT at
- ,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby affirm that l have a cenificate ofconsent to self-insure.or a certificate of FIXTURES.PER TRAP RECEIPT#
I Workct%Compensation lnsuancaora certified copy thereof(Sec.3g00,Lab CJ which PARK ME Y N
covers all employee's under this permit GAS-EA.SYSTEM-l/C.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM/VER 4(EA) PLANCHECK FEE
❑ Cenlfedcopylsherebyfumishad.
❑ Certified copy is bled with the city inspection division. GREASEONDU$ L WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETR SOILS FEE
COMPENSATION INSURANCE
(This section read not be completed Offie permit is forome hundreddollars(9100) SEWER- ANITARY-STORM EA.200FT. ENERGY FEE
or loss.)
I comfy that in the performance of the work for which this .I,is issued,I shall WAY&HEATER W/VENT/ELECTR
not employ any person in any meaner so as he become subject to the Workers I PAID
Compensation Laws of Califomia. Date ATER SYSTEMITREATIN Date Receipt#
Z Applicant
O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. TOTAL:
Ln become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such previsions or this permit shall be deemed revoked. 16, BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the performance ofTOTAL: ELECTRIC IEE /'#
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name PLUMBING FEF.
O F Lender's Address QTY. CHANICAL PERMIT FEE
Wr I certify that I have read this application and state that the above information is MECHANICAL FEE
mmc I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUA E
.Fi rA building construction,and hereby arthro ieu representativesof this city to enter upon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO CH.
(Wo)agree to save,indemnify and keep harmless the City of Cupertino against
liabllities,judgments,costs andexpenses whichmay in any way accrue ainste id C�y AIR HANDLING UNIT ITO1 ,
In or. ucnceof the gmn/Iof this Permit. (1
�J AIR HANDLING UNIT(OVER IO,OW CFM)
lirre., m Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOEOW BTU) Date Receipr#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOT
iho'eardins
defined by the Cup viorm Municipal Cade,Chapter 9.12,and the Health and Safety _
ale,Section 25532(a)1 #pqq
❑Yes El No VENTILATION FAN(SINGLE RESID) #�
BOILER-COMPOHPOR 100,000 BTU) ISSUANCEDATE
Will air contamicarat nants
nts as building by the
Areequa Air
Manage emit
air contmninents as defined by the Bay Area Air Queliry Management BOILER-COMP(OVER 100,000 BTU) /yn
�my2 �
❑Yes11 No ;�- NEW RESIDENTIAL MECH. SQ.PT. ��� uI- 995/S
I have read the hazardous materials requirements under Chapter 6.95 of the "t,81/NO
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does not currently have a renant that it is my responsibility to notify the
occupant of the requirements which must be met prior m issuance of a Certificate of
Occupancy,
Owner
e
Owwner or authorized agent Date TOTAL: ISSUED BY:
,OFFICE ` '