25611 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -ELECTRICAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IDHANIFIC 25611
BUILDING PROJECT IUEN'HFICATION
BUILDING FSg:IS 6bga/C W0,3 0UNIT# LOT# SANITARY NO. Ao�NS�AL DA•IE
WNERS /� ,rygNE• C RACTOR'S NAME: IC NO:
L J� UV -4 61 J1 J N/C CON'fROLq
•ARCHITECT/ENGINEER: LIC NO: KESS: 9 f� =# 6 /s�
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ sp ❑
LICENSE,DCONTRACTOR'SDECLAhapmr9 APPLIANCES-RESIDENTIAL � ppb
pCZ IhercM1y affirm than I CENSE licensed LACI R'SD DECLARATION
9(commencingwith
�0WC[=� Section 7WO)of Division 3 of the Business and Professions Code,and my license is infull PANELSLicemae Cluss Lic.N
Ur,J eeandeffecf UP TO 200 AMPS
G'yz Upy Licens
'o'. Date Contractor 201-1000 AMPS
ZOr`hiK ARCHITECTS DECLARATION OVER 100)AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O'Z^p I understand my plans shall be used as public records.
qr'+N 1pj...�.)] Licensed Professional SIGNS ELECTRICAL
Syz�Ua OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°�0 m U I hereby affirm that I am exempt from the Contractors License Law for the
w'3 tutu following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
"4,0.5which requires.permit to comou n,eller,improve,demolish,or repair AnystrucNre
W ad priaorls issuance,also requires the applicant for such peittofile aligned statement POWER DEVICES / n - n 7 7j ` I1
W 0 that he Is licensed pureuaat to the provisions of the Contractors License Law(Chapter
rn1� I II
d o 9(commencing with Setdan 7000)OfDivlsion 3 off.Business and professions Code) SWIMMINGPOOLELECTRIC _ YALLATIONI
41s2m orthat he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES L
Z an
Q Section 7031.5 by y applicant for a permit subjects the applicanto.civil penalty of
^� O not more than five hundred dollars($500).
MNEW RPSIDENTIAL ELECTR S FT.
. '
0 ❑ I,asawnerofthepmo rty,ormyemployas with wagesastheirsolecompensation, -- Q yT ST T PE CONSTRUCTION
M0
willdo the work,and the structure isnmintended oroffered Aussie(See. Business V
and Professions Code:The Conlracmr's License Law does not apply to an owner of
ownpropenywhm a,promlmproveatheremmandw tsmenotin work ourofffonhmughhis
mnpwholmpdsorimvided that such improvemehoduessuch work
imselredforsale.is OCGGROUP RES.UNITS
however,the buildingor improvement is sold within one yearofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowneroftheproceny,amexClusivelycoatrectingwithlicensedcontmctorsto QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
combat,the project(Sec.7UPI,Business and Professions Code:)The Conuactar'e PERMIT ISSUANCE
License Law does not apply 0 an ownerofpropenre
y who builds or improves theon,and
whocontracts forsuch projects witha commands)licensed pursuant to the Contractor's ALTER (EA) ARY
License Law. ) FEE SUMM
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Data SANITARY RECEIPT# N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX YN
• ❑ I hereby affirm that lhweucenificateofecaust toself-insure,orecenificate of FIXTUFEE Y
RES-PER TRAP RECEIPT
Workers'Compensation Insurance maceN
tfied copy thereof(Sec.3800,Lab C.)which 0 PARK N
rs nil employee's undenhis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECFIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA,.SYSTEM-OVER 4(EA) - PLANCHECK FEE
❑ Certified copy Is hereby fumishcd.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEB
CERTIFICATE OF EXEMPTION FROM WORKERS' . GREASETRAP SOILS HE
COMPENSATION INSURANCH
(This scedenneed aotbe completed ifthe permit is foronehrrindl dollars(MM) SEWER-SANITARY-STORM EA.2WFT. ENERGY HE
or less.)
I certify that in the perfomrance of the work for which this Permit is issued,I shall WATER HEATER W/VENT/ELECTR -
.1 employ any person in any manner so as to become subject m the Workers' PAID
CompensationLossof California. Date WATER SYSTEM/TREATING Date Receipt#
Q z Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLAIN. SQ.FT. TOTAL:
Z become subject o the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with,such provisions or this pcmrit shall he deemed revoked. BUILDING FEE
pW, z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(See.3097,Cis,C) ELECTRIC FEE
Lks PLenders Name PLUMBING FEB
U Lenders Address QTY. MECHANICAL PERMIT FEE
1 terrify that 1 have read this application and state that the above information is
correct.l a to comply with all cit d count ordinances and state laws ch atin to PERMIT ISSUANCE MECHANICAL HE
gree pdhe yon county g
U buildsngcotionedoa,andherebspectiri purples. atives of thiscityto errorupon the
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
G7 (We)agree to save,indemnify and keep h ny of Cupertino against
iumdures, is andranensee whichm yw yaccrue egvnst said City AIR HANDLING UNIT(TO 10,000 CFM)
in rence ftting omi �r
AIR HANDLING UNIT(OVER 10.000 CPM)
1.01
Signature of Apphcunt/Contracmr Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt It
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,W0 BTU)
as defined by the Cupcnino Municipal Cade,Chapter 9.12,and the Health and Safety
CN e,Section 25532(n)7 - VENTILATION FAN(SINGLE RPSID)
❑Yes ❑No
BOILER-COMP(3HPOR IOQOOOBTU) ISSUANC AT
Will theepplicanwrfmurebuilding nccupanmseequipmemord¢vices which emit p
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I WIXIO, BTU) IP A � D
DistrieO
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ,FT.
I have read the hamrdous materials requirements under Chapter 6.95 of the OCT 61993
California hbuling do&Sofetycur Code,have
a to 25505,25533 it is and 25534. 1 undo lord that C1�
ifthebuilding Joelnot correctly hoveasenate,thatd is myresponsibility
arnotify the 4 ,1
cu plat of Ne requirements which must be met priono issuance of a Cenifiwte of Ut- LUr
Owner acy. _ ll
VLJ
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE