24956 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMITNO.
JBULDING,ADDRESS:
OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 24956
LDING DIVISION BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATIONSUBMITTALDATE
C.�� UNIT# T PHONE: CONTRACTOR'S NAME: LI NO: ._ ,2'1 N/C CONTROL#
ECT -NGIN-CR: IC NO� DRESS:T: PHONE: BUILDING PERMIT INFO`'
M KIG 1 44 77-57-C917
5 QTY. ELE T FEE
lY ly/'Fp-e7,�� 7 � Bu7� u ec
PERMIT'IST-/Il'T''.
LICENSED CONTRACTOR'S DECLARATION APPLI - ESI T OR DE PTION
Qwz Ibereby rationalism had licensed underprovisionsofChapmrt?bommencingwith
P400 Section7W0)ufDivisinn 3ofthe Business and Professions Code,and my license is in PANELS
{� Poll rce and effect. UP TO 2o0 AMPS '� 1
F'yV$ nse Class Lic.q
Qq a Contactor 201.1000 AMPS
F'ON ARCt1ITECT'S DECLARATION SQ:FT. 00 ARE SQ.h .
'z'O'n3 1undersandm 1 shall be asedns blit records. OVER TWO AMPS
'O,z,—O ypunss a pu _
SIGNS ELECTRICAL
yG
t 1m
4g� Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oy U I hereby ME.that 1 am exempt from the Contractors License Law for the O/
W 3
11- following reason.(Section 7031.5,Business and Professions Code:Any tiny or county TEMP.METER OR POLE INST. DATL
t:iEz on; which requires a permit in construct,alter,improve,h,amdemolish,tt or repel,any structure .._
ais licensed puma thea provisions
softhe Contractor's
License
ed sta¢menr POWER DEVICES
poor requires pp p gn
4 p that Ire is licensedpursuant 7the)of Di isiof the Contactors License Law(Chapter
o tr. 9(cnmmencing with 5eminn]uW)ofDivision3of me Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis for thealleged exemption.Any violation of
r Section 7031.5 by any applicant fora Par subjects thenpplicanuo u civil penaltyof LEfs-SWITCHES-FIXTURES 1�•l.
at.
than five hundred dollars($500). Q. STORIES TYPE CONSTR N
pw ❑ ofhavork,athepmpeny,ormyemployedormfiwad sa
formle(Sce.compensation,
NEW RESIDENTIAL ELECIR S FT.
q will dothewons and the stacareiacto0nteicense Law
apply to an Business
end Professions Cade:The Contractor's License Law drcs not apply[a an owner of
is
ownerrywyers,pdvidedtmves[hereon,andwbedoesoinumbkhimaelfonhroughM1is OCC.GROUP ERESUNownempinyebuiprovori that such improv ldwit ere not intendedmoffered forale.lf,
one
however,Neavet a urdenof ementmovin ishat hedi inotbuil,or comm eforp,pose ofbuilder will have the buNen of proving that he did not build or improve for purpose of❑ I,usownerofthepmpeny,amexclusivelyconvactingwi,blicensedcomracmab QTY, PLUMBING PERMIT FEE FLOOD ZONE
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not apply tomownerofpmo nywhobuildsorimprovesthereon,mdPERMIT ISSUANCE
who contracts forsuch projects with acomraetor(s)licensed pursuarrotheCommcmr4 ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
License Low.
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECF.IPf#
WORKMAN COMPENeinfoo DECLARATION SCHOOL TAX Y N
Ihereby'Compeaffirm in Immohave a in.caatifieda end to,thermalf(Sesure,or Lab C.)ate ofwhich FIXTURES-PER TRAP 1 RBCEIPTp
orkas'Cmmpensntimnder thinceoannit.fled copy Hereof(Sea.3800,Lab CJ which PARK PEE Y N
re ell employee's under this permit. GAS-EA.SYSTEM-1 INC,4OUTLETS RECEIPT If
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
❑ Candied copy is hereby furnished.
❑ Cenified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASETRAP SOILS FEE
COMPENSATION INSURANCE
{ (This section need not becompleted ifthe Permit is forma,hundred dollars($100) SEWER-SANITARY-STORM EA.200CU ENERGY FEE
littill
or less.)
I certify that in N,parformanceofthe work for which Nis permit is issued,l shall WATER HEATER WNENTIELECTR
not employ any person in any manner so as m become subject to the WorkersPAID
Compensation Laws of California. Date WATER SYSTEM/IRFATING Data Re ipt w,
(] Z Applicant
z NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must
4 FF" forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING
W Q CONSTRUCTION LENDING AGENCY SEISMI E
7-. Ihereby affirm that hem is a construction lending agency fat he performance of TO 1: E IC PEE
the work for which this permit is issued(Sec.3097,Civ-C.)
Lenders Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that 1 have reed this application and sant chat Ne above information is MECHANICAL FEE
correct.Iagree m comply with all city and county ordinances and state laws relating. PERMIT ISSUANCE
-' building construction,and hereby amhmrfze representatives of[his city to enter upon the CONSTRUCTION TA
U 7-. above-mention xI papery for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save,Inde ify and keep hmmless the o C rtimo against
liabilitics,judgments,00sts expense hichm 'nany y againstaaid City IR HANDLING UNIT
(TO 10,000 CFM)
in consequence of It gophl it.
AIR HANDLING UNIT(OVER 10,000 CFM)
guamre of plic outac r - Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IO0,000 BTI) Date Receipt#
Will the applicant m f ante building occupant store m handle hazardous erammid
as defined by the Cupertino Municipal Code.Coupler 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) L:
Code,Section 25532(a)] VENTILATION FAN(SINGLE RESID)
El Yes ❑No
ISSU CE DATE
Will Neapplicamnrfu[umbuilding occupant use equipmentordeviceswhich emit BOILER-COMP(3HPOR IW,OOOBTU) gip
--hazardous air contaminants he he defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0011 BTU) Y"
iirrict4
❑Yes ❑No NEW RESIDENTIALMECH. SQ.FT. ®p y
I have read the hazoum
ards aterA Oials requirements under Chapter 6.95 of the , #w V sv 1993
California Health&Safety Code,Sections 25505,25533 and 25534. I enders sad Nat
vr
if the building does not currently
y have a tenant,that it is my responsibility to notify the ` Sr
CII Y GC y/1V^ryC/f`1wA(�tj/ '
occupaof the requirements be w ents which must mer prior issuance of a Certificate of
Occupancy.
Owner or authorized agent Dem TOTAL: ISSUEDBY:
�E OFFICE