26720 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL A L n O
SANITARY NO. APPLICATIONSUBMITTALDATE
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILD/INL�/G ADDRESS:
I ��►�.1� V(24NITM LOT
O NNAME: -NqP N CONTRACTOR'S# E LIC NO:
N/C CON TROL#
RLAIHI NGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
I QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
El lyPERMIT ISSUANCE El CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
q y�Z Thereby of n thatDivision
3 of the
Business and Profeuo(Chapter and mmeneise with
�i100
Section Division3of tM1e Business and Professions Code,and my license is in PANELS ^
C W, full fora and effect.
kn<y Date Class Com IIP T02W AMPS
m=y Dane Conrmmur 201-UIN AMPS
Z FONZ. ARCHITECT'S DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ,FT.
O0 ve O I understand my plans shall be used as public funds.
SIGNS ELECTRICAL
Q ,� LmemedProtesvowl
ff�5
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISCtINIT OaF I herebyMas affirm that 1 am exempt from the Cnnions C's License Law for the
I�z130m which following Mason.(Section 70315.Business i pr Professions Co de:Any city or county TEMP.METER OR POLE
Lr]O<5 which requires a permit reconstruct,aper,improve,demolish,file
repair any sructme
120 priorto,licensed personal also
requires 0eapplicant fIle Co commit to License
La smtemrnt POWER DEVICES
'�pp thusheisncing with
pursction 'he)of Divisin[the Contractor's License Law(ChapterCode)
a4o� 9(commethat he is(commencing therefrom
and
Division Sof the Business and Professions Cod e) SWIMMING POOL ELECTRIC VALUATION
W_m mction731.5b anyap morns!the basis fonhealleged exempnt to civiny l
of OUTLETS-
2Q, Section7031.5any dreddantforu permit subjects the applicant mecivil penalty of SWITCHES-FIXTURES
t� 66f,
t more than five hundred dollars($500).
Co Lasown love theproperty,many employeeswith wages as their sole compensation, NEW RESIDENTIAL ELELTR _SQ.FT. STORIES TYPE CONSTRUCTION
a3= wi tlo the work,and the srucmru isnot haturedof olferedforsale(Sec.7044,Ba,amas
n Professions Cade:The Carbamdr's License Law does oat apply In an owner of
progeny whoboilds mimprovesthereonand who does such workhimselforthroughhis
nemployees,pmvidedthatsuchimpruvementsarenotinteadedornfferedforsale.If. OCO GROUP RES.UNITS
however,the building or improvement is sold winhinone yearofcompletion,theowaer-
builderAd[have the burden of proving that he did not build or improvefor f TOTAL:
sale.). purposed
❑ I,as wourofthe properly,am exclusivelyconuacting with licensed contractors to QTY' PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7144,Business and Professions Cale:)The Contractor's
License Lawdoesnotapply loan ownerdfproperty who builds or improves thereon,and PERMIT ISSUANCE
whoenntracts forauch projects with aconvaetor(s)licensed pursuant to the Contractors DRAIN (BA)
License Law. ALTER- FEE SUMMARY
❑ 14M exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE. OUTSIDE
Owner . SANITARY Y N
Dam GRAINS-FLOOR,ROOF,AREA, RECEIPFp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
(hereby eff rte Nalhave ecenifcme of consem meelf-insure,macenificute of FIXTURES-PER TRAP RECEIPT'#
rakers'Compensation lnsumnama cenifiedapy thereof(Seo.3S00,Lab C.)which PARK ME Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS /� RECEIPT
#
Policy# v BUILDING DIVISION FEES
Company
o
GAS-EA.SYSTEM-OVER 4(EA) PLANCHFCK IE❑ Cenified copy is hadby
EI Certified cpyle fled wail thecity
inspection division. GRFASEI�ND T�:T R PT T i GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA SOILISNG
COMPENSATION INSURANCE
FEE
(This section need not be compound!ifthe permit is Future hundual dollars($100) SEWER-SANT(ARY STORM(A]2 FT. LENEJGY FEE
odes.)
I certify that in the performance of the work for whichmas permit isisaued,Urban WATER HEATER W/VENT/ELECTR
not employ any person in any marmer so as to beootmo subject to the Workers' Pip ppI
O .� Compensation Laws of Culifomia. Date WATER S STEM Dam Receipt#
Applicant .-
O NOTICE TO APPLICANT:IL eller making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
V) become subject o the Workers Compensation provisions of the Labor Cade,you most
L>!i , forthwith comply with such provisions or this punch shall be deemed revokul. BUILDING FEE
2
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that here is a construction lending agency for the performance of
V C) the work for which Ods permit is issued(Sda.3097,Civ.C) T ELECTRIC FEE
0 Lender's Name PLUMBING FEE V Lenders Address QTY, MECHANICAL PERMIT FEE
I unify that I have read this application and state that the above information is
cometl agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
uj building construction,and hereby authorize representatives ofthiacity to enmrupon the
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
r7 (W c)greet save,indemnl[y and keep h less the City of Cupenlao egains
liuldities,ja ts,cionindexpenseaw 'c any wayaccfue against said AIR HANDLING UNIT(TO FLOW CFM)
in co of the r
AIR HANDLING UNIT(OVER 10,000CFM)
S' muren pp' Date EXHPOM AUST HOOD(W/DUCTI
PAID
HAZARDOUS MATFRIALS DIS CLOSURE HEATING UNIT(TO IW,OW BTU) Dme Rmeipr#
Will applicant or future building occupant stare or handle hazmdous material
by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I HEATING UNIT(OVER 1BLOW BTU) TOTAL:
Code,Section 25532(aC
El Yes 0 N VENTILATION FAN(SINGLE RESID)
BOILER- ISSUA DA
Will then applicant future occupant COMP OR IW,oOp BTU)
ppt building equipment which
TEI
I sMorris if contaminants as defined by he Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU) JUL 12199
stricfl
I% ❑Yes CI No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the haemdous materials regraccur s under Chapter 6.95 of the ca UI- Wr
Califnmia flealOt&SafetyCode,Suctions 25505,25533 and 25534. I uaderstand that CT7I 11yu
if the building does not cumenfy have nation.that it is my responsibility to notify the
occupant of the requirements which most be met prior to issuance of a Ceniftcam of
Occupancy. ���//���//��
O.ancirauthori,edibur t Date TOTAL: ISSUED BY: \ VI Vs#' � I
OFFICE