26236 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMUTING.
APPLICATION/PERMIT PLUMBING-MECHANICAL
PROJECT2 6 2 3 6
BUILDING DIVISION BUILDING PRECT IDENTIFICATION
BDILDI2GAZDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
LA
OWNERS NAM PHON : � GC IP RACfOR' ME: LOT# LIC NO: �
NIC CONTROL#
RCHITECTIEISGINEER: LIC NO: A � V O
0
ONTACT: 1� PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
VN (�/ L 3-JqVPt? PERMIT ISSUANCE BLDG ELECT PLUMB. MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION of Ch TION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
WPOO Ih7000) fRnnthatl wan ofthnsediness and
Prolinsof Chnpler9(co mmencing with
yF 00 Section]000)of Division 3 of the Business and Profession�s CoJdeI,1and my license is in PANELS
a ZUy, License Cled off Ls# �lV UP TO 200 AMPS
on o,, Dale ARCHITECT'S DF.0 A TI VACD `�i\ 201-1000 AMPS
ZOm— OVER TWO AMPS
SQ.FT.FLOOR AREA S/SQ,FT.
O Z-'Z 1 and my plans shall fenced as public records.
SIGNS ELECTRICAL LED
Licensed Professional L 16}—�
< OWNER-BUILDER to the
SPECIALCIRCUIT/MISC.
wO�F 1 ngm os d.affirm(Se that 1 am exemp[hum the Contractor's License Lew Ironic p II T E R
W 3 O m following reason.(Semon 7031.5,Rosiness and Professions Code:Any city or county TEMP.METER OR POLE INST. / tlVX
1'J�y a which requires a permit m conswq,alcor,improve,demolish,m repmr any marine
prior to its issuance,also requires the applicant forsuch Permit to file a signed statement POWER DEVICES DA
<O [hat he is licensed personal to the provisions of the Contractor's License Law(Chapter
dyoC 9teomeremm,with Section]0M)of Division 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC k
µ)my Sahel heisexempuheapI ant for
the permit
subjects the
to civil
of OUTLFTS-SWITCHES FIXTURES
4 Seclion]03 LS'y any applicant fora permit subjects the applicant to acivil penalty of
tY onot more than five hundred dollars(1500). NEW RESIDENTIAL ELECfR
[II,asownerofNepropeny.ormyemplayxs withwegesas Neirsolecompensation, STORIES TYPE CONSTRUCTION
will do the work,and the strocmm isnorimendedorofferedforsale(Sec.]0ahl Business
and Professions Code:The Contractor's License Law does not apply to as owner of
propenywhobuildsorimprovesthereon,a ndwhodoessuchworkhimselfortNougbhis OCC.GROUP RES.UNITS
n employees,providedthat suchimprovermar are not intendedoroffemd forsale.If,
however,the buildingor improvement is sold within one year ofcompletion,the owner- TOT
builder will have the burden of proving Not he did not build or improve for purpose of
sale.).
❑ I,asowurofthepmperty,amexclusivelycontractingwiNlicensedcontacmrsm QTY. PLUMBING PERMIT NINII
E FLOOD ZONE APN
construct the project(Seo.7044,Business and Profusions Code)The Contractors
License Law does not applyto aaownerofproperty whobuildsorimpervesthericn,and PERMIT ISSUANCE
who contracts forsuch projects with arommuctor(s)licensed pursuanuo Necontractor's
License Law. ALTER-DRAIN&VENT-WATER(EA)
FEE SUMMARY
❑ 1 am exempt under Sec, ,B a,P C for this mason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
OwnerDam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION UECfARATION SCHOOL TAX Y
❑ Iherebyaffirm thud hnveacertificele ofconsemmselGinsure,orz cenificem of FIXTURES-PER TRAP RECEIPT#
Wmket%Compensation Insurance ora certified copy thereof(Sec,3800,Lab C.)which PARK FEE Y
covers all employee's under this permit #
GAS-BA.SYSTEM-1 INC.40I1TLET5 RECEIPT
Policy# BUILDING DIVISIO E
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
C3 Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nolle completedif]beperand is for one hundreddollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY
orle's.)
I cenifythat in the performance of the work for which this permit is issued,i shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner
so as to become subject to the Workers' PAI
Compensation Lawsof Califomia. DateWATER SYSTESMREATING Data Receipt#
Z Applicant
O0 NOTICE TO APPLICATI:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. 'TOIL:
ti become subject tothe Workers Compensation provisimvsofthe Labra Code,you must
�i , forthwith comply with such provisions or this permit shall be deemed revoked, BUILDING FEE
z CONSTRUCTION LENDINK AGENCY SEISMIC FEE
I hereby affirm that them is a coneirn Ic g agency for performance of
C) Q the work for which this pemtit ie issued(S 1309 , Iv.CJ TOTAL: ELECTRIC
C) FLenders Name
fender's Address QTY. MECHANICAL PERMIT FEE PLUMBING SEE
LU I certify that 1 ha
ves pleb n nd lam Net the above information is MECHANIC L FEE
comet.I agree m coI ty ad r ty N' a sand state laws rclalingto PERMIT ISSUANCE
building condemnornh 'z ofthis city to enterupon Ne CONSTRUC ONTAX
above-mentioned proe ALTER OR ADD TO MECH.
(We)agmumsIf 1 the City of Cupertino against
liabilities,jodgments, ayinanywayaccrue wastsaid ity AIR HANDLING UNU9010,000 CFM)
In a ue ce of thn.
AIR HANDLING UNIT(OVER 10,000 CFM7
Signature of Applic PC D;t1 EXHAUST HOOD(W/DUCT) PAID
HA US ATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Willtheapplam rto boding occupant store or handle hazardousma[erial HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the C Wino nicip it Cade.Chapter 9.12,and the Health and Safety
Code,Section 255 (a)P u CO3 No VENTILATION FAN(SINGLE RESID)
❑Ye
BOILER-COME QHP OR 10(1,000 BTU) ISS NCE ATE
Will the applicamorfumre batli ingoccupc l a seequipmenmrdevices whichemit Y�
hazardous air contaminants as defined by one Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU) P
Disr'v[t
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.ET.
I have read the hazardous materials requirements under Chapter 6.95 of the
Califomia Health a,Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenanq that it is my responsibility to notify the �r L
occupant of the requirements which must be met prior to issuance of a Cenificate of
Occupancy.
Owner or awlorimd agent Dam TOTAL: ISSUED BY:
OFFICE