27320 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION HUILDl -ELECTRICAL PERMIT NO. O
APPLICATION/PERMIT PING FROG C.TIDEANICAL
FIC
BUILDING DIVISION BUILDING PROJECT'IDN.N'1'IN'ICA'1'ION
BUILDING ADDRESS:
ADDDRGIEINSGS:IFiV �' �.'J•. O �� �s�y.{a,�.�` S L'1P� p♦.OpO. SANITARY NO. APPL1VIC—AT�IONS`U__
BMI{{T••
ALDKE
IoTS-7 U 4DY. UNITpLOT#
OWNIRSNqMEN 'MS NC CONTROLN�J
HEIL LIC NO: ADDRESS:
❑
CONTACT: PHONE: QI'Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
ED
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
mxz I hereby afford that l am licensed under provislonsof Chapeau(commencing with
ts10O Section 7")of Division 3 of lie Business and Professions Code,and my license is in PANELS
la 6z(F� fullforceandefect.
FZBJ LicenseI s c L Lic.# rs UPT0200AMPS
oozy Date Contractor /#IS 201-1"AMPS 1
Z O,z ARCHITECT'S DECLARATION OVER 1000 AMPS
O Z— SQ.Fr.FLOOR AREA E/SQ.FT.
1 undersand my plans shall he used u public records.
VJ SIGNS ELECTRICAL
2Q� Licensed Professional
OWNER.BUILDER DECLARATION SPECIAL CIRCUITIMISC.
4x4x O a F I hereby affirm that 1 am exempt from the Conwcmes License Law for the
u13O rn following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which reilmota a permit to construct.alma,improve,droud,h,or repor any structure
f }� priormits issuance.also requires the applicnatfor such Permit o file a signed statement POWER DEVICES
that he is licensed Poisoner the Provisions oflha Commerce.License Us.(Chaplxr
d p� 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
air that he isrxempnhendmin and the basis far the alleged exemption.Any violmionrf OUTLETS-SWITCHES-FIXTURES
FZa Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
nut more than five hundred dollen($500). NEW RESIDENTIAL ELECfR —SQ.Ff.
Po ❑ I,usnwneroDhe Prnpcay,nrmyemployees with wageamtheiraole compensation, STORIES TYPE CONSTRUCTION
a will dothe work,and the structure isnot irmadbilmmffered forsale(Site.7044,Business
and Professions Cade:The Contractor's License Lew does not apply to sn owner of
pmpenywhobuildsor improves thereonandwhodoesauchwmk himulfonluough his
empinyre......ided that such improvements...,immilelmofferedfn.aLe.If, OCC.GROUP RFS.UNITS
huweveq the building urdenmvemcnt is sold within one yam or improve for the owner- TOTAL:
builder will have the burden of Arming that he did not build or improve for purpose of
seta). QTY. PLUMBING PERMIT FETE R.00DZONE APN
❑ 1,as r test Property.am Business
ely and Professions
with de:) he Contractor's
construct[lie Ser.7044,Business and ywhobiona Codep The Ceram,and
License Law does
rsuch apply to a with ac rdescamy whored ds puouart to eConeon,and PERMIT ISSUANCE
w@ano tructsLass, rsuchprojatswithecontrnemr(s)IicemeJ pursuemm�the Contrnemes ALTER FEESUMMARY
License Luw. <' )
I sat exempt un er Site B&P C for this reason OU I SIDE FEES
BACK PLOW PROTECT.DEVICE SANITARY Y N_
Own<r Da¢ DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COM SATION DECLARATION SCHOOL'rAX YN
❑ I hereby affirm that l have a calibrate RE
e ofcomenoself-insura,oracerifcateof FlXTUS-PER TRAP RECEIPT#
WorkersCmnpmrsdior lnarancemacertified copy thrmnf(Sec.3800,Lab Cd which PARK FEE Y N
covets all employee's under this permit. GAS-EA.SYSTEM-1 INC,4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEF.
❑ Ceniftedeopyisherebyfumished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRLWASTEINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section madam becompleted ifNc permit is foronehundred dollars I$Ino) SEWER-SANITARY-STORM EA.2 ENERGY FEE
or less.)
I cetifydo,moe perfonamaceofthe work for which Nis permit is issue,I shall W/VENT/ELECI'It
not employ any person in any mmaer so as rc become subject to Ne Workni PAID
Compensation Lawsof California. Date WATER SYSTE EATINGZ Applicant Dale Rtteiptp
O O NOTICE.TO APPLICANT:If,after making this Carifirme of Exemption.you ahould NEW NTIAL PLMIL SQ.Pr.
',Z, B TOTAL:
becowithc mply it such Provisions
Compensation pmvit shall be
enied revoked.
must
frMwiN comply with such provisions or this permit shall be deemed invoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby off=that there is a corrsnuction lending agency for the perforemance of L: - ELECTRIC FEE
L) O the work for which this permit is issued(Sec.3097.Civ.CJ
4L lenders Name
Landers Address QTY. MECHANICAL PERMIT FEF. PLUMBING FEE
V I really Nat I have read this application and suite that the above information is
PW. correct.l agree to comply with all city and county ordinancea and sate laws relining to PERMIT ISSUANCE MECHANICAL FEE
y buildingcnnsnuction,and hereby oudodze representatives of Nis city memer uponthe CONS'rRUCfION TAX
U z above-mentioned property for inspection purposes. ALTRRORADDTOME
(We)agree to save,indemnify and keep harmless the City of Canadian against
liabilities,judgmrness a.and expo es which may in any way accrueagainemid City AIR HANDLING IT(TO 0,000 CFM) v'
y of egrentyµ spermit.
AIR HA NG
Sig a> ApplicmUContructor Via—
ia Dater HAUSTHOOD(W
PAID
HAZARDOUS MATERIALS DISCLOSURE H TING NIT 00,IXIOB / Dam Receipt#
Will the the Cupertino
Mu buildingoccupanterre2r handle hHealth a decrial HEA ING VER W OT
u.defined by the Cuncnino Municipal Coda Chapter 9.12,madras tleehh and Safety
Coda Section 25532(u)7 VENTI TIONF (SI RESID7 as
El Yes ❑No
Will BOILER-\(MPOHY IOOAOOBTU) ISSUANCE DATE
Hheepplimm mature buildingoccupmmseequipmem ordevices which t emi //,,��
hazardous air conusminants as detailed by the Bay Area Air Quality Management BOILER-CO VER 108000 BTU) p /,1
District? ❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. n'o 1'
to
1 have read the hazardous mumdala regoircment.under Chapmr 6.95 of the 'tl I/ 21
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a terant,that it is my responsibility to nmify the Coy 99,
occupant of the requir nmms which must he met prior to issuance of a Certificate of �h (rut
Occupancy, e•' /
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE