24692 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY4OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^ a�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L 6{9 L
BUILDING PROJECT IDENTIFICATION
BUILDING A
DD
RESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
K d��.I rT , WNVDOWN UNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'SN E: ' LIC NO: �� N/C CONTROL
I.s ARCHITECT(ENGINEER: LIC NO: ADDRESS: u\ El .
1 o Alm
ry CONTACT: PHONE:
1 1 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT LUMB MECH
PERMIT ISSUANCEEl El
El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
-QWz I hembyaffirm Haul amliceased underprovisionsof Chapter9(commencingwith IOP DESCRI ONS
qOF Section
udefD1vision3 he Business and;ofession�otle,and my license is in PANELS
fall
Gy WVjy Lic eClass Lic.# LLLLII UPT02MAMPS
rFFn.=y Da Contractor IN� 201-I"AMPS
ZOrroiizK ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.ET.
O z"C I understand my plans shall be used as public records.
161 SIGNS ELECTRICAL
LicensedProfesaienal - '
O V OWNER-BUILllERD TION SPECIAL CIRCUIT/MISC.1 hereby affirm that I am the Can exempt from the Conoacmrs License Lew for the
3 E- following reason.(Section 7031.5,Business and Professions Code:Any city creamy TEMP.METER OR POLE INST.
which require,a permit to consumer,alter,improve,demolish,or repair any structure -
yY� prior to its issuance,alsorequires the applicant for such permitto file a signed statement POWER DEVICES
WA O that he is licensed Pursuant to the Provisions of the Contractor's License Law(Chapter - -
0.po
-
9(commencing with Section 7010)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC u A AM)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of 1TY IOF._�n
G Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES 1,1VE igl P
not more then five hundred dollars($500). NEW RESIDENTIAL ELECTR S .Pf. II
❑ I,asowneroftheprop ay,ormyemployceswith wages astheirsolecommemimn, _SQ.FT. RI PE CONSTRUCTION
d3— will do the work,and the combine is not intended or offered for sale(See.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of TE .—
propmywhobuildsorimproves thereon,and whoderx such workhmeaelforthroughhis - OCC.GROUP RES.UNITS
ownemployees,provided thatsuchimpfnvements arenotintendedoroff reed forsale.If,
however,the buildingor improvement is sold within one year ofcompletiem,theowner- TOTAL: -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthepmpent ,=exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE 'V Q
License Law does not apply to sn owner of,imperty w ho bei it ds or improves thereon,and
who contracts for inch projects with a contractors)lioensed pursuant to the Contractors
License Law: ALTER-GRAIN&VENT-WATPR(BA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES-
- SANITARY YN
Owner Date IPT'
DRAINS-FLOORROOFAREACONDRECENT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN—
I
JrP� IheH,y affirm that l have a certificate of consent m self-insure,or a certificate of W)CfURES_pF.R TRAP PARK FEE RECEIPT# N
Workers'Compensation Insurance ora certified copy thereof(Sce.3800.Lab C.)which RECEIPT#
ars ell em sy'yu r«hn� GAS-EA.SYSTEM-I INC.4 OUTLETS - BUILDING DIVISION FEES
Policy hy
Compan^ L'CP, AL2 GAS-EA.SYSTEM-OVER4(EA) PLANCIIECK FEE
❑ Caddied copy is hereby famished.
f�Certified copy is filed with the city inspection division. GREASEANUUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less) >
Icertify that in the performance ofthe work for which this .it is issued,l shall WATER HEATER W/VENT/ELECTR 5y
not employ any person in any manner so as to become subject to the Workers' PAID
Compeneationlawsof Califomia. Date WATER SYSTEMiTREATING Date -Receipt#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
become subject to the Worker's Compensation previsions of the Labor Code,you mast BUILDING FEF.
�i , forthwith comply with such provisions or this permit shall be deemed invoked.
;7 CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affimr that there is a construction lending agency for the performance of
U O the work for which this Permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name
Lender's AddressQTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have read this application and state that He above Information is MECHANICAL FEE
correct.Iagree to comply with all city end county ordinances and state laws relating to PERMIT ISSUANCE
U) buildingeonstaction,uadhereby authmiz<retativesofthis city to enter the
U �2 presenr upon -proCONSTRUCf10NTAX
HHHL above-mentioned perty for inspection purposes. ALTER OR AOD TO MECH.
(We)agree nt save,indemnify and keep harmless the City of Cupertino against
liebilibies,jodgmenms,costs endexpenses which may in any way eccruaageimtsaid City AIR HANDLING UNIT(TO I0,000 CFM)
in consequence or the granting of this Permit. ��1
K , ` �_ V AIR HANDLING UNIT(OVER IQIXN)CFM)
ppll? i�i�lln
Signature of Appli nt/Condactor - pate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) AL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)P
❑Yes /,,..///No VENTILATION PAN(SINGER REBID)
BOILER-COMP QHP OR Halt BTU) /IqSSUAI�,CF}j1ATE
Will the epplicantmrfumrebuildingocwpant useeyuipmrnturdeviceawM1ichemit P NW 1 �J
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? EI Yes, ax 21993
YNo NEW RESIDENTIAL MECH. SQ.FT. APR
1 have read the havardous materials requirements under Chapter 6.95 of the r R u
Califomia Health&Safety Code,Sections 25505,25533 and 25534, I immix and that I I
ifthe building does nm currently have a tenant,that it is my responsibility to notify the Guy Ur (iVHa
'occupant of the requirements which must be met prior to issuance of a Certificate of
`cupancy.
Ownermictutmlzedagem Date TOTAL: ISSUEDBY:—y��/— .
OFFICE