26903 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -ELECTRICAL PERMIT NO.
CAL
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING Ilii -MF:CHATIFICA 26903
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITALDATE
f
^_UNIT# LOT#
OWNERS AMR; F PIIONB: CO RA R'S NAM A LIC 0: N/C CONTROLp J
�� !
ARCIIITF.C'f/ENG Elili: CNG: ADDRESS: A ❑
CONTACT: PHONE: �' I I
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT 13130
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPI'ON
pmly I hereby affirmthal l em licensed underprovisionsofChmun9(mineencingwife
1400 Section 700fmf Division 3 of the Business and Professions Code,and my license is in PANELS
�W full flad effeN�
F;ZW License...Class_s„]C� I.ic.p UP T0200AMP5
mDy Dam Cont r 201-IOWAMPS
Z O.zm,'3q HITS SDEk6ATIO1 OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ—qWty tante ub'
G��3 Lie dPr SIGNS ELECTRICAL
WG WNER-BUIhDER DECLARATION SPECIAL CIRCUIT/MISC.
EMU
aW.V mrcby that I am exempt from Ne Contractor's License Law for the
following rcason.(Section 7031.5,Business and Professions Code:Any city or mumy TEMP.METER OR POLE INST.
which requires a permit to contuse,alter,improve,demolish,or repair my muctum
tYj2Q� pron
ioitsiss...ce,also ulre
reqrtheepplicmt frmanth permit to fileasmt
igneci ement POWER DEVICES
W(1 0 that he is licensed Panama India provisions of the Contractor's License Law(Chapter
a p�' 9(commencing with Section 7")of Division 3 offal Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
' mow or that he sexempt therefrom and the basis for be alleged exemption.Any violation of
t y< Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
W mnot more than Eve handled dollars($5(0). NEW RESIDENTIAL ELECIR $ .FT.
❑ I,as owner offer property,ormyemployms with wages m theirsole comsamom. n, Q STORIES TYPECONSTRUCTION
a will do de work,md feommeure isnot imendedof0ffered fmiale(Sce.7044,Busin
.ad Profess ns Code:The Contractors License Law does not apply he an owner of
properly who builds orimproves Barron,and whodoes such work himselfomhmugh his OCC.GROUP RES.0 ITS
own empfoyees,pmvided that such improvements menmintendedoroffiami formle.If,
however,the built ingor improvement is sold within oneycarefcompletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ 1,mownerofthe propeny,umexciliuvely contracting with licensed contractors to QTY, PLUMBING PERMIT FEE FLOODZ NL APN
construct fee project(Sec.7094,Business and Profession,Code:)The Contractor',
License lawdcesnot epplyto mnwrherofproperry whmbuildam improvufeertrn,md PERMIT ISSUANCE
whocontmeta formula prejamwife.cadmousr(s)licensed punuanuofee Contractors AI:IFR-DRAIN@VENT-WATER(RA)License I., ALTER SUMMARY
❑ I am excmin under Sec. ,B @ P C for this ream. BACK F10W PROTECT.DEVICE D'
SANITARY Y N_
s Owner Da¢ AINS-FLOOR,ROOF,AREA,C11 RECEIPT#
WORKMAN COMPENSATION DF,CLARATION SCHOOL TAX Y N
❑ Ihercby effim thmlhuveecertificem of cmneenno sal Gimurc,nrncenifi 00f RECEIPT#
Worken'Compe aillum[asumnce or ac.nified copy thereof(Sec.7MW,Lnb . which FIR URPS-PER TRAP PARK FEE Y N
coven all employed gyp r s it GAS EA.SYSTEM-I INC.40U'fLETS RECEIPT#
Pali �•i BUILDING DIVISION FEES
Company GAS I EA.SYSTEM-OVER 4(EA
) PLANCHECK FEE
❑ CeNfial copyn rc y 'aanlr
f�CertifiW copy is fled ilh laeciryimparmn division. OR SPJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFItnmy
OP EXEMPTION FROM WORKERS' GR SCTRAP SOILS FEF.
PENSATION INSURANCE
(Thissectlonneedompleted Him permit is formate hundred dollars T$10(1) SE ER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I amifythat in Ne announce of the work for which this permit is issued.I shift ATER HF":'/VENT/ELECIR
not employ my person summer so as to become subject the Workers PAID
Z Compensationlawsofie. Dale WATER SYS'IEM/1'REATING Dem Rccciptp
zOAOTICEl
NOTICE act altIC :IL after making Ois Catfica of ..You should fiW RESIDP.NTIAL PLMB. SQ.FT. TOTAL:
Vu biome subjatmfecW heM1 Coope rim provi' nso bur Code,you mu
ai ; forfewife comply wife ¢h provisions th' ad. reCv,oY#�J! BUILDING FEE
NS7RU I DINGA \�/ SEISMIC FEE
Uz (hereby atfirm at them ince sat on lrntlinli my so a rfomanc� TOTAL: ELECTRIC PEG
0 the work for which lM1' permit is issued( 3W7.Civ.C:)
Isx Lender's Nnme
Lender's Address / QTY. MECHANICAL PERMIT F13E PLUMBING FEE �^
I vanity that I ave mad his application and sante that the above igfoimatm is
4
correct. Iegree to ply with all city mdcoua ordinmeu andvure laws miming to PERMIT ISSUANCE
MECHANICAL FfiP.
building consmct al and hereby authorize repmentabsesoffeis city meteoritical fee CONSTRUCTION TAX
.brae-mentimnedpm rryforinspemionpu ALTER OR ADD TO MECH.
rte• (We)agree tesec emnify cap les, 'City of Cupntno.gainn
liabiluies,jadgment swh' as y way memeagairet said City AIRHANDLINGUNIT(TO10,OWCFM)
inconsequence s is 11
T AIR HANDLING UNIT(OVER 10,000 CFM)
Sig u n pp' ntmenr Date EXHAUSTHOOD(W/DUCT) PAID
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Data Receipt#
Will the licmt orfuture building occupant amus or handle hamrdoms materiel
as defined by the Cupertino Municipal Code,Chapter 9.12,and fee Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cale.Section 25532(.)7
13 Yes ❑No VENTILATION FAN(SINGLE RESIDE
BOILER-COMP(3IIP OR 100,000 BTU) (SSU LDgTF
m �
Will lheupplicmr(murebuildingoem
cup. use equail #�V1
ipmcmordevicwhichemtl
hemott'f lY
mrdous air cmnmrninams as defined by the Bay Arca Air Quality Management BOf1.ER-COMP(OVER 100,000,WO BTU) D�
J1
❑Yes 11 No NEW RESIDENTIAL MEC11. SQ.Ff. �2 r
1 have read fee hamNous materials requirements under Chapter 6.95 of the Cpy L! 1995
California I lealfe @ safely Code,Sections 25505,25533 and 25534.I undersmnd that f (-Lt.- `
Ifthebuildingdmsnmcm tlyhovealenanl,(hatiiismymWnsibilitywnotifyfee tlylJA—
,..Pa.[of the"ithamenm which must be at prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Data TOTAL: � ISSUED BY:
OFFIC