27230 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL n O
BUBANG PROJECT IDER'1'IFICA'1L
N'
'IO
BUIIAINGADDRISS: SANITARY NO. APPLICATIONSUBMITT'ALDA'R
OUNIT# LOT H ^/
OWN NA E: PHO CONTRACTORS NAME: LIC NO: (J
D �J NIC CONTROL#
Wet .1 ..ffN(jNF,E L C 0 ADDRESS: ❑ �
f
CONTACT: f4A.N1: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
SLUG ELECT P� MECH
� — PERMIT ISSUANCE �IC�J\
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
C=Z I harebyaffirm Nal lam licensed underprovisionsof Chapter!)bommencingwith
❑l00❑ Section?Wx))of Division 3ofthe Business end Professions Cad,,endurylicenceisin PANELS
F�tBE LUIIIns Clas
U 'UPT021NIAMPS
IrJW�
License Class Ccuin
y6co Uide Conmuaor 201-lqp AMT'S
1 ,Z ARCI II TIiC'I'S DECLARATION 'SV PI'.h1,00R REA $/SQ.IT.
ZOtA� IunJcrsmnd my plans shall he used as public rccnrds. OVER IIXtO AMPS
OZ—q 1 Q2� /N'I11
CZF� SIGNS ELECTRICAL ` lJ ��JJ
Qy�J Licensed Profcsimad
.56,56 OWNER-BUILDER DECLARATION SPECIAL CIRCUFOMISC. , •nn, �y \/�
KOi V I thereby off than I am exempt Tran the Cmumustars Licemsc Law far the
m36y following reason.Section 7031.5,Business and Professions Code:Any city in county TEMP.METER OR POLE INST.�
which¢quires a .it,.consnua,alcor,improve,demolish,or repair any suueture
E14Y7m its issuance,also the applicant for such oro file a signedstatement POWER DEVICES
prior 9 pp Permit
,9Q0 Ihm he is licensed pursuant lathe provisions of the Contractor's License Low(Chapter
660 4SWIMMING POOL ELECTRIC VALUATION
(coimnendng with Section 7000)of Dl scorn,3 of the Business and Professions Cade)
W,"^_y or than be is exempt thercfromand the husis f..the aIleged exemption.Airy violminnof / �y /i _/1
tKG Section]031.5 by any applicant fora Terni,suhleculhe applicanrro a civllparaiyof OU'TLET'S-SWIT'ClIES-FIXTURES /`wJ`-'T1 tIG-1/v1Ia1T0
not n Lie,oan BvehundreddollarmycinB.' NEW RCSIDFNDAL ELECTR —SQ.K�o ❑ I,asnwnerof the propcny,ormynnployamwilM1 wages as thcinnlen,mpensmion Q ti'1'ORIES TYPiz CONS'IRUCI'ION
t a3c0 will do the work,and the structure is not intended or offered for sale Sec.70,14,Business
and professions Code:The Contractor's License Law does not apply to an owner of
progeny who builds or improves thereon,and who does such work himmlfor through his
own employees,pmvidedthatsuchimprovementsarenot intendscoroffered muscle.If, OCC,GROUP RES.UNITS
however,the buildingm improvement is sold within oneyearof completion,theownef- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
vale.). QTY. PLUMBING PERMIT -FEE FLOOD ZONE APN
C] I,av nwnerofthe propene em exclusively connecting with licensed contracmmm
Lmsmicl the project(Sec.7044,Business and professions Code:)The Contractor's
ieanc Law does not apply to an owncrofProperiy whohmidx or improves tberam,nnd PERMIT ISSUANCE
whocontrois lbrsucb pmjcclswithaconlmaorfs)Ilcunsed pursuua m lbs Connuam''e AL'ITR-DRAIN&VENT-WATERR(EA) PEE SUMMARY
License Law.
❑ 1 an exempt under Scc. .B&P C for This rcmoa HACK FLOW PROTECT.DEVICE OUTSIDE FEL
SANITARY YN
Owner Date RECEIFF#
WORKAN COMPENSATION DECLARDRAINS-FLOOR,ROOF.AREA,COND.ATION SCHOOLTAX N
I❑ Ihetebyaff Ibatlh1heveacenir.. of conxnuo self-insure.oracenificam of FUCLURES-PERTRAP ECEIPTN
Worker Cnmpenvation Insurance m.method copy thereof(See.3800.Lab C.)which PARK IEE: N
n all cmpluyee's under this Tenni,. GAS-EA.SYSTEM-I INC.4 OUTLETS .CEIPf N
Policy# B 1, G DI ION FEES
Company GAS-I3A.SYS'T'EM OVER 4 EA) PI. I:'K I,
❑ Ccamedcopyishumbyfumishcd.
❑ CaniliaJ copy is EleA wish the city inspection Jivisinn. GREASE/INDUS'IRI,WASTE INTERCEPTOR OR I GI
CERTIFCATE OF EXEMPTION I7ROM WORKERS' GREASETRAP SOILSI
COMPENSATION INSURANCE
(-hi,.chonnccd.m be completed ifthe Permit is(crone hundred unions(1100) SEWER-SANITARY-STORM EA.200FI'. ENERGY FEB
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any Person in any manner or as to become subject to the Workers' PAID
Cumpensation Lawsof Califomia. Dae WATER SYSTEM/1RFATING Data Receipt#
Z Applicant
Z 2 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RES]DENTIAL PLMB. SQ,IT. TOTAL;
�+ Ln become xubjee,to the Worker's Compensation provisions of the Labor Code,you muss BUILDING FEE
7 Bmbwil h comply with such previ shoos or this permit shall be deemed revoked
QCONST RUCTION LINDI NO AGENCY SEISMIC FT �+
UQ. 1 hereby affirm that there is a conswmion lending agency for the performance of
O tTOTAL: ELF.CTR "tLemdern Name PLO FEE
lander'¢Address QTY. MECHANICAL PERV I cenify that I have read this application and state that ate above information is MECI LVJ cormn.lugreemcomply with ell city and county ordinances and state lows rclmingm PERMIT ISSUANCE
naaamgennxwm �.anerey aaammpr�eaveaoayenpZafosioototioned progeny for inspection purposes. ALTER OR ADDTO MECII. CONSTRUCTI TAX
Wc)u gree 0 y of Cu ino ugninB liuhillles.' I , sy in any wayaccmcagaint said City AIR HANDLING UNIT ITO 10,M)c tll nits writ
AIR HANDLING UNI'1'(OVF'R It.INNCFM)
Signmurc an rumor Date EXHAUST HOOD(W/DUCfI PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Recei #
Will the applicant or form,building occupant sons,or haedle hrrarims material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Cale,Section 25532(m? VFMILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Willthcapplicam orfmurchuildingacupamuseeyuipm,m ordeviccswhichemil BOILER-COMP(311P OR I(p.0IX1 BTU)
a ,v air contaminants as defined by the Bay Area Air Qu:dity Management BOILER-COMP(OVER I00,0J0 BTU)
�hnr7iv nlouhent q /p
Cl Yes ❑No NEW RGSIUtiNTIAL MECII SQ.PI'. AATT
1 have mad,tic fa,y Coo.materials requirements under Chapter erste of the //��a/a11 s(8 S
Celifn have
miss the
requ.ements under hapten 6.95 of
1 O
if the building does not currently have a taaant that it is my nesporixibildy m naify the C� y C/r�. 9 ,
occupant of the requirements which must o met prior m issuance of a Certificate of ti
Occupancy. //
Owner or autborie,d agent Use TOTAL: ISSUED BY:
OFFICE