26786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMIT NO. ff
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL Z 6 T 8 t
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
!� C UNIT# LOT# 0 et
IOC S NAME: PH E: CONTRACTOR'S N ME: LIC NO: LW •rte••�7
N/C CONTROL#
2CHITECT/ENG NEER: LIC NO: ADDS: /
CONTACT: PHONE: QTY-1 ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLECI ELECT PLUMB MECH
PERMIT ISSUANCE I 1:1 ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
C ]OB DESCRIPTION0.Z I hereby affirm that I am licensed under provisions of Chapter 9(commencing with w
L`1 OO Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS /•_
F W FJll force and IT V
0.Ci U —� �(, UP TO 200 AMPS
Z yicense Class Lte.#
rn¢a. ate `' Contractor. W/7 20I-1000 AMPS
=rn SQ.FT.FLOOR AREA $/SQ.FT.
F-"Z ARCHITECTS DEC ARATION OVER 1000 AMPS
Z O rn— I understand my plans shall be used as public records.
Cz—o
SIGNS ELECTRICAL
F�F,wj
Licensed Professional
C C;z Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO a U I hereby affirm that I am exempt from the Contractor's License Law for the
6"'n following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
O< which requires a permit to construct,alter,improve,demolish,or repair any structure
CA-J POWER DEV ICES
y} prior to its issuance,also requires the applicant for such permit to file a signed statement
Op that he is licensed pursuant to the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
0.6. 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F..Z Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
5�—< not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT.
c49-- ❑ I,as ownerofthe property,ormy employees with wages as their sole compensation.
Q STORIES TYPECONSTRL`CTIO
4 300 will do the work,and the structure isnot intended or offered for sale(Sec.7044,Business ITOTAL:
and Professions Code:The Contractor's License Law does not apply to an owner of "' nr
property who builds or improves[hereon,and who does suchworkhimselforthroughhis �� O6GGR0 �2ES.UAIIT$
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or improve for purpose ofsale.). PLUMBING PERMIFEE
QTY - I� �O ZO E APN
❑ [,as owner of the property,am exclusively contracting with licensed contractors tork 79
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE __
Lj
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's ALTER-DRAIN&VENT-WATER(EA) I FEE SUMMARY
License Law.
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
L1I hereby affirm that I have a certificate of consent to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
PARK
Workers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which FEE Y N
RECEIPT#
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) I PLANCHECK FEE
❑ Certified copy is hereby fumished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOUS FEE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that 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' PAID
Compensation Laws of Califomia. Date WATER SYSTEMfrREATING Date Receipt#
OZ Applicant
P NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. I TOTAL:
cnbecome subject to the Workers Compensation provisions of the Labor Code,you must
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
4 [� (04
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name MECHANICAL PERMIT FEE PLUMBING FEE
OF" Lender's Address QTY- -
U
I certify that I have read this application and state that the above information is MECHANICAL FEE
>. correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F" Cn building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any;a a against said City AIR HANDLING UNIT(TO 10,000 CFM)
in con uence n ting o permit.10001'
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature ph ant/ on r Date EXHAUST HOOD(W/DUCT) I PAID
H DOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Recerp[#
Will the applic• or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices which emit BOILER-COMP(3HP OR 100,000 BTU)
r
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? ®
❑Yes ❑No NEW RESIDENTIAL METH. SQ.FT. Jy���jj
I have read the hazardous materials requirements under Chapter 6.95 of the i9194
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the budding does not currently have a tenant,that it is my responsibility to notify the -
rtrr
occupant of the requirements which must be met prior to issuance of a Certificate of /�u
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE