28024 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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I CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAT[ON SUBMITTAL DATE
� `� UNIT# LOT# �.���
OW E S N /` P � CONT CTOR'S NAM • LIC NO:
v �� N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
��OtVTACT: PHONE: QTY. ELECTRIC PEItM1T �E BLTILDING PERMIT INFO
D ELECT PLUMB MECH
PERMIT ISSUANCE ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-RESIDENTIAL JOB DESCRIPTION
Q p,,.z; I hereby affirtn that[am licensed under provisions of Chapter 9(commencing with
W O O i Scction 7000)uf Division 3 of the Business and Professions Code,and my license is in ppNELS
�v F I full force and e(fecL ���
�z� License Claes Lic.# UP TO 200 AMPS
v�a'�I, Date Contractor 201-1000 AMPS
F�z i ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $,/SQ.FT.
���0 1 understand my plans shall be used as public records.
E=.�F"'j SIGNS ELECTRICAL
Q �� Licensed Yrofessional
��W U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X�f1.� I hereby affirtn that I am exempt from the Con[ractor's License Law for the
W 3�v� following reasoa(Sect�on 7031.5,Business and Professions Code:Any city or county T'EMP.MET'ER OR POLE INST.
F'u"�� which requires a permit to cons[mct,alter,improve,demolish,or repair any shvcture
�W}� prior[o its issuance,also requires the applicant for such permit to file a signed statement pOWER DEVICES
�y fx¢0 tha[he is licensed pursuant to the provisions of Ihe ConVactor's License Law(Chap[er
�0.0� 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) S W IMMING POOL ELECTRIC VALUATION
W�� or that he is exemp�therefrom and[he basis for[he alleged exemption.Any viola[ion of
F.z'T�I Section 703 L5 by any applicant for a pertnit subjects Ihe applicant to a civil penalty of DUTLETS-SWITCHES-FIXTURES
��Q�not more than five hundmd dollars($500). ,
�E.. NEW RESIDENTIAL ELECTR SQ.FT.
p ❑ I,xsowneroftheproperty,ormyemployeeswithwagesastheirsolecompensation, STORIES TYPECONSTRUCTION
pW„,3°_,° will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
�and Professions Code:The Convacto's License Law dces not apply[o an owner of
�property who builds or improves[her n, nd who dces such work himself or through his
ownemployees,providedthatsuc mpro entsarenotintendedorofferedforsale.lf, OCCGROUP RES.UNITS
however,the building or impro ment is sol wi[hm one year of comple[ion,[he owner- TOTAL:
builder will have the burde proving that h did no[build or improve for purpose of
saleJ.
❑ I,as owner e property,am exclusively c ntracting with licensed convactors[o QTY• PLUMBING PERMIT FEE FLOOD ZONE APN
construct t roject(Sec.7044,Business and ofessions Code:)The Contractor's
Liccn aw does not appty to an ownerof property ho builds or improves Ihereon,and PERMIT ISSUANCE
wh ontracts for such projects with a contractor(s)'censed pursuant to the Contractor's
C ense Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
I am exempt unde Sec. ,B&P C for th�s reason BACK F1.OW PROTECT.DEVICE OUTSIDE FEES
I SANITARY Y N
RECEIPT#
�O er O MPENSATION DE L DATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
I
❑ ereby .ve a cemficate of consent elf-insure,or a certificate of RECEIPT
Worker'C n nsurance or a cemfied copy ereof(Sec.3800,Lab C.)which �XTURES-PER TRAP pARK FEE Y N
Icuvers al emp 's nder th�s permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEI #
Policy# BUILDING DIVISI
�Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
l ❑ Certi ed copy is hereby furnished
i ❑ Certi d copy is filed with the ty inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CF.RTIFICAT F EXEMPTION FROM WORKERS' GREASE TRAP I SOILS FEE
Ii C PENSATION INSURANCF,
I (This s tion need t be completed if the permit is for one hundred dollars($100) SEWER-SAN[TARY-STORM EA.200FT. ENERGY FEE
�'I nrlesn.)
i I cemfy t at i he performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
�not employ an rson in any manner so as [o become subjec[to the Workers' pp�p
Z Compensation Laws of Califomia. Date WATER SYSTEM/I'REATING a eceipt#
Applicant
O � NOT[CE TO APPLICANT:If,after makin this Certificate of Exem tion, ou should NEW RESIDENTIAL PLMB. SQ.FI'.
Z rr B P Y TOTAL:
� C/� I become sub�ect to the Worker's Compensation provisions of[he Labor Code,you must
�""' Corthw�th comply with such provisions or this peRnit shall be deemed rewked. BUIL E ��
�. ;
aQ I CONSTRUCTION LENDING AGENCY � SEISMIC FEE
� z 'i I hereby affirm that[here is a consVUC[ion lending agency for[he performance of
U the work for which th�s permit is issued(Sec.3097,Civ.C.) TOT ELECTRIC FEE
� � I Lender's Name PLUMBING FEE
O U , Lender's Address QTY. MECHANIC ERMIT F$E
I certify that I have read[h�s apphca[ion and state tha[the above infortnation is
Fa �'�wrreci. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUAN i MECHANICAL FEE
� � buildmg construction,and hereby authorize representatives of this city to enter upon the CONSTRUCT[ON TA
V z ��, abuve-menuoned propeny for inspection purposes. ALTER OR ADD E � �' �
""� �� (We)agree[o save,indemnify and keep harmless the City of Cupertino against
'liabilities,judgme costsandexpenses hmayinanywayaccruea ' stsaidCity AIRHANDLINGUNIT(TO]0,
' in c nleyue the [ing of t'�I//�/'/""_ •
�� AIR HANDLING UNIT(OVER]0,000 CFM)
g r f Appl�canUCo ac[or � �� EXHAUST HOOD(W/DUCT)
PAID
�, HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
' Will the applican[or future building ocwpant store or handle hazardous ma[erial
as deFined by the Cupertmo Mumc�pal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) �
'Code,Section 2553?(a)? VENTILAT[ON FAN(SINGLE RESID)
❑Yes ❑No
ISSUAN D E
Willtheapplicantorfuturebuildingoccupantuseequipmentordeviceswhichemit BOILER-COMP(3HPOR100,OOOBTU)
hazardous a�r contaminants as defined by the Bay Area Air Quality Management gOILER-COMP(OVER]00,000 BTU) F p',
DititriCt? .
❑Yeti ❑No NEW RESIDENTIAL MECH. SQ.FT.
i [have read the hazardous materiais requvements under Chapter 6.95 of the 1�C,,�1' �,i?
I Cahfomia Health&Safery Code,Sections 25505,25533 and 25534.I understand that � ����
�if�he building does not curtently have a tenant,that it is my respons�bility[o notify[he i �
i occupant of the requiremen[a which mus[be met prior to issuance of a Cert�fica[e of - ,
i Occupancy. �``.��_' - +
� 7 j�/n
Owner or authorized agent Date TOTAL: ISSUED BY: i ri r �
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OFFI���