26944 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO H ILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL L o J LI n C A A
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION 4
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE,
9 L A AOD /n/ UNIT# LOT#
O 919IA4F P}JflN�: CO 'S MF.: ��
01�C� PL 104 NIC CONTROL#
ARCHHLCUENGINEER: LIC NO: A _
'ONTACT: PHONE: QTY ELECTRIC PERMIT l/. EEE BUILDMG PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El X 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
nzz I hereby am that l am licensed underpvixtras of Chapter9(commenciagwi,h
affirm m
WO0 Section 700SEof Division 3utlhe Basins d Professions Code,and my,license is in PANELS
FFW1'1--". fiill force and a fhrjyiTt-.�� Q UP TO Rt 1
Qzw licen�se Cs-las �y—Lic.# I I 1P
may DateConrac 201-10WAMPS S FT.FLOOR AREA $/SQ.FT.
700 z A CIIITECI'S DE OV17R 1UMI AMPS Q
0 z^ undccsamJ my Alma,hall he used as public records.
SIGNS ELECTRICAL
Licensed Professional -
TL TLQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
K
KO W I hereby affirm that I am exempt from the Conreaors License Law for the
W3ay following reamn.(Section]0315,Business and Professions Code:Any city commty TEMP.METER OR DOLE INST.
which requires a permit to construct.alley,improve,demolish,or report any structure
is.,to Its luuancgehnrequnesthe applicant for such penoluo file.signed stammer POWER DEVICES
W z p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aXOC 9(commencing with Section T00()of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC UA ON
W or that he is exempt therefrom and the basis for the aIle ed exam r An violation f
p g pion.Any OUTLETS-SWITCHES-FIXTURES
Fz< Section than03 by hmy undred
delt,,($50nnit subjects the applicannoacivil penalty of
nm more than five hundred Dollars(5500). NEW RESIDfiAL ELEM SQ.ET. S TYPE CONSTRUCTION
5F1 ❑ 1,asownerofthepmperty,ormycmploymswithwagesastheirsolecompensation.
y3:L will do thework.and the structure is not intended oroffred foreelC(See 74 ,Business
and POa,,ions Cale:The Conractors License Law does not apply,o an owner of
propertywhobuildsor improves themon.and whod«ssuchwork himselforthrough his
mlo ddthatsuch int I t t dedorotfrred forsale.If. C.GRO RES.UNITS
e p y«he uildinie pis soldnhinne in en
however,illhave the burden ofproving that
he within or improve for the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpnx of
ale.).
❑ I,as orwncnrf the pmpecty,um exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the police,(Sec.704q Business and Professions Code:)The Contractor's \ pERMI'T ISSUANCE
Licensd.aw does notapply loan awnerofproperty who halldzorlmprovesmartion,and 1
who contracts for such projm¢with a contractor(s)licensed pursuanuo the Contractors
License Lots, AL'1'17R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE;FEES
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX YN
❑ I hereby affirm that l have a cerloicale ofemsen,to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
Warkers'Compensaio.lnsumaeema certified copy lhereof(Sec.3800,Lab CJ which 101 PARK FEE Y N
mor"illlem Imo+ de RECEIPT'#
Policy#If /� /'I�y'� GAS-FA.SYSTEM-I INC.40UTLETS BUILDING DIVISION FEES
Compete �`��T+� a GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Catifa,17 yishereby amismil.
6 Certified copy is filed with the city inspection division. ORGSRRNDUSTRL WASTE INTERCEPTOR GRADING EEE
/� CERTIFICATE OF EXLNPIION FROM WORKERS' GREASGTRAP SOILS FES
COMPENSATION INSURANCE
(This section need not be completed iftbe permit is fortune hundred do&[.(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FLIT
Or lits.)
I rectify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECIR
no,employ any person in any manner so as to become subka to the Workers PAID
Cuntimosioal.awsof Califomla. Dae WATER SYSTEM/TREATING Date Receipt#
0 z Applimm
z C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESI DENTIAL PLMB. SQ.FT. TOTAL:
D,) become subject to the Workers Compensation provisions of the Labor Cade,you most
F' > forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
W� Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aflinn that,he,.is a sueructimn lending agency for the performance of
1..) 0 the work tar which Ili rlwrmit it i,—c! Sce.3097,Civ.C.) O ELECTRIC EEIi
Lender's Name
u-' F Lenders Adorer, QTY. MECHANICAL PERMIT FEE PLUMBING PEE
0 U 1 eerily that 1 have rcud This aptlitmion and sale that the above informaina is M17CEIANICAL EEE
>" W correct.l agree to comply with all city rand county ordinances and state laws relining to PERMIT ISSUANCE
F-' D'5 buildingeonsruction.and hereby authorize representatives ofthiscily memerapon the CONSTRUCTION TAX
U z abwc-mentite ed popery far inspection purposes ALTER OR ADD TO MECIL
(We)agree m sav indemnify and k«p harmless,he City of Cupertino against
Iimahim,lidgyrn t its nndexpenux which may in.ny way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
onsequence tin ofthi"Ouni,.
t AIR HANDLING UNIT(OVER IO.OW CPM)
S' ameof Appimyy/C, tractor Date EXHAUS'PHOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Doc Receipt#
W 111 the applicant m fuwre building ox—pant core of haMle havrdbus metrial
as HEATING UNIT(OVER 100000 BTU) TOT
defined and and ,
by,he Cupertino Municipal Code.Chapter 9.12, ,he Health Safety
CWc,S«u 25532(ep
El Y5 ❑No
VENTILATION FAN(SINGLE RESID)
❑
Will the applicumorf umm builJingo<cupwmse equipmenrordevices whichemit
BOILER-COMP CHP OR I OOA00 BTU) ISSUANCE DATE
�hmmdaus air contaminants as ddined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
DisWc!! n
11 Ya, 11 No NEW RESIDENTIAL MECH. SQ.FT, Q A 9 ID
I have rcud the a robot nmterimis requimments under CM1ap,m 6.95 of the
California l lcxhb&S Ery Code,Sections 25505,255JJ and 25534. 1understund that AUG p O
i1a, Anes tcurently have nl«anl,lha,it is my responsibillrymnodfy the J 19Q4
«up t of n remeal which must be met poor to issuance of n i ilicate Of k#
reap
Q yr UL-' :r - . .J
w olizedagent - D' e TOTAL: ISSUED BY:
OFFICE