26780 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDIN -ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL O O
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION o
BUILDING ADDRESS: SANITARY NO. APPLICATIONSIfBMITTALDATE
19 S � UNIT LOT It
OWN' N M PHONE: CONTBpCIOR�SNgME:
S$XYf'//'SJp NACONTROLp
�ARCTECT/ENGINEER: LIC NO: Ya /C El
HI
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT P UMB XPERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p p.Z I hembyaffirmshat lam licemseduaderprovislonsof Chapter9(wmmeneingwida
[ 00 Section 7")of Division 3 of me Business and Professions Code,and my license is in PANELS a�/1-���/�/y±�s�^JAS_ .T
ttp zw full force and effect. /�-L X17`7 C UP TO 200 AMPS l \ \`��� T •1` \�E
H'y Commnor 201-1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
z ARCHITECTS DECLARATION OVER 1000 AMPS
OZ-0 l understand my,laas shall be used as public records.
Q .,
W SIGNS ELECTRICAL
Licensed Professional
Lq i OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Lto
�•
X O a V I hereby affirm that I an exempt firm the Conaai License Law for the
u13 tr.y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.ME OR POLE INST.
C.¢] which require'n pe71,
mit m conswn,niter,improve,demolish,m repair any swaure
T� prior to its issuance,al so requires the applicant forsuch permit to file aligned itatemear POWBR
that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter SWIM G LELECTRIC
L o�' 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) - VALUATION
or that he is exempt therefrom and the basis for alleged exemption.Any violation of UTLEB-S T IXTURES ��a t/qD AA/T Section 7031 any apps inatfmapermitsubjeetstheapPllcanuoacivh prnalty of V W�/
p not more than five hundred dollars($500). N W ENTIA EL _SQ.PT. STORIES TYPE CONSTRUCTION
❑ I,asowneroftheprrpeny,ormyemployeeswimwogesastheirsolecompensation,
awill dothewrrk,and mestructure is not mundedorrffered frrsale(Sec.7044,Business I Q fX B }
and Professions Code:The Contractor's License Law does not apply to an owner of CI /� u NVH
propenywhobuildsorimprovesthereon.and whodoessuchworkhimselforthrough his
proh - In.UNITS
wnemployees, videdlhatsuchimprovements r notimoendWofferedforsale.If, OCC.,. rh�B
however,the building or Improvement is sold within one year rfcompletion,the owner- ,p �' / ( t 11
builder will have the burden ofproving that he did not build or improve for purpose of \ -0
sale.).
❑ I,mownerof the property,am exclusivelycontraning with titansedconuanors QTY. PLUM RMIT PEE to DZO E AP
construct the project(Sec.9044,Business and Professions Code)The Contractor's I E
License Luwdoesaotapplymanownerofpmpertywhobuildsorimpmvesthemon,end PERMIT ISSUANCE
who contracts fnrsuch projects wima<ontracmt(s)IicensW porsowttothe Contractors se Law.
License
yy.pHR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l stn exempt under Sec. ,B&P C for thio rceeon BACK FLOW PROTECT.DEVICE Ol1T.ID ES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPfq
WORKMAN COMPENSATION ofoomeDECLARATION SCHOOL TAX Y N
❑ era Co afOrmthan lha cert fct f her If c If [ f RECF.IPI'#
Workers Compensation lneurwcearaI�certifiedempy Hereof(Sea3g00,LebrCJ which FIXTURES TRAP � PARK FEE YN
ersallempmy ' un - ! ^i/ 1 GAS-EA.SYSTEM-1 INC.40IITLETS RECEIPT#
Policy# y 7 l BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE d
❑ Cenifedcopyisherebyfumished.
jCertified copy is Pled with the city inspection division, GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE I _
(This section need not becrmpleted ifthe permit is fsrome hundred dollars T$100) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or least
I certify that in the performance of the work for which this permit is issued,I shall TWATER HEATER W/VF.NT/ELECTR
not employ any person in any towner so as to become subject to the Workers' PAID
Crmpensminn Lwsrf Califrmin. Date WATER SYSTEM?RENTING Date Receipt#
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLATE, SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must BUILDING FEE
fnnhwiib comply with such provisions or this permit shall he deemed revoked.
Lkl Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE O O
z I hereby affirm that there is a construction lending agency for the performance of .�q ELECTRIC FEE
the work for which this permit is issued(Sec.3097,Civ.C.)
4U Lender's Name PLUMBING FEF. ��
F Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have read this application and some that the above information is MECHANICAL.FEE
coma.Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
rF-t 1,0 building construction,andhereby amhorizerepmsentatives ofthiscity toemerupon the CONSTRUCDONTAX
L) Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
ti (We)agree to save,indemnify and keep hermless the City of Cupertino against
liabilities mincems,eostsw xpenses which may in ny way accrue against said City AIR HANDLING UNIT IT010,000
cote of t of this pemtit. .
]i AIR HANDLING UNIT(OVER 10,00 CFM)
Signatareof Applicant Comrector 0 Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) ��� One Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Coperino Municipal Code,Chapter 9.12,and me Heahh and Safety
Code,Section 25532(a)Y VENTILATION FAN(SINGLE REBID) �/�
❑Yes C3 No
ISSUANCE DATE
WilHheapplic torfmure buildingoccupwmuequipmentordevices what chemit BOILER-COMP(3HPOR 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) q
District? ❑ 11r
Yes No NEW RESIDENTIAL MECH. SQ.IT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that l`Y
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be not prior to issuance of a Certificate of
Occupancy. W ('
Owner or anthodzed agent Date T ISSUED BY:
OFFIC