26804 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECT RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL IO _ 2 6 8 0 4
BUILDING DIVISION BUILDING PROJECT IDENTIFICATN
BUILDING-ADDRESS SANITARY NO. APPLICA'GONSUBMMALDATE
/O NAIV UNIT# LOT# rte){/(
ERSNAME; a PHONE: CO RAQOR' NAME: LIC NO: vV
T N/C CONTROL#
CHI'1'ECT/ENGINEER: LIC NO: ADD /� ��
O C /R a
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ron Ih70M)ereby ffir vision amlicensed inssand monsofC Csh,9nd(commencing with /r J pDFj�y�J
00 SerxioncmdefDlvision3of the Business end PrwGrselons Coda,and myllowse is in PANELS
K� full force and effect. �f
FZUZ,,Iy License Cl s Lie.as UP TO 200AMPS L` / D �T/✓Y 'r
vi Q=y Date Contractor As 201-1000 AMPS
zOyZ ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O z 1I•....•❑ I understand my plans shall be used as public records.
�L C w SIGNS ELECTRICAL
y4$ p�lj Licensed Professional
OaOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xF I hereby affirm that 1 am exempt from the Contemtor'I License Law for the
m 3Om following reason.(Section]031 5,Business end Professions Code:Any city or county TEMP.METER OR POLE INST.
o,J which requires a permit to construct,alto,improve,demolish,or repair any structure
primmns issuance also requites the applicant for each permit fileasigned statement POWER DEV ICES
tiOOthat he is licensed promo ed b the provisions of the Contractor's License Law(Chapter -
o�' 9(commencing with Section 70(1 Division 3 ofthe Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
E, ordeal he is exemptrberefrom and the basis for the ellegW exemption.Any emla[ionwf d�
G Sermon]031.5 by anyepplicemfor ePermit suM1jwttNn
eepplicanoacivilpenaltyof OUTLETS-SWITCHES-FIXTURES 12—CCP
mora than five hundred dollars($500). I
Q ❑ I,asowneroftheproperty,ormyemployeeswithwagesastheirsolecompensation, NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCTION
B:L willdo the work,anA the structure isnot intendeAoroffered for sale(Sec91144,Business
and Professions Code:The Contmctur's License Law does aot apply to an owner of
property who buildsorimprovestherson,andwhodcessuchwark hiriselforthroughhis 11
ownemployces,providedthat such improvementim,not imeadederoffered hassle.If, OCC.GROUP RES.UNITS
however,the building orimprovemeat is sold within one yearofenmplanom theowner-
builder will have the burden of proving that he did not build or improve far purpose of TOTAL:
sale).
❑ I,as ownmofthe property,amexclusively contracting with licensed contractors to QTYPLUMBINGPERMIT FEE' FLOOD ZONE
APN
License the asjnot ,plySaaoma Business and Professions Code)The Coatrmtor'e
License Lawdoesnh Pplybamwnerofpbpenywhnsedcsorim,brims thereon,and PERMIT ISSUANCE
License Law.
forsuch projects with a<ontractor(s)licensed pursuam tothe Contractor's
License Lew. ALTER-DRAIN&VENT-WATE (EA Ul !� $U MARY
❑ I em exempt under Sec. ,B ffi P C for this reason BACK ROW PROTECT.DEVICE SID ES
Owner TAY I Y_N
Date DRAINS-FLOOR.ROOF,AREA, OND. RE F.IPT#
• c WORKMAN COMPENSATION DECLARATION .T Y N
❑ ers Co pensati nInsurance craveri a consemereof(Sec.38,o,Lab C.)which FIXTURES-PER TRAP RE EIPfp
Workers Compensation neer this ormawrtifled copy thwwf(S<e.3800,Lab C.)which Y N
rs all empinyede under this Formal. GAS-EA.SYSTEM- INC.4OUTLETS
CCEIPT#
Policy# FEES
Company
BUILDING DIVISION any
❑ Certifed copy is hereby fumiehed. FEGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK E
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASH INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE -
(This semionneed not ba completed ifthe permit is forone hundreddollers(SIM) SEWER-SANITARY-STORM EA.200FT, ENERGY FEE
wriest.)
I certify that in the performance ofthe work for which this ermitisissocd,Ishall WATER HEATER W/VENOELECIR
m employ perso a any manger so est oma 0'p t the Workers PAID
z Compens on aws of lifomia. WATER SYSTEM(IREATING Date Receipt#
Q O NOTIAppliCE
NOTICE TO P}}�� (CANT:If ter 1 g this Cenificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
U) become subjef#'fo the Worker On y tion pbviskmi of the Labor Code,you must
a forthwith cw ply with such provisions or this permit shall be deemed revoked. BUILDING FEE
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) z I hereby affirm that there is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lendw's Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
Lkl I certify that 1 have read this application and stare that the above information is
4 correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
co� building construction,and hereby authorise representatives of Nis city b entempon the
V above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTIONTAX
(WeLmiasaAq save,indemnify and keep harmless the City of Cupertino against
liablll' ,judgmwt molmdaxpar, hichcrt ay ecmasagainstseld City AIR HANDLING UNIT G`0 10,000 CFM)
in sequence of th dog of W' permit.
7I
AIR HANDLING UNIT(OVER 10,00)CFM)
APPI moCipa mor pa EXHAUST HOOD(W/DUCTJ
PAID
HAZARDOUS MTERIALS DISCLOSURE HE.ATINGUNIT(TO 100,000 BTU) Date equ
Will the applicant wr,Munbuilding oe,Chap store or handle hazardous materiel
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T :
Codd,Seadom25532(x)7 _
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP JHP OR 100,000 BTU) ISSUANCE DATE
Will theappllcantor is res refineg by he Bay Are.Aenmrdevi Morroichemit nn qq `
hazardous air cnntnminants as defined by the Bey Area Air Quality Managemem BOILER-COMP(OVER b01,000 BTU) P p ! D
•
District?
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.FT. JUL 281gg4
1 have reed the hazardous materials requirements under Chapter 6.95 of the
California Basin&Safety Code,Sections 25505,25533 and 25534. I understand Nat
if the building does not currently have a team,,that it is my responsibility to notify the
occupenl of the requirements which most be met prior to issuance of a Certifwte of CITY OF CU tl
Occupancy. -
Owner or mumme d agent Dam TOTAL: ISSUED BY:
0FFIC