26803 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILD NG-ELEC I RICA[CITY OF CUPFPERMIT NO.
Buun[Nc DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDINGPROJECTIOENTIPICATION 26803
BUILDINGA II V I SANITARY NO. APPLICA NSUBMITTALDATE
22
UNIT. LOT#
O7EN
PHONE: NTRACTOR'S NAME: LIC NO: _
r
N/C CONTROI,p
ER: LICNO: A R ❑11
14
PHONE' O BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUM MF.0
PERMIT ISSUANCE �#
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ;K—
LICENSED
I hereby offirmthat l am licensed under provisionsofChapter9(commmcingwiN JOB DESCRIPTION
t400
Section](100)of Division 3.17 the Business and Proofffession,Code,and m license is in PANELS
IJcense Clad effect. Lint.. v UP T0200 AMPS � 1
rn=yData Contrecmr 291-IOW AMPS v
O Z^ RCHITECTS DECLA A 10 OVER IIXp AMPS SQ.FT.FLOOR AREA $/SQ.FT.
undersr my plea shall be us as phy 'c records./ �� I
P4 / 2s (iS SIGNS ELECTRICAL O
Lmmsed PMeeabRpf aMIVJ
ER-B exempt
bo m the Cor TION SPECIAL CIRCOIT/IWSC.
k 06 F Iherehy affirm Nat I am exempt from the DECLARATION
ore License Lew for the
W 3 Orn following reason.(Section]031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
f±1 m J which requires a permit to coastrucq altar,improve,demolish,or repair any structure
co¢2 prior to its issuance,also requires the applicant for such Fermin,file asignedsmtemmt POWER DEVICES
µ) Q0 that he is licensed pursuant o the provisions ofthe Contractors License Law(Chapter
9(coimnencingwith SectUa7t)()ofDlVision3ofthe Businessand Professions Code) SWIMMING POOL ELECTRIC VALUATION�1/'J
optionhat 7031.5 rnin by any applicant
p romaaa the Permit
abets thedexemptlod civiny l
.
Q not
Section than iv any apermit subjects the applicant mecivil penalty of OUTLETS-SWITCHES-FIXTURES fJ`
onot more than five hundred dollars($500).
❑ I,asownerof\he m NEW RESIDENTIAL ELECIR _SQ.FT.
p perryne iammmplayees whhwml foricalle thei(See.compensation. STORK TYPE CONSTRUCTION
a3°-° will do thework,and'be he Contractor's
Licensraded e
Law does notaply to rd,Business #�
and Professions Cale:The Co climmo'e License Lew aces not apply to r owner of r!,
progenywhoes,Idsorimproves Hereon,andw is aressuchwork himutfedthroughhis
owderr.thepro
drimpredthat such improvements sold within
ne lmminfromoffercd foe own If, OCC GROUP RES.UNITS
however.vthe building orimprovemem is sold within one year or improve far random
owner-
builder will have the burden of pnwing that he did not build or improve for purpose of
salty).
❑ I,esownerofthe Pmpeny,amexclusivelycontmaingwiHlicnsdmntr t.rsm QTY• PLUMBINGPERMIT FEE FLOOD ZONE APN
mnsmlcl the project(Sec.7044,Business and Professions Coda)The Commumea
License Law revision imply to an nwnerof property who builds or improves thereon,and PERMIT ISSUANCE ,
whoccatrnets fersuch projects with a comaddlo(s)licensed pursuant t0 He Contractor's
License Law. ALTER-GRAIN&VENT-WATER FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.D OUTSIDE EEg
SANITARY Y N
AIIMOw cr Date DRAINS-FLO OF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherehy affirm that l have a certificate of consent to self-insure,or a reconceive ES-PER TRAP RECEIPT.
IWFWorkns'Compereadon Insurance Ora cenified copy thereof(Sec.3800,Lab C.)whic PARK FEE Y N
covars all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT.
Policy# BUILDING DIVISION FEE
Company GAS-EA SYST4 ER4(RA) O
❑ Certified copy is hereby famished. ( PLANCIIECK FEE
❑ Cenified copy is filed with He city inspection division. OR 5 TRL WASTE INTERCE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR P SOILS FEE
COMPENSATION INSURANCE r
(This section need not be completed ifthepemhit is for one hundred dollars($IW) RW ER AN t5krTbfMEA.20J ENERGY FEE
LOIA
or less)
I certify that in the performance of the work for which this permit is issued,IAdd ATER HGTER WIVENTIEL
not employ any person in my manner so as to become subject to the Worker% PAID
Z, Compseumionlswsof Celifomia. Date TER SYSTEM(FRE G DateApplicanR eipt
ZNOTICEITO APPLICANT:If,after making this Certificate of Exemption,you should N W RESIDE 1.PLMB. gQ.FT. WO
TOTAL:
V) become subject m the Worker's Compensation provisions of the Labor Code,you mus[
�-' forthwith comply with such provisions or this permit shall be deduced revoked. BU
pW- Ca CONSTRUCIONLENDINGAGENCY SEf
Z Ihereby aRIrmthaons.is a customs.lending agency for the performance of
V O the work for which this permit is issued(gm.3097,Civ.CJ L ELECTR FEE
Lender's Noma
ULender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FE
I certify that I have read this application and state that the above mmuchution is MECHANICAL F'L
Fa correct lagree to cmmplywith allciryand county ordinances andstatelewerclalingro PERMIT ISSUANCE
building construction.and hereby authoned eeprosentatives ofthiscity to enter upon the
L) Z above-mentioned property far inspection purposes. ALTER OR ADD TO MECH. CONSTRUC ION TA
(We)agent to save,indemnify and keep harmless the City of uperlino against
liabilitieajudgments,costs and expenses which may in my ways in againsts ACity AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting or
this permit.
As
AIR HANDLING UNIT(OVER 10.000 CPM)
Signature Appllmn ommct am EXHAUST HOLD(WMUCq
PAID
HAZARDOUS MAB occupant store
HEATING UNIT(TO IW,000 BTU) Dvta Receipt#
Will the the Cupertino
or future building occupant erre or handle hazardous matanal
as defined by the Cupertino Munlclpal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Coda Section Y5532(e)] 0 N VENTILATIONOFAN(SINGLE RESID)
BOILER-COME(3HP OR 100,000 BTU) USSUANCE DATE
Wil"ai applicant oands as huildied by the Bay Area
Air Quality
Management
I,
hazaranus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOf"BTU) �Ep 19 �g9
Vslrid2
% ❑Yea ❑No NEW RESIDENTIAL MECH. SQ.ET,
1`
I have read the hazardous materials requirements under Chapter 6.95 of the r vV(GKI,ry
Q� Czlifomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand Het ur V�1�
ifthebuilding does not currently
ts whave atenantthanitis my rcuance ofd tonotify the !/
.O cupa n of the requirements which mull be mel poor to issuance of a Certificme of
Occupancy.
OwneroramhmmiJagent Data T T ISSUEDB .