26640APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELE TRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
/� �1 p(� O
G o
BUILDING
SANITARY NO.
APPLICATIONSIIBMITTALDATE
IAD^DRESS'. `
UNIT# LOTH
�, Let r-
SNAME: PHONE:
(CMA 0 6,r,_ '
NTRACTDECAME: - LIC NO:
^ ` L`84L i s 014-1
NIC
❑
CONTROL#
ARCHITECTMNGINEER: LIC NO:
AD ESSS:� (5
�� `ELECTRIC
CONTACT: PHONE:
QTY, PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE'
E] L.G• El 11LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm shat I am licensed under provisions of Chapter 9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
fullSecion c and effect. on 3 of the Business and Professions Code, end my license is in
Lull tome and eHCx
Licens Classn^�o Lic.# O
PANELS V
UP T0200 AMPS
/
(`
Date ' Comment, 'Q 5L
201- 10011 AMPS
ARCHITECTS DECLARATION
I understand my plans shall he used es public records.
OVER 1000 AMPS
SQ. IT. FLOOR AREA
® a T
LL
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License Law for the
SPECIAL CIRCUIT/MISC.
I�I
L'following
-
TEMP. METER OR POLE INST. �
reason. (Section "1031,5, Business and Professions Code: My city or county
11,which
IT
requires a permitn construe'.ulmr, improve, demalish, ar repar any structure3
prior n its issuance, also requires the applicant for such Tommyo file a signed statement
POWER DEVICES
that he is licensed pursoanvo the provisions of the Comment's License Law (Chapter
9( commencing with Section 7000) of Division 3 ofthe Business and Professions Code)
QATE
SWIMMING POOL ELECTRIC i,.._ _
-- VALUATI0
or that he is exempt herefrom unit the basis for the alleged exemption. Any violation of
Section 0031.5 by any applicant for a permiu
t subjects the applicano a civil Penalty of
OUTLETS - SWITCHES - FIXTURES
net more than five hundred dollars ($500).
❑ I,esownernftheproperty, ormy employeeswith wageseetheirsolecompensmion,
NEW RESIDENTIAL ELECIR_SQ. IrL
STORIES
TYPECONSTRUCHON
will do the work,and the structure is not inteadedomfferedforsale(Sec. 7044, Business
and Professions Code: The Contractors License Law does nut apply to an owner of
property whobui[dsorimprovesshereon, endwhodoessuch work himselforthrough his
own employees, provided thatsuchimprovinvarmarenot intendedoroffea lfofsale. If,
-
OCC GROUP
RES. UNITS
TOTAL: uV
however, the buildingor improvement is sold within one yearofcompletion, them,mr.
builder will have the burden of proving that he did not build or improve for purpose of
QTY, PLUMBING PERMIT FEE
s' IeJ.
❑ I, as owneroftheproperty, am exclusively contracting with licensed contractors to
FLOOD ZONE
APN
construct the project (Sec. 7094, Business and Professions Code:) The Contractor's
License Law does not applyto anownerofprogeny whobuildsorimprovestherean,and
PERMIT ISSUANCE
who contracts for such projects with aconmedor(c) licensed pursuanttodu Contractor's
'License Law.
ALTER -0RAIN&VENT-WATER EA
( )
FEE SUMMARY
❑ I am exempt under Sec. , B &'P C for this reason
BACK FLOW PROTECT. DEVICE
OUT SIDFEESN
SANITARY
RECEIPT#
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECN
LARATIO
SCHOOLTAX YN
❑ Ihereby affvmthat l have a certificate ofewasent to self-Insum, ora cenificate of
Worke.'Compensetian Insurance ore0ettlfled copy thereof (Sea. 38!X1, Lab C.)which
RECEIPT#
FIXTURES - PER TRAP
PARK FEE YN
cave. all employee's under this permit
Policy #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT' #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby, furbished.
GREASF(INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not be completed lithe permit is for one hundred dolla.(SIX)
or less.)
WATER HEATER WNEW/ELECTR
,
I really that in the performance of the work for which this permit is issued.)shall
not employ any person in any mannerso a5 to hecpsn^sWtiact to the Workers'
PAID
WATER SYSTEM TREATING
Compensapon Lawgo`QCahfy(�a.` Dete T 7X 7 �m
Dale Receipt #
Applicant C`"
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Worker's Compensation Provisions of the Labor Code, you most
forthwith comply wish such previsions or this permit shall he deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
TOTAL:
ELECTRIC FEE t7 is
Lenders Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that 1 have read this application and state that she above information is
cored I agree to comply withal[ city and couarymiinences and ante laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby aushodzerepresenntives ofthis city neater upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TA% '
(We) agree to save, indemnify and keep h rrydow the City of Cupertino against
'
liabilities,judgments, costs and expenses which may in any weyaccu eagatnat saidCiy
AIR HANDLING UNIT (TO I0,00OCFM)
in asequence of the granting of this permit.
l�^�I`'+�``-�',�`�^ [�0 T^,1�-9
AIR HANDLING UNIT (OVER 10,000 CFM)
Sign a'ure of ApplicaroCommcnr Dete
EXHAUST HOOD(W/DUCI)
PAID
HEATING UNIT (TO IM,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant or future building onarmat store or handle heamidbus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100.000 BTU)
`
TOTAL:
VENTILATION FAN (SINGLE RESID)
Code, Section 25532nd?
❑ Yes ❑ No
BOILER- COMP IMF OR 100,000 BTU)
S DATE
Will fins
e applicaorfpmre huildingoccupantuseequipmensmdeviceawhichemil
BOILER - COMP(OVER 100,000 BTU)
hazardous air contatninsum; as defined by the Bay Area Air Quality Management
District?
JUN 281994
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
1 have read the hazadous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
CI I i 1,/r UUP L' m i IvU
if the building Ones cot currently have a tartans, Nat it is my responsibility n notify the
'
Occupant of the requirements which must be met prior to issuance of a Cerificam of
Occupancy.
q7��llllll\.
ISSUED BY: ' T i� V`� J
Owner or authorized agent Data
TOTAL:
OFFICE