26063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIMIN�ELECTRRSCL PERMITNO.
APPLICATION/PERMIT PING PROJECT IDIIANICAL
FICA 26063
BUILDING DIVISION IIUILU14iG PR(1JR6'1'111ENTINICA'IION
BUILDING ADDRESS: SAN["I'Ally NO. APPLICATION SUBMITTAL DATE
aOl�E UNIT LOT#
OW ARS NAME &'k Q _PI{pGE: C CI'OR'S NAM E: LIC NO:
NIC CONTROLn
AR III'I'ECDENGINEER: TIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDGF,LECT PLUMN MECH
PERMIT ISSUANCE 50 /�1_pTr ❑ ❑
LICENSED CONTRACTOR'S DECLARATLON APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p02, Ihereby 70(th Division
armlicensedBmirdmpmWsionsions Castle,
9nd my[I.g with
00 Section]Ut]%of DivisionJn(the Buxinesa and Professions Cade,nM mylicenae is in PANELS
god 11--. full forte and effect. \
I<Z, License Class Lit.# UPT02MAMM
,n6a
Data Cme.mm 201-1000 AMPS
Fy Z_ ARCHITECTS DECLARATION SQ.IT.4100@ARfiA E/SQ.FT.
zoZoO Z— 1 understand my plans shall he used m public records. OVER 1000 AMPS
oz—o r7
NS ELECTRICAL
hLicensed Professional
ce< OWNER-BUILDER DECLARATION CIAL CIRCUR/MISC.
'06U I hereby affirm that I an exempt Irom the Contractor's License Law for the
m3 U.tofollowing reason.(Section 7031.5,Business and Rofessioms Code:Any city m county TEMP.METER OR POLE INST.
F.
O J u' which requires a permit reconstruct,alter,improve,demolish,or repair any swnare
yru3 QE priorto its ixsuanor.also requires thespp[icant for such permiuo filcasigmed statement POWER DEVICES
iC O p that he is licensed pursuant o the provisions of the Caricatures License Law(Chapter SWIMMING POOL ELECTRIC
ti,o LL. 9(commencing with Section]00))of Division 3 of Ne Business and Professions Cade) �VA�LU
yl
'X_,, or that he t%exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES.
F-'Za Section 7031.5 by my applicant for a permit subjects the applicant tu a civil penalty of FIXTURES
not mart than Eve M1undrcJ dollars(5500). NEW RESIDENTIAL ELECIRSQ.FT.
d' o ❑ 1,®ownerofthepmo "yormyempleyaxwiNwagc wiMirsolecompemaum, STORIES TYPE CONSTRUCTION
y3o_° windo the work,and the structure isnot imendedoroffiand fm We(Sm.]044,Business
and Professions Cade:The Contractor's License Law does not apply in an owner of
property who builth nr lniproves thereon.and whodoes such work himselfonhroughhis
own vmployms.provided that such improvements are not intended mothered forsale.IL OCC GROUT' RIS.UNITS
however,the buildinger improvement is sold within One yearofcompletion,dteownm- Q
builder will have the burden of proving that he did not build or improve for purinae of
sale.). QTY. PLUMBING PERMIT FEE FT.00DZONE IN
❑ I,axawreronne rrapenr.amexewameyanrammg with Nanxw tontmeturatu
construct the project(Sec.7(A4.Business and Professions Code:)The Contractor's
License[.uwdoes not apply to an ownerofpmpeny whobuildsor lmpmvesthemon,and PERMIT ISSUANCE
who corbacts for such projects with a mm meter(s)licensed pursuanuo the Conwcmr's
Lima.Law. ALTER- RAI ^VT�I'�WATC�( M
) FEE SUMARY
❑ I am exempt under g . .B&P C for this reason BACK FLOW P kOTECT.DEVICE ' 1'• " "ID FEES
_ SANT ARY Y N
Owner Dam DRAINS-FL RROOF,ARBA.COND'� _ RECE1 PTp
WORKMAN COMPENSATION DECLARATION SCI( [.'TAX Y N
❑ Ihembyaffirmthatl Mveacenificateofconwnttostlbinsum,oracenificateof FIXTURESPER TRAP FEE
Workers Compensation lmurance ora ceniEed copy shamed(See Jg00,Isb C.)which PAR FEE Y N
covers W]cmployce'•under this permit. GAS-EA STEM-1 INCA ftEC 1PTe
Policy _ BUILDING DI ISI NFL[S
Company GAS-EA.SYSTUM-OVER 4(EA) PLANCHECK FEE OL `
❑ CemEed copy ix hereby furnished.
❑ Cen[fiedcopy is filed with the city inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Has section need not be completed ifthe Permit is for one hundreddollars(51007 SEWER-SANITARY-STORM PA.200FT. ENERGY KE
or less.)
I certify that in the performmceofthe work for which this permit is issued,l shell WATER HEATER WNENT/ELECfR
not employ any person in any manner so as in become subject to the Workers P
Compevation Lex,mCalifornia. Date WATER SYSTEM/rREVDNG (((((( Date Rectipt0
O z Applmunt
z 0 NOTICE TO APPLICANT:If,ager making this Certificate of Exemption.you should NEW RESIDENTIAL PCMB. SQ FT. TOTAL:
E-' become subject to the Workers Compensation provisions of the Labor Code,you must BUILDING FEE �a
a > forthwith comply with such provisions or this permit shall be deemed revoked.
f� Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
0.. I eby affirm Nat there is a construction lending agency for the performance of
� Z' herthe work far which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
U Leaders Name
Lcmim's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L..) I certify that 1 have read this application and sure that the above information is MECHANICAL hF.'
correct I agree to comply with all city and county ordinances and state laws calming to PERMIT ISSUANCE
(•^ building concoction,and hereby authodm represenativesofthiscity to enter upon the CONSTRUCTION X
Uabove-mentioned propcny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnirr and keep harmless the City of Cupenim,against
liabiblics,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,0X0 CFM)
insertfthe granting of this it.
H ""° fs.�. AIR HANDLING UNIT(OVER IO.OOCFN)
iJgnat c Appbcunt/Contramm 7y Date I EXHAUST HOOD(W/DUCI')
PAID
HAZARDOUS MA'TIBUALS DISCLOSURE HEATING UNIT(TO 103,000 B'I'U) Dote R eipl a
Will theapplicantorfuurre building occupant store or handle hazardous material HEATING UNIT(OVER 100,003 BTU) OTAL:
to defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)7 VENTILATION FAN(SINGLE RE ID)
11 Yes ❑No
ISSUANCE DATE
Will thea licantor future building ruse eardeviceswhich emit BOILER-COMP JHP OR 11X1,001 BTU)
DP 6 by the creamer
�herardous
an contaminenta as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 103.000 BTU)
11 yea ❑No NEW RESIDENTIAL MECiI. SQ.FT. I� A I
1 have read the harmdets mmcriata nlmournem,under Chapter 6.95 of the Aa�
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understood that
if the building does not currently have a Central,that it is my responsibility to notify Ne Q
occupant of the requirements which must be met prior to ixsuance of a Certificate of C/ vx S
Occupancy. /Yf t,V
Owner or authorized agent Date TOTAL: ISSUED BY: _
OFFICE