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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
RI A
CITY OF CUPERTINO APPLICATION /PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION ,ING PROJECT 'IDENTIVICATION'sy.pd ";'„£. v. .. ?'
PERMIT NO.
r� Z O C r
G J[
BUILDING ADDRESS:
SANITARY NO.
APPLICATTONSUBMHTALDAI
UNIT It LOT#
C1 fvfflq,�e
pWNERS NAME: PHONE:
e(
CONTRACTOR'S NAME:- LIC NO:
\ C{ I.CT/F.NGINEL : LIC NO:
ADDRESS:
-
/a
CONTACT: PHONE:
'•' < -�- ", ><.-r* e
"
i" T A'$;
^�, - „ "�.5 @BUILDING PERMIT- INFO,,,ti,: "`, �_r:
BLDG ,ELECT PLUMB MECH
PERMIT ISSUANCE
-1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herehyaffirmthall am licensed under previsions of Chapter9(cmrunencing with
7000) of Division l of the Bc,inassdnd Professions Code. and my license is in
I
APPLIANCES - RESIDENTIAL
PANELS
Ie�O�B.agD��ESCRIPTIONl , -�.Section
g. U
full ra.,nd eRce,
Lic e C s 6��7oG
UP TO 200 AMPS
bbbb �VV��������11����'•` �• �1
{`J1`8/SQ�FT.
3B1 -RMq AMPS
�Lic.N
ae C.nracmr -s- �r-- `•--- t -Yl -�
�
SQ. FT. FLOOR AREA
ARCI IITECTS DE A TIO
OVER IOW AMPS
tdersl my I 'ad sedaspudicreco(ds.
SIGNS ELECTRICAL
SPECIAL CIRCUIT /MISC.
DERm
OWNa.
the CATION
1 hereby n. Section the 1 am exempt from the Conionors License ity for the
x1pr
a Cade: Any city or co
following reason 7831.5. Business and Professions
TEMP. METER OR POLE INST.
t.m
which requiresnpermiva uireRUm,aimgimprove,demolish. orrepairved swcturc
m improve, d rot
prior'. statement
theapplaterf
pamtors
POWER DEVICES
eis li.ansed..mrequires
the Co License La
Natmisncing with Suamm000)od iaviscom the Contractors
Business and (Chapter
9 (commencing with Section 900(11 Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that 7031. by refromandthe hermit schij alleged thpplica exemption. Any violation of
he
Seniors by anyapplicant for a pcamil subjects the upplicanno acivil pcnelty of
OUTLETS - SWITCHES - FlXTURES
NEW RESIDENTIALELECTR_SQ. FP.
tr1.5
not more Nan ofthedreddollarmyem).
❑ Las.w yemployeeswiN
c01Business
STORIES
TYPE CONSTRUC101'
nedforsalei(ec. Business
work, souhepropernmeis notim offendfm sale (Sec.
will do the andthe
to an
and Professions Code: The Conuacmi s License Law does not apply m an owner of
he Contractor License
,
property whobuildsorion,mas thereon, and whod.esstch work hinumlforthrough his
employees, provided Nut such impmemacrosamnot intendedoroffered missile. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one yearofcompletion, Iheowmer-
builder will have the burden of proving that he did not build or improve for purpose f
.1c.).
❑ i.0 rofthe property amexclusavelY conhaclingwlNlicensed contractors to
commet the project (Sec, 7044, Business and Professions Code:) The Commcmrs
License Lawdvesnotapply to an ownerofpmNny who builds orimpowesimmot ,and
QTY.+'k+.
re
_
Pli[IIMBING PERMITt zP
kn.R. Y{ t;tx'fias'*.z ..z., -;rssm yva Yse. -x
'�'FHH
Sli ..xh-dw.,„$
FLOOD ZONE
APN
PERMIT ISSUANCE
whoconuacts forsuch projects with acoonaetods) licensed pursuant mthe Cantmctor'S
raI
License Law.
ALTER. DRAIN &VENT - WATER
xw
t =,a,,¢ • ,. FEE SUMMARY-.
❑ am exempt under Sec. . B & P C for Nis rtuon
BACK FLOW PROTECT, DEVICE
0710
O TSID FES
ARY YN
RECEIPI'M
Owner Dom
WORKMAN COMPENSATION DECLARATION s
❑ Ihereby affirm that (have aceniCicaleof consent,.self.insllm,oracemfi.amof
%Veneto Compensation Insurance or acetified copy thereof(Sec. 3800. Lab C.) which
coven all employees under this Permit.
Policy#
DRAINS - FLOOR.R
�. rfR�A, CONDS, :�
tl
I''_,+ ;.
SCH OL TAX YN
RECFIFT
FlXTURES -PER
..
P �..: ., i 1 J
l:4\OUTLET5'
n
j I I,
P1. Ij FEE Y N
RECEI #
GAS - EA.SYSTEM -1 J
BUILDING DIVIaJ NF
S
_
Company
GAS - E.A. SYSTENI
NCHECK FEE
--'
❑ Certified copy is hereby fum{shed.
-❑ Certified copy is fled with the city inspection division.
GREASE (INDUSTELWASTEINTERCEPTOB
—
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SO ---- --
COMPENSATION INSURANCE
SEWER - SANITARY -STORM EA. 20017.
ENERGY FEE
(This section need not be, completed ifthe permit is forone hundred dollars (5100)
or less.)
xntry that in the perforn (the work for which this permit is issued .)shall
Z,
WATER HEATER WNENT(ELECTR
n mploy any n n y so as to become subject m the Workers'
mperasatio oat /6[c
PAID an
D' Receipt#
WATER SYSTEMITREATING
Appllcanl
.OTICE 11JJ :If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
bccom ubjem t he lon. Campemalion provisions of the Labor Code, you mull
fanhwith comp lywi such provisions or this permit shallhe demand revoked.
BUILDNC E
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat them is a con are ction lending agency for the perfomunce of
Ne work for which this permit is issued! Sec. 3097, Cis. C.)
TOTAL
ELECTRIC FEE
Loncer's Name
QTY.
:iax eMECHAMCAL PaERMIT KF1�,kR,,
�4ff
`fyFEe ":y
PLUMBING FEE
Lenders Address
I codify that I have mad this application and state that Ne above information
correct. l agree to comply with all city and county ordinances and state laws retailing to
-
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authoriurepmsernmives of this city [center upon the
above - mentioned progeny for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO IO.OW CFA)
(We) agree m , indemnify and keep harmless the City of Cupertino against
liabHoon.jad ones and ex rases which may many way accrue against said City
sII
AIR HANDLING UNIT (OVER M.00D CFM)
to conve to I,. is secret.
EXHAUST HOOD! W/DUCD
PAID
c 11 ca anuacror a
HEATING UNIT (TO IOO,OOs) BTUI
HAZARDOUS MATERIALS DISCLOSURE
Dote Receipt#
a.
[RATING UNIT (OVER IW,WO BTII)
TOTAL:
I the applicant or future building occupant store or handle hazardous mtirial
as defined by the Cupenine Municipal Cade. Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RES ID)
Code, Section 25532(a)?
❑ Yes ❑ No
ISSUANCE DATE
'
Will Neapplicanmrfumrebuiiding« cupantuseeyuipmemordeviceswhich emit
BOILER - COMP 131 {p OR IW,000 BTU)
BOILER - COMP (OVER IIXI," BTU)
mrdoos air comamina ds as defined by the Bay Area Air Quality Management
dsrI
-
NEW RESIDENTIAL MBCI{. SQ. FT.
❑Yes C1 No
x, v read the houstral mutenti. rommannems under Chapter 695 of the
SEP 19 1594
"calth 5 Safety Code, Sections 25505.25533 and 25534. 1 understand Nat
- :does mot cmmnJy have a tenant. Nat it is my responsibilitym notify the
ic requirements which must be met prior to issuance of. Certificate of
--- - -- --"
liters agent Date
T'.
ISSUED BY:-
TOTAL:
OFFICL