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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING LLLU RI AI-
BUILDING DIVISION APPLICATION /PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDRN'FIFICA'I']ON
PERMITNO.
25098
BU L.II/yIJNG ADDRESS:
!] C UNIT #. LOT#
SANITARY NO.
yAAPPLICA'GON SUBMITTAI. DATE
WNIi
NAM''
PHONE: -
COMI'Rr�E�I('.SIAME: )In
)I
LICL NO:
NIC
El
C(JN'1'ROL#
RCHITECfp?NGINEER: LICNO:
DR
ren
IU
CGNTAC T: PHONE:
-
QTY.
L LECIRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ER PLUMB MIECH
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
licensed underpvisions of Chapter9 om
E herehyaffitm that I am m h mencingwith
APPLIANCES - RESIDENTIAL
LOB DISCRIPPION
PANELS
i Section T100)of Div 'on 3offlc Businesaa c lion' simm Code, an don, iceocashi n
fullfnrcoandelfw '}`.% C
I �LO�J
L'cen! I hie.p I
`
UP TO 200 AMPS
ate Cartnetor
201 - 1000 AMPS
RCHITNCTS DECLARATION
1 understvnd my plena shall he used m public redool,
OVER RX10 AMPS
SQ. PT. FLOOR AREA
S /SQ, Fr.
SIGNS ELECTRICAL
Licensed Pmfcssionnl
SPECIAL. CIRCUIT /MISC.
! P .
BUILDER DECLARATION
Or
`'�' I N
I min
1 hereby aft inn that 1 am exempt from tM1,Contractors License Law for ,he
t tmlowing rem»n.(Seclion]I111.5, Business and Professions Code: Any ally or coupy
_
TEMP. METER OR PoLF ?INST.
which
ai
u ' `
• to its also rleaq resthppplicuim for such permit to file a signed statement
POWER DEVICES
that he is licensed pursuem to the provis ons of the Cnonicle rs License "w ( Chapter
: 9(commencing with Section 7")of Divi.sino 3 ofthe Businessaad Professions Cale)
SWIMMING POOL ELECTRIC TE
ALUATLON
ar l hal he is exnnptaherefmnn and the basis for the alleged exemption. Anyviolation of
Section 7031.5 by any applicant for a admit subjects the applicant n v civil penally of
OUTLET'S - SWITCIIIES - FIXTURES
not more than five hundred dollars (8500).
❑ I, asowneraf thepropeny, ormyemploymswilhwagesaslheinolecompcnsation,
NEW RP_SIDIi2j`f1ALELECTR_SQ. PI.
STORIES
TYPECONSTRUCIION
will do he work,and the slrucmre is not imendedoroffeted for sale (Sec. 7044, Business
mtd Professions Coin: The Contractor's License Law does not apply to an owner of
y.
1
pmpenywhabuildsorimprovesthereon, and whodoes such work himselforthrough his
wnemployees, provided that suchimprovememsare not imenJW orn ffertdformle. If,
OCC. GROUP
UNITS
however, the building mrimprovement is sold within one ye trofcomplelinn, the awner-
bnllder will have the harden of proving that be did not build or improve far purpose of
QTY.
PLUMBING PERMIT
sale.J.
El I, aeownen)fthepmpem y. amexclusivelycontnetingwithlicensMd ontmclonto
FLOOD ZONE
[�M.
APN
construct the project (Sec. 7044, Business and Professions Cade:) The Contractors
PERMIT ISSUANCE
License Lawdoesnotapply to an ownerofpmpemy who builds or improves thereon, and
whocnmmcts Insect projects with a eonourouns) licensed,tmamnlla the Contractors
License Lew.
ALTER - DRAIN & VIENT- WAILER (CA)
PETE SUMMARY
❑ I am exempt under Sce. B & 1' C for this reason
MACK FLOW PROTECT. DEVICE
Olfl'. IUE PE
SANITARY YN
RECEIPT#
Owner Date
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ Iherehy affirm thatl hove acenificate of cons<m ur wlf- insuu,o. acenffleme f
Workers Compensation Insurance ora mooed copy theemf(Sec. 3800, Lah C.) which
SCHOOLTAX Y N
RECEIPT#
MIXTURES - PER TRAP
PARK FEE. Y N
GAS - F.A. SYSTEM -I INC. OUTI.IH'S
covers all employee's under this permit.
Policy #
RECEIPI' #
BUILDING DIVISION FEES
y -
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE '
rifted copy is hereby furnisher.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING PTE
Certified an, is filed with the city inspection division.
C13RI IFICATE OF EXEMPTION FROM WORKERS,
COMPENSATION INSURANCE
CREASE IRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200 p.
ENERGY FLT;
This section need not M1ecoun red ifthe permit is Porous, hundred dollan(GEP)
or less.)
WATER HEATER W /VrW/ELGCTR
I celifyibul in the perlbromme of thework for which this pernllis i ... od, l shall
not employ any parson in any manner so as m become subject in the Workers'
PAID '
Compensatioi Lawsof Califimiv. Date
WATER SYSTEMGrRFA']'ING
Date Receipt
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workers Compensation Provisions of the Labor Cade, you most
NEW RESIDENTIAL PL.MB. SQ, Fr.
TOTAL:
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
CONSTRUCTION 1. ENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency For the performance of
the work for which this permit is Islam! (See 31N7, Cis. C.)
Lender's Name
TOTAL:
ELECTRIC FIRE
Leaders Address
QTY.
MECI IANICAL PERMIT
[ZEE
PLUMBING FEE
I certify that I have read this application and some that the above information is
l agree to comply with all city and county ordinances and smm laws relining to
PERM] f ISSUANCE3
MECHANICAL. FEE
building consuuctior, any hereby aulhodu mprehemvtives ofthiscity to en¢rupnn the
above- memioncy pmpeny for inspection purposes.
ALTER OR ADD TO ALLEGE.
CONSTRUCTION TAX
(W am no save, indemnify and keep harnlekthocky f C penin insn
liabilitie, p • ents,cost ante pause. whlyh may in rue dgaimta its by
AIR HANDLING UN IT ITO 10,00( CFM)
in cruise a 'u of the gr inga this petmitfl '1
V1 y1/ps'I
AIR HANDLING UNIT LOVER III,t1fq CFM)
Si mere of Applican/UCOnu or Date
EXHAUST HOOD(WNUCT,
PAID
14 Ml ING UNIT (TO 100,000 BTU)
Dam Receipt #
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building warpean store or handle hauNous mmemil
asdefinedbytheCupertinoMunicipalCode, Chapter 9.12, and the Health and Safety
-
HGTING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE REBID)
Coda, Seetiot 25532(a)]
❑ Ycs ID No
BOILER - COMP pHP OR 100,110(1 BTU)
ISSUANCE D
m A' D
�/
Will theecommmm�ts as building by the Bay Area Air.Quality Management
hazardous air comuminunns as defined by the Ray Area Air Qualify Management
4 Oisuinl
BOILER -COMP (OVER 100.000 ETU)
❑ Yes ❑ No
1 have read the hazardous materials tequirmanis under Chapter 6.95 of the
MAY
� INr11 1993
NEW RESIDENTIAL MF.CIT SQ. IT.
Cullfomla I loalth & Safety Code, Sections 25505, 25533 and 25534. 1 undemm�d than
if We building docs not currently have a lenanl, that it is my responsibility to notify the
C� I Y Ur
occupant of the requiremems which mud be met poor to issuance of o Cenificum of
lk ul Cfl I D ay
Occupancy.
^
i
ISSUED BV:
Owner
Owner .,auto 'ed ngrnt Ume
TOTAL:
VFI'ILIC