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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUu.VIN1i-- ITEC'TR .A
BUILDING DIVISION APPLICATION /PERMIT PLUMBING - MECIIANI'AL
BUILDING PROJECTIDP „NI'IFIL-ATION
PERMIT NO,
(� fl 7Q
L (� r o
B ILDING ADDRESS �: yA� I(�� f� /�' n {� `1 r ry
10 ✓^' ! \^ `-� I' �I Lu (�R� (' "aNITa LOT
SANITARYNO.
APPLICATIONSUBMfITALDA'IP.
F
\ \OLp
OWNFAS NAME :
PIIONG
CO TRAf'1' R'S NAME: 1 LIC NO:
N/C
CO�_MIR
❑
TE /F G NE R: LIC NO:
AD RFSS: ..
CONTACI': HON: 0
QTY.
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BL ' 8 PLU MECLL
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ibnmbyafflusidolemlicenaede provLsl mmene
APPLIANCES- RESIDENTIAL
sewhh
Smioretand of Division3of the BUSinessm fosronx Code, end my license is in
fewma Coe, and
full force end elfec R 9
R
ppryE{S
I.i uClasa_�_Lic.N ✓ "" S
UP T02(NIAMPS
IFT-se Contractor "Y”
201 - Fund AMPS
ARCHITECTS DECLARATION CC.
1 understand my plans shell be used as public records.
VER I"
PS
SQ. F. FLOOR AREA
a3
8 /SQL IT.
1(�s�
SI ELF,
1
License) Professional
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Conlraebr Li cAy
P 1 CIRCUIT/MISC.
�aa
P.MEI'ER OR
LP T.
following tcusonSeninn 7031.5, Bminessnd Profesios Cod a city or county
which requires a permit to construct, alter, improve, demolish, or repay any awe
priormitsi .... not, Ms. equiresthe applicant fmsuch permirtofle eeigneJ nareme
POWERDEV
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter
9( commencing with Section 9000) of Division 3 ofthe Business and Professions Code)
SWIMMING 01
.CTRIC
VALUATION
or that he iaevempnhcmfromand the basis for alleged exemption. Any violation
Section]031.5 by any applicant for a permit su acts the applicantto. civil peranyof
a1 '�L awe
(�s(r bS�C
24
OUTLETS- CHES -F RF.S
`�
no more than five hundretl dollars(E5W).
❑ LssownerofUepropeny , ormyemployecs with wagesustheiraolecompenaetion,
NEW RT:SIDI LECIR S .FT.
Q
STORIES
TYPF.CONSTRUCfION
will do the work, and the structure is not intendedorofRred Battle (Sec. 9044, Business
and Professions Code: The Commutes License Low does not apply to an owner of
I
A tV
propenywhnbuddsorimproves therenn.and whodess such work himselfortho ugh his
employees,pmvidedthet such improvements are notinrendedoroffercd fatale. IL
howevco the buildingorimprovcurent is sold within one yearofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
f
OCGGRO P
N
��J ;f
RES. T
1 `
/
QTY.
PLUMBING PERMIT
FEE
❑ I, asowner orthe property, son esclmivelycommcting with llcensedcontramors to
construct the project (Sec. 7044, Business and Professions Code:) The Convector's
FLOOD ZON
DATE
License Lawdoesnot apply toanownerofp ropeny whobuildaor improvesthereon ,and
PFRMITISSUANCE
-
whocontmctsforsuchpmjectswithacontmctor (s) hemaed pursuenuothe Conwctor's
License Law.
ALTER (FA)
��
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this reaun
BACK FLOW PROTECT. DEVICE
LIT, ID a FE
SANITARY Y N
RECEIPT#
Owner Data
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR, ROOF, AREA, COND.
SCHOOL TAX YN
I❑ Iherehy affirm thmlhave acenifcare ofcansrnuo self - insure, ore ¢niGcare of
Workers Contaminants Immadromiteenified copy thereof (Sec. 3gW,Lab CJwhicla
RECEIPTp
75
FIXTURES - PER TRAP
��
PARK LEE Y N
coves all employee's under this permit.
Policy#
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RF.CEIPI'
BUILDING DIVISI NFEES
Company
GAS - EA. SYSTEM -OVER 4 MA)
PLANCHECK FEE
1
l�
❑ CertifiedcnpyisherebyfumishW.
GREASFJINDUSTRLWASTEINTERCEPTOR
GRADING FEE
❑ Cenifed copy is file)with the city inspecion Division.
CERTIFICATE. OF 17XEMMON FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FF
ENERGY FEE CIO
(This section need not bo completed It the permit is intone hinJreddollars ($100)
or less.)
WATER HEATER WNENTRiLECIR
I certify that in the performance of the work for which this Permit is issued.I shall
not employ any person in any manner so so in become subject to the Workers'
Compensation Lawsof Culifedis. Dote
Applicant
WATER SYSTEMffRFATIN4
PAID
Date Receipt#
NOTICETO APPLICANT: If, aftumeking this Cenificam of P ,amr,lica.yo..hould
become subject to the Workers Con,enution provisions orthe Lebo-Codq you must
NEW RESIDENTIAL PLMB. SQ. IT.
OF TOTAL:
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
si
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction leading agency for the performance of
ELECTRIC FEE
the work for which this Permit is issued (Sec. 3097, Cis. C.)
tondos Name
Lender's Address
QTY,
MECI IANICAL PERMIT
FEE
PLUMBING HE
�.
1 certify that I have read this application and state that the above information is
correct. l agree tit comply with all city and county ordinances and steelaws relmingm
building cosbaction,and hereby amhrrinerepresemnivesofthiscity uemerupoa the
above - mention) property for inspection purposes.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
MGCt {pNICAL IF
L
CONSTRUCTION X
(We) agree ton save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmems, costs and expenses which may in any wayaccom against said
in onsequence he granting of this permit. 1 ��2
N�
AIR HANDLING UNIT (TO 10," CFM)
AIR HANDLING UNIT (OVER 10," CFM)
Signatum of ApplicarWormartor Date
EXI IAOST I IOOD(W/DUCry
PAID
HEATING UNIT (TO 100,00X1 BTU)
Date Recciptp
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant none or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
❑EATING UNIT (OVER 100,000 PTO)
VFIJ TILATION PAN (SINGLE REBID)
Code. Section 2525532(a)? EJ
❑Y ❑No
Will me upplicanmrfumrt builJingoccupamuaecquipmemordevicnwhichemit
BOILER - COMP (311P OR 100,000 DTO)
ISSUA CE DATE
hsrzrdoua air contaminants as defned by the Bay Area Air Quality Management
�0nin9
BOILER - COMP(OVER 10)," BTU)
❑ Yes ❑ No
I have rend the hewdous.,costs rc to mere, under Chapter 6.95 of the
pp to
a'Y
NEW RESIDENTIAL MECH. SQ. IT.
California Ilatllh & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does not currently have a tenank Net it is my responsibility m notify the
N�BSI
es��
occupied of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
93
ISSUED BY:
Owneroraithorized agent Date
T
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