25854APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE.BALL POINT PEN ONLY
CITY OF CUPERTINO II IIAI, - . ,C'T I AL
BUILDING DIVISION APPLICATION /PERMIT PLUMBING- Mb:CHANIC.A].
BUILDING PROJECT IDEN'I'RICA 'ITON
PIiRMI'I'NO.
G J o �J (,�
2 5 8 5 p
BUILDING ADDNESS: Y [/� �
O' � \vim NI'IWa�X LOTp
SANITARY NO.
APPLICATION _SUBMMIyTTAL IJA9'Is
--
W S N _ PHONE:
)M
A1;( R' N M' L NO:
Ilr Xl
' N/C
11
CONTROL#
ARC IiCr GINGER: LICNO:
D
R Ris 1r✓ 5.
5i_
CONTACT: PHONE: '
QTY.
ELECTRIC PERMIT
PEE
BUILDING PERMIT'INPO
BLDG ELECT' PLUMB MEET
PERMIT ISSUANCE
'
❑
LICENSED CONTRACT'OR'S DECLARATION
1 herehy off ml the I vm licensed under provisions of Chapter9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DFSCRIITION
PANES
Section 70M) of Divis on 3 of the Business sort Professions Code, and my license is in
full farce and effect. I
6-M
License Class
UPTO 20OAMPS
m Contractor
Conte
2UI- IW(IAMI'S
_
ARCI1 barred
I undcrstanA my plans shall be used as public records.
OVER IIXNI AMPS
FLOOR
SQ. pr. FLOOR AREA
$ /SQ. M.
SIGNS ELECTRICAL
License] Fnfcasinml
OWNER-BUILDER
SPECIAL CIRCUIT' /MISC.
1 hereby Iha 1 O from the CommION
Law for Na
rail from the CnnionsCo
TIiMP. METER OR PoI.G INST.
following mason. (Se 31 Code: Any city
7o3L5,BUSinessund Iva,
m .eortion
which demolish. or tocoumy
which requiresaperms. recount t cialmaimprovgh formeh, orrepair any xmacmre
PH ft, lso reclaims thevisio for aamment
se
POWER UIiVICS
n p
^ P I'
^.
that he La
that he is licensed with Si m the provisions of the Canwnars and P .. Law (Clasper
licensed pursuant Co trrmitroLice
9(rommencingwithSmion71N10)of Divisinn3of Ora Business and Pndessinm Cmle)
aniton 7031.5 by any the Permit subjeas thedexcmpti to civil of
LS by
Section 7031.5 applicant domrs(S50rmil mbjats the applicant toacivil Penalty of
SWIMMING PC
OUTLGI'S -SW
LF.1,tC11tIC- ..
TCH FIXTURES ., �'
...
7.�—..
t t
qy
{I I
VALUATION
In
nm more Than live hander] dollars 155110).
hundred
❑ I,asnwnerafNcpmpcny, ormyemployees with wageavtheiraolaompcnsetion,
NEW RESIDEN
'IAL ELe R._
ad
TORIES -
TYPE ?CONSTRUCTION
will dome work, vadthe slrmare Isnot intcedWnro1ferWfo ...E(Sce.7044,1Busineas
and Prafesxlons Code: The Contractors Liccnse Law does not apply la an owner of
property who builds compactors Hereon, and whodoes such workhlmselfor lhmughhia
own employee., provided that such improvemmre
es a not intended err offered for sale. II;
DEC. GROUP
RES. UNITS
'TOTAL:
however, the building or improvement is sold withinone yearof completion, tbeownm-
builder will have the burden of proving that he did not build or improve for purpose of
QTY.
PLUMBING PERMIT
FEE
sale.).
❑ I, as owneroflhe property, am exclusively contracting with licensed contractors to
FLOOD ZONE
APN
o.. met the project (Sec. 7044, Business and Professions Code) The Conmumors
r�
License Lawdocs not epplyno anownerofpropedy who hullds nor improves lhamnn and
PERMIT ISSUANCE
whocamransfor such projects with acanlractor(s) licensed pursuant o the Contractor's
Liana law.
pLTIiR- DRAIN &VENT -WATTiR (EA)
FEE SUMMARY
❑ I am attempt under See. , B & P C for this reason
BACK FLOW PROTECT, DEVICE.
OUTSIDE FEP,S
SANITARY Y N
RECEIPT'#
Owner Data
DRAINS- FLOONft00P, AREA, COND. .
,
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ I hereby affrm that l have a cmiGcme ofcansert to self - insure, or a anificamof
Workers Compensation lnsuruncevrs coped copy lhercaf(Sec. 3800, Lab C.) which
RECEIPT
FIXTURES - PER TRAP
PARK E?E Y
creartall s
PnlicyX
RE
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
_
Company
GAS - FA. SYSTEM -OVER 4(A)
PLANCHHCK TEE
❑ Ctifedropyisharehyhmishcd.
GRIASEBNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Canifed copy is filed with the city inepectiondivisinm
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRRASHTRAP
SOILS I'EE
SEWER- SANITARY -STORM EA. 20OFT.
ENERGY TEE
Cfais section need not be completed ifthe permit is for one hundred dollars (SIM)
or lass),
WAT'IiR I(EATER W/VENTpiI.BCTR
I eerily that in the perlbrmance of the work for which Nis permit is issued, I shall
so
oat eniplay any person in any m as m became subject m the Workers
PAID
-
Compensatioulawaaf California. Data
Applicant
WATER SYSTEM/I'RFATING
Dam Rcceipl#
NOTICE TO APPLICANT, If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Werker's Compensation provisions chic Labor Code, you must
fnnhwith comply with such provisions err this pcmlit shall bar deemed revoked.
BUILDING FE-E
CONSTRUCTION LENDING AGENCY
STRSMIC PER
I hereby of irnt that there is a construction lending agency for the performance of
the work for which this permit is issued (Sea. 3097, Civ. CJ
Lender's Name
ELECTRIC FEE
Lender's Address
QTY.
MECHANICAL PERMIT
FHE
PLUMBING FEE
1 cenify that 1 have rwd Nis application and some Nut the above information is
caned. I agree la comply with all city and ctanDondurawas rand satn Iowa relating to
PERMIT ISSUANCE
MECHANICAL FRI?
mildingcomaruction , and hereby autho m, representatives a(Ms city betterupon the
above-mentioned pmpeny for inspection purposes.
ACI ER OR ADD TO MECH.
CONSTRUCTION TA%
(We) store m save, indemnify and keep hetmless the City of Cupertino against
liabilities, ludgmarovuim, and expenses which may in any way sumaeagaim"wid City
AIR HANDLING UNIT (TO I ROM CFM)
m cons of the granting of lh' it.
/ �JD
AIR HANDLING UNIT (OVER IQO(1(I CFM)
Signature of A icanl/ tiftectai Dme
E%I IAUST I IOOD(WMUCI)
PAID
HEATING UNIT (TO 100,000 BTII)
Date Retrain #
HAZARDOUS MATERIALS DISCLOSURE
Willlheapplicanlorfuarc building occupant stare or handle houndaus mamrial
as dcfned by the Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
HPATING UNIT (OVER 1100,000 BTU)
TOTAL:
-
VENTILATION FAN (SINGLE RFSID)
Cade, Section 25532(87
CI Yes ❑ No
BOILER - COMI'(3HP OR 1110,000 BTU)
-
ISSUANCE ATE
Will thee plicabi orfamrc buildin recu luu
p g pat
Quality
BOILER - COMP(OVER 100,000 BT(J)
hamrct? air contaminants as Jei1nW By the Buy Area Air Quality Management
Area Air Management
Diaries?
❑ Yes ❑ No
NEW RESIDENTIAL MECH, SQ. Fr.
I. have read the haezrdoua asterisk requiements under Chupmr 6.95 of the
PAID
California Health & Soar, Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a moral, that it is my responsibility to notify the
rccupant of the requirements which must be met prior to issuance of a Cenifeam of
Occupancy.
ISSUED BY:
Owneroraut camedagent Dme
TOTAL:
-
OFFICE ' "' °•