25678APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO mHO, Imai - let VUTR[i.n1.
BUILDING DIVISION APPLICATION /PERMIT PLUMBING - MN.CHANICAI.
BUILDING PROJECT IDENTIFICATION
I
PERMIT NO.
6� C Q
- GJ o
sa
kIIILDEN'. tAIDDRESS: /�
',,l At-PINK QR UNIT# LOT#
SANITARY NO,
APPLICATION SUBMITTAL. DATE
OWNERS AVi5i: �� A�h�Pz l�' ���CONfkACfOk'S
N VL�J V YJ
NAME: I,ICNO:
C� ��� � Q J� 6 1 9 3OG
N/C
CONTHOLp
,ARCHITECT /ENGINEER: LIC NO
ADDRESS:
I I1 r Re,x� 2 S -G.
.ONTACI': PHONE:
-
QTY.
ELECTRIC PERMIT
PEE
BUILDING PERMIT INFO
Ii1.L'CT PLUMB MI[CI{
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with
APPLIANCES - BESIDE NTIAL
LOB DESCRIPTION
PANELS
-
UP T0AG
Section 7")of Division 3 of the Business and Professions Code, and my license is in
full force and ' effect.
DatenslClass Lic #1 L I
Date O nor a one m0 V I"
201 - IOW AMPS
ARC[ II'1'F.CTS DECLARATION
I ECT
1 uMerstund my plans slut I be mr,i m public mundx.
OVER AMPS
OVER IOfN1AMPS �-
SQ. FT. FLOOR
11
AREA
$ /SQ. FT.
SIGNS ELECTRICAL
N
'
Licensee Professional �
OWNER-BUILDER DECLARATION
E hereby affirm that 1 am exempt from the Contractor's License Low for tiro
SPECIAL CIRCUUUMISC. -,
MP
J
'TEMP. METER OR POLEENS .
following rcasea lSenion]Ol LS, Business and Pmfesions Code: Any city ar county
which requires a permit to construct, aline improve, demolish, or repair any structure
prior to fix issuance,alxorequircn the applicant for such permit to f leasigmednatemem
POWER DEVICES DATE
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9homucaming with Section 7") of Division 3 ofthe Business and Professions Craft)
SWIMMING POOL ELE -
- - --
VALUAT10�
or than he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section ]1131.5 by any applievm far a permit xubjects the epplicum to a civil penalty or
l
0 O d
QV11FT5 - SWITCHES- PI %I'URES
not more limn five hundred d.11... ($500).
❑ 1, aanwnermDhcprnpeny .nrmyemploymswilh wages asnheirsolecompertsarion.
NIiW RI3EDFNTIAL ELECTR —SQ. FT.
STORIES
TYPECONSIRUCTION
will dothework, the sh isnot immndee, rdofor axle(pee]044, Business
used Co Con Law
Law does mat m an owner of apply
the Cmmrumon.
propenywyers, powidedpmvesth impareundwhodoessuchwmk himsedealf rough his
popery v Irons ldsori and hincr
earofdoroffered for If,
OCC GROUT'
RES. UNITS
'TOTAL:
however, thebuPing or improvchimprovememsarene
own .
however, the building or improvement is sold within one year ofmprov eifor the owner.
of
builder will have the burden of proving that he did rim build or improve for purpose of
QTY.
PLUMBING PERMIT
FEE
ale.).
❑ Las any,
PLOOD LONIi
APN
Linton the project (Sec
the project (See. Busiaeas unJ ProPoxsian, CndeO The Contmetor's
, Business and Professions Code) The Contractors
-
main
Licenseiuisfosuc aproj tisnownern propenywhobdpumui
PERMIT ISSUANCE
whenseLo sforsuch proj¢ts withecontraaoKs )licensed pursuenuonhe Convanor'c
hove, Can=tors
License Lnw.
ALTER - DRAIN &VENT - WATER Q'-.M)
FEE. SUMMARY
❑ I am exempt under Sea , B & P C for this reason
BACK FLOW PROTECT. DEVICE.
SIDE ES
SANITARY YN
RECEIPT#
Owner Data
DNAINS- PLOOk, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
❑ Ihercby affirm thmlbavcucertifcmc ofconsent losel(- in .... amucenii,emof
Workers'Camp'ew" nEer eranit. fed copy thereof (Sec.38W, LOb CJ which
FIXTURES - PER'] RAP
RECEIPT#
PARK FEB Y N
this
rs ell employ «sunder This permit.
Policy If
GAS - EA, SYSTEM -t INC. 4 OUTLETS
RDO/II N
BUILDING DIV ION 17 tS
Company
GAS - FA. SYSTEM -OVER 4 (BA)
PIANCHECK FEE
❑ Cenar M ifi Copy is hereby famished.
GREASEVENDUSTRL WASTE INTERCEPTOR
GRADING R?E
❑ Cenificd copy is filed wish the city impenion division.
CER'TIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GREASETRAP
SOILS THE
SEWER - SANITARY - STORM IAA. 2WIT.
ENERGY IT
('This section need not be completed iflhe permit is for one hundred dollars (SIM)
or less.)
WATER IIEATER W /VEN DELELTR
I cmify that in [lot pedomemsee of he work for which this permit is issued,I Shall
not employ any Person in any manner sr av m bed am ivied, to the Worker%
PAID
WATER SYSTEMITRFATING
Date Receipt#
Compensation Safi California. Dam yU' 1. / Y f
Applicant `511 T (—wds A'G'E
NOTICE I'O APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENT LM. TIME. SQ. FT.
TOTAL-,
bwom subject to the Workers Compensation provisions of the lather Code, you must
-
forthwithcemplywithsuchprovisionsorthispermitshallbcdeemedrevoked.
BUILDING FEE
/•
SEISMIC FEE,
CONSTRUCTION LENDING AGENCY
I hereby affirm that is o construction lending agency for the perforrtwnce of
the work for which Ibis Permit is issued (Sec. 3097, Cie. CJ
TOTAL:
LLECBIC FEE
Lender's Nume
Lenders Address
QTY.
MECIIANICAI. PERMIT
FEE
PLUMBINGPF!
I ccnify that 1 have read this application and state that the above information is
dread. I agree to comply with all city and county nrllnanees and state laws ecatingm
PERMIT ISSUANCE
MECHANICAL PER
building construction, and hereby sufamiu represemutivesofthis city to eater upOnlhe
ahrve- mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCT
NTAX
(WU) agree to save, indemnify and leap ham the City of Cupertino against
liobililica ptogmen¢,p..laritexpense, which may many wayaccrueuguinsts.idCity
AIR HANDLING UNIT (TO 10,0W CFM)
eyucnce of the granting of this permit.
AIR HANDLING UNIT (OVER ID,000 CFM)
ignamrcof Aid,hemm/Ciname., Date
EXHAIISTHOODt W /DUCT)
rota
HEATING UNIT (TO IOBOM BTU)
011ie Rec #
HAZARDOUS MATERIALS DISCLOSURE
Millar vpplioum or future buildingrwctpnt stem or handle hrtardaus material
as define) by the Cupertino Municipal Core, Chapter 9.12, and the Health and Safety
1113ATING UNIT (OVER 10011W BTU)
T AI
VENTILATION FAN (SINGLE RESID)
Cede, Section 25532(x)^
❑ Yes ' 1yNa
Will the applicant orfmurcbuildingcecopann useequipmem nrdevi¢s which emit
BOILER - COMP (31 OR 1(X1,000 BTU)
S DANCE DATE
BOILER - COMP (OVER IW,WO BTU)
hamidom air conmminants as defined by the Bay Area Air Quality Mareagemenl
District'!
❑
' Yes Ig�Nn
!JE
(r
A O
NEW RESIDENTIAL MECH. SQ.IT.
I have read the hazardous materials requirements under Cbpmr 6.95 of the
OCT ®
California health &Safety Cmda Sections 25505, 25533 and25534. understand ut
Ih
if the huilding dres not currently bavice¢nnnh thin it is my responsibilitymnotify the
rccupam of nhc reyuircmenns which man «m prior to is of a Certificate of
Occupancy
S �oTf .� `/
r is
r
Cu' r
yr .' � ry
ISSUED BY:
Ownm nr uuthomal vgem Date
TOTAL:
OFFICE