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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO1.11,111Nli' H.LT-i`RICA.
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDEN9'IFICAI'ION
PERMIT NO.
e� C e�
G J G
BUILDING ADDRESS: /�
i 11 ee La rt e UNIT# LOTH
SANITARY NO.
APPLICATION SUBMITTAL DATE
&J-A.-9�
OW IBS AME: PHONE:
CONT A;T' R'S Nq➢Qli: 8 \ELI N8
1JJ
NIC
❑
CONI'ROLq
C
R li'IT3CT/EIJGINEER: LIC NO:
ADDRESS.
�A
LJ
'ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ��
1A ISI 0 El
LICENSEDlCONTRACfORlSD1is(d Cha PION
IM1ercby affmt Wow Iion me sed
rofirinf Cbaode,an (commencing with
APPLIANCES - RESIDENTIAL
JOA DP RIPTION
'!
Section7000)0)afDvixlon3 nl the Buxinese and Rofeaeione Coda, and my license is in
3 olithe Business and
PANELS
rOCt(.�
S
full force end ellen. Ilk:( 1 I
UPT02WAMPS
eed
G^(•�OJ uJK�
- I" AMT'S
Dote ECpS D
1 I ARCHITECTS DECLARATION
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER IIXp AMPS
OVER
1 understand my plans shell be used az public records,
SIGNS ELECTRICAL
Licensed Profeseional
BUILDER
Dn
SPECIAL CIRCUIT'/MISC.
I a exempt h Crouni0N
1 hemby fl inn tM1m um a unin from the Cnsion, ro License Law for the
TEMP. ME] OR POLI INST.
inns Come:Aay,
Ii4lowm,mosms(Seit
to comarcBosinessnndove,d repair any
x a panni( demolish,
which Tit,
elle imfor
POWER DEVICES
iss reamewa,
thetriplicate,for such fi mamem,
perminuLie.Lad statement
islicensed
that he pursuantto Co
9b anislicensedpursuantmrhe ie'Diisiof the Contractor's License Law (Chapter
9(mmmeis ixemith5enionnandthe Division 3ofthe Business and Cod e)
SWIMMING POOL ELECTRIC
VALUATION
.Any violation
Pesis for rmitsubects thedexcmption. Any violmionof
heisexeby my
or Section by Por$500). Permit subjects the applicant to acivil penuhy of
yapplicnt for
i
OUTLETS-SWITCHES-FIXTURPS
notianTthan ve hundre deft
not mnrethan rofhundmddollarmyem).
❑ I, asnwnernOhe property.ormyemployeeswith wugeaustheireol¢compensation,STORIES
NEWRESIDINTIALELECfR—SQ.FT,
TYPE CONSTRUCT 'ION
doth¢ work, and the sh le nor is town, Business
tindwill
Liverve Lowrdo s not a(See.
Professions Crile: The Contractors License la(w does not apply if an owner of
Cont
pro
properlywpres, dsorimprat such improvements
doessuch workhimffiermihrmle.Is
not e.
onvocmploebuildingor
dedopletio
OCC.GROUP
RES. UNITS
,then r.
i provchimprovcmenthin eyourr of completionpurowner
not
issoldhe
however,illhave
brimpmvemem
ii
the build
FuilJer will have @e buNen olproving that he did not build or improve for purpose of
QTY, PLUMBING PERMIT FEE
❑ I, as ownerolrheproperly.amex<laivelycommningwith licensed contractors to
FLOODZONE
APN
construct the project (See. 7044, Business and Professions Code:) The Contractor's
Limmec Lewdoes not apply m an ownerofpmperty whobuilds orimprovesthereon,and
PERMIT ISSUANCE
whownwts for such pmjec(a with acommctor(s) licensed pursuant mthe Conweror's
Limem Law.
ALTER-DRAIN&VENT-WATGR P.A
0 )
" -FEE SUMMARY -
❑ 1 am exempt under See.�, B & P C for this o nxmt
BACK FLOW PROT
DE ]TIES
SA 1' Y N
RHCIHPTp
SCFIOOLTAX N
Owner Dme
RAINS -FLOOR, DROOF, REA;COND,
_
WORKMAN COMPENSATIONDECIARATION
crticiamofcandamot opytherrod(insum,0r eeertificmmf
Ih' Compensator I have Insurance
rkeri Compensation lnsurancpeyo�r�yacertifed copy thereof (Sea 3800. Lab CJ which
FlXTIIRFS-PER TRAP / 1/ II
\. l
I RECEIPT#
K � ( YN
Tz";1I cmn0. ySt, yJ IWs S1ri 5 /1 I
►►111-035
GAS-EA.SYS'MM- INC.4 OUTLETS
RF.CI?IPI'#
UILDING DIVISION FEF;S
4`9"IAC
_
Con an N OMV�
P Y
GAS - EA. SYSTEM- VER4(
❑ Certified copy ix herehy furnishul.
Certified copy is filed with the city inspection division.
GREASEgNDUS'I'RL WASTELNTERCEPTOR
GRADING TEG is
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPFNSATION INSURANCE
SEWER-SAN]TARY-STORM EA. 200 It
IN12ROY FEE
Tdiseedion need not be computed ifthe permit is for one hundred do)[. ($100)
orles'.)
WATER HEATER W/VENT/ELECR
I certify that in the performance ofthe work for which this permit is issued, l shall
not employ any person in any run a come subject to the Workers'
PAID
WATER SVSTI?M/1'RFA'fING
Compensation Laws of Ca" .. Unie
Applicant
Dale Receipt#
NOTICHTO APPLICANT: 11. nfermicking this Certificteof Esmaxion,you should
NEW RESIDI?N'I AL PLMB. SQ. FT.
'PO'1'AL:
become subject m the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE la
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is construction lending agency for the performance of
the work far which this permit is issued (Sec. 3W7, Civ. CJ
Lender's Name
TOTAL:
ELECTRIC FEE
Lenders Addraxx
QTY. " - - MECHANICAL. PERMIT " ; . FEE
z
PLUMBING FEE
I certify that I have trod (his application and scam thin rho above informmion is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMITISSUANCI?
MI?CIIANICAL FEF.
building construction, and hereby nuNorize representatives of this city renter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECI I.
CONS'IRUCfION TAX
(We) agree to save, indemnify end keep harmless the City of Cal ertino against
liabililies,judgmears, costs end expenses which may in any way aumeegainst said City
AIR HANDLING UNIT (TO 10,0100 CFM)
I. cuniopiener of rhegmnt gof his pertnir.
✓ /
AIR HANDLING UNIT (OVER 10,00) CFM)
Ir/�/j),
gnvture o��man orhamr If I •CCA7(/bC Datate/1
MIAUST HOOD(W/DUCU
PAID
HEATING UNIT('IO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle M1arerdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 1011,000 BTU)
T'OT'AL:
VENTILATION PAN (SINGLE RESIDE
Code, Section 25532(a)?
❑ Yes I� No
/ •
Will the applicant or future M1uilding«cupanruxequipmenmrdevices whichemii
harnfdous air contammanu as defined by the Bay Area Air Quality Management
District? , !
❑ Vas /�y/l No
I have read the hazardous materials requirementunder. Chapter 6.95 of the
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
A � fA
8.P
a�/1
/�Gs 4
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENT ]AL MECII. SQ. PT,
if he uil Health & Softy Coda Sections 25505, 35533 and 25534.1 understand that
ifrM1ebuildingdoesnot haveatenant, re, it is mspnceofity mnotify
19
c
C�)1'ur
occupant of Ne requirements M1ich must be tat prior m iuuena of Ce ificata of
firmand to of
VVrr,
nma"9I
ISSUEDB
Ownerminduari Engem Date
TOTAL:
OFFICE