26713APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
-
PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIF'IC-ATION
PERMIT NO.
n C q
L o 1
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
7I EL a�
IR E C7: G HON�/E: a D, 4L
UNIT # LOT N
7-l
OWNERS t¢
,N rM.E,•�^s
O✓1'VL SE r4.V Q 7L ��Ob�
I
CONTRACTOR'S NAME LIC
NO:
NPC
❑
CONT OI.#
A f11TECT/ENGINEI:R: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT
FEE
EUILDING PERMIT INFO
ELECT PLUMB MECH
❑
PERMIT ISSUANCE
0 0BLDG
LICENSED CONTRACTOR'S DECLARATION❑
I hembyafund that l am lievownunderprovisions of Chapter 9 pommmea, with
Section 70W) of Division 3 of the Business and Professions Cade, and my license is in
fall fare and effect.
j License Class Lic.#
Dare Ceramic.1
APPLUWCMS-RESIDENTIAL
JOB DESCRIPDON
S ' I �J v x V—i.4 PV
y Ilve
PANELS
UP TO 200 AMPS
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
SQ. FT. FLOOR AREA
SISQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
d Licensed Profeasronal
SPECIAL CIRCULT/MISC.
I OWNER -BUILDER DECLARATION
I hereby affirm Net 1 am exempt from to Contractors License Law for the
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or county
I which requites a permit to construct, alter, Improve, demolish, or repair any structure
prior m its issuance, also requires the applicant for such Permit o file asigned statement
POWER DEVICES
j that he is licensed pursuant no to provisions of to Parameter's License Law (Chapter
9( commencing with Section 0000),(Division 31fthe Business and Professions Code)
arthro h7031.5 by therefmmand te badPermit subjects thedexempnt to civiny l of
t subjects the applicant to a civil penalty of
L5 by any applhundred dollarsant
SWfMMING POOL ELECTRIC
) VAL ATION
�
7 OUTLETS - SWITCHES - FIXTURES
_]
eOl
not momthan
not morethanfivethepro dollars ($500).
$500).
❑ Lhaveor roddthe openy,orm
(�
NEW RESIDENTIAL ELECTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will Jothewons Cotte not is red
of amendedm ohwagesaade(Stw. 0,Pi,Bsiness
Business
he Corrie
and Professions apply in a4,
ons Cole: The License Law
Communes License Law Joes not apply lf an owner of
not
wh ves imselfortluough his
pmpeny wh,builJsorimproves thereon, and whodoes..
ownemployees,p atsuch
nm imaded
fine
OCC. GROUP
RBS. UNITS
building or i ponvchimpis sold within earofdoroffered
ow. r-
however. the have
at build of completion. pause f
he burimprovementissol he
will have the burtlen,f proving that he did not build or improve for purpose of
,TOTAL
S�
m1c.).r
ale.).
❑ I,ct
Enhancers
QTY. PLUMBING PERMIT
FEE
FLOOD ZONE APN
the Project (Sec.
the project (Sec. Business and
Business and Professions CoJeJ
Profesinnts Coac)The Contmcmrs
License
License Law Jcesnan o an o who ove Corton,and
PERMIT ISSUANCE
Projects with a crofproperty to the
whocomraw. for suchprojecns withacnntractor(s)licensed pursuant to the Contractors
sed! pursuant
Liwnse Law.
ALTER WATER (EA)
PEE SUMMARY
❑ 1 am eumpt antler Sec. , B & P C For this reason
&R6r R C DE
1�Y�
t
OUTSIDE FEES
SANITARY YN
RECEIPT#
Owner Date
—
D NS -FLOOR, RO f RED, QNq
..
-RES - PER T"PI
WORKMAN COMPENSATION DECLARATION
❑ ers'Coyaffirmon Insurance
arta cerfi ecopyther sef(Sem. re,or Lab C.) which
I Workere'Compensationlneurance orneertified copy thereof (See.3B00, Lab CJ which
covers all employee's under this permit.
Policy #
SCHOOL TAX Y N
RECEIPT#
PARK PER YN
RECEIPT#
GAS. YSTEM-I 4 S
BUILDING DIVISION FEES
Company
GAS -EA. SYSTEM-OVFJt4 (E
't
PLANCHECKFEE
EIsamosa eepy is nefwy mmian� '
❑ Certified copy is filed with the city inspection division.
GREASH([NDUSTRLWASTEMTERCEPIOR
6TADINO FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
(This section need not be completed Lifthe permit is for one hundred dollars($IKE
or less.)
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
I certify that in to performance of me work for which this permit is issued, Ishall
not employ any person in any manner so as to become subject to the Workers'
Compensation Laws,f California. Date
Applicant
WATER SYSTEM/TREATING
PAID
hate Receip[N
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the, Workers Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
BUILDING FEE go
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE a 71J
I hereby affirm that he. is a construction lending agency for Ne performance of
TOTAL:
ELECTRIC FEE
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Ixnder's Address
QTY. MECHANICAL PERMIT
PEE
PLUMBING FEE
1 certify that I have read this application and smte our the above irdmmation is
PERMIT ISSUANCE
MECHANICAL FEE
correct. I agree to comply wit all city and county ordinances and state laws relating to
building concoction, and hereby authrrizerepreseroa[ives ofthis city incineration the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree no save, indemnify and keep harmless me City of Cupertino against
liabilities,judgments, costs and expenses which may in any way acme against said City
AIR HANDLING UNIT (TO 10,030 CFM)
in consequence ofnting of this p it. I 117n
�7 r� 7 a•
AIR HANDLING UNIT (OVER 10,010 CPM)
Signamreof Appll bContmemr I 1DWZEXHAUST
HOLD(W/DUCT)
PAID .
HEATING UNIT (TO INN0 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle huzurdous matedal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Heath and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Code. Section 25532(0)^
VENTILATION PAN( SINGLE RP.SID)
❑Yes El No
Will thea licaut orfu[ure buildin occu antusee ui
pp g p q purer Quality
hazardous air contaminants as defined by the Bay Aree Air Quality Management
Management
Dishict?
BOILER- COMP(3HP OR 100,00) BTU)
-
ISSUANCE DATE
C'-A
BOILER - COMP (OVER 100,000 RTU)
❑ Yes ❑ No
1 have rend the hazardous materials requirements under Chapter 6.95 of to
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand Nat
JUL����
u`, +
NEW RESIDENTIAL MECH. SQ. PT.
tonotify the
occupante
nccupam of the requirements which must be met prior m issuance of a Certificate of
regnotearnestlyhoveast be met itis my issuanceof
C I I Y lif v V r en I 114U
Occupancy.
ISSUEDBY: I I'� 5/V� Vl1J�-LIC
Owneror milionzedagent Date
TOTAL:
VI -r - Hit