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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IJILIBN r - F.LECI RICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING- MECHANICAL. BUILDING/I
UILDING PROJECT IDExG7IFICA'1'If1N
PERMIT NO.
aJ
4{ N7
BUILDING ADDRESS. G
SANITARY NO.
APPLICATION SUBMITTAL DATE
UNIT# LOT#
OWRS NAME:_ PHONE:
1 11 ��
CONTRACfOR;S NAME: LIC NO:
NNX
❑
CONTROL #
fll '/ENGINEE LIC NO:
ADDRESS:
CONTACT: PHONE'
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
® ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I amlicrnsed under provisionsofC'hapter9m
(comencingwith
APPLIANCES - RESIDENTIAL,
JOB DESCRIPTION
Section 90(10) of Division 3 oflbe Bminessund Pmfessiom Code,md my license is,.
ronmrceannalrw /
len
License
PANELS
UP TO 200 AMPS
_SAY �G..�e /",;a—
",T
,are Conwcmr 1G,
ARCHITECTS ATION
1 understand my plans shall be used m public records.
201 - I" AMPS
OVER I" AMPS
SQ. FT. FLOOR AREA E/SQ. FT.
SIGNS ELECTRICAL /
I
Licensed Professional
as
OWNER -BUILDER DECLARATION
SPECIAL CIRCUITIMISC.
I hereby arlirm that I am exempt from the Contractor's License Law for Ilic
following reason. (Swim 7031.5, Business and Professions Coda: Any city or county
nn
TEMP. METER OR POLE[ NST. v'
which requires a permit to construct, alter, improve, demolish, or repair any structure
_
,omits icuimme,ako requires theapplicant for such pmmiun file. signed smmmem
POWER DEVICES
that he is heensed pursuant to the provisions of the Canwnar's License Law (Chapter
9(commencing with Section ]000)af Division Sof Ne Business and Profession. Code)
ALUAT19N
SWIMMING POOL ELECTRIC ATE
or that he is exempt herefrom and the basis for the alleged exemption. Any violmoon of
Swoon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
O�Z.7J
OUTLETS-SWITCHES-FIXTORES
nI more than than five hundred dollars ($30d.
❑ Lasownero0hepnsperty,ormy empleyeeswith wages uvlheirsolecompensatTun.
NEW RESIDED JAL CLECTR_SQ, FT.
STORIES
TYPECONSTRUCTION
will do the work, and the squcture is not fntended or affered fur sale (Sec. 1094, Business
and Professions Cale: The Commctoes License Law does not apply to an owner of
Pmperry whobailJr orimproves lion n, and whodot such work himxli'mthrough his
own employees, pmvidedminsuch improvemen mairaotiatendedorofferel formis. If,
OCC. GROUP
RIS. UNITS
TOTAL:
however, the building or improvement is sold within one yearofcompletion, the owner.
builder will have the burden of proving that he did not build or improve for propose of
QTY. PLUMBING PERMIT FEE
arta).
❑ LasowncrnDM1c property,.mendusivelycommcting with licensed conlracloram
FLOODZONE
APN
oast., the project (Sec. 1044, Business and Professions Coded The Cnmra<mr's
Lice selswd«snot apply tomownerofpmperry whobuildscrimpmves Narcan,and
PERMIT ISSUANCE.
whocantmets forauch projects with aconwetor(s) Iiansed puramntto the Contractor's
License Law.
ALTER - DRAIN & VENT - WATER (BA)
FEE SUMMARY
❑ 1 oro exempt under Sec. , B & P C for this reason
CT
BACK FLOW PROIL. DF.V ICE
11TSI0E FEF_
SANITARY Y N
RECEIPT#
Owner Did—DRAINS-1100RROOry
, AREA. GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
Ihe¢by affirm that l have a cenificme ofromeno to alf-insum, or a certificate of
orkers'Compensation Insurance ora certified copy themcf(Sec. 3800. WbC,) which
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
covers all employee's under this permit.
Policy #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
0
RECEIPT p
BUILDING DIVISION FRES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GRFASEANDUSTRL WASTE INTERCEPTORGRADING
FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GRPASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not be completed ifthe permit is portion hundred dollars ($100)
less.)
WATI7R HEATER WNENUELECTR
I ccrti fy that rima FerfornxncenI the work for which this petit is issued, l shall
s
not employ any ny,/rs t i any manners o be m c m the Workers'
PAID
WATER SYSTEM/IRFATING
Compcn tion yryr `dCWiform
Appliw&� YYY //Lie.
Data Receipt #
q .¢�
NOTICET PPLICA ermakirt; rtiBwm ofCe Exemption, you should
NEW RESIDENTIAL PLMIL SQ, FT.
TOTAL:
became sub no the kers Cmrr,mationp visions dthe Labor Cade, you must
pothwith comply til such provisions or this permit shall be deemed revoked.
BUILDING FEE l^ O
SEISMIC FEE 5-0J
CONSTRUCTION LENDING AGENCY
I hereby of End most hem is a construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3091, Civ. CJ
TOTAL:
ELECTRIC FT:E
Lenders Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify thm I have read this application and slam that the above information is
correct. l agree it) comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL. FIiE
building construction, and hereby aur tafte represmontives admix city Bremer upon the
move -mentioned property for inspection purposes.
ALTER OR ADD TO MSCIL
CONSTRUCrION'I'AX
(We) agree I sav,f indemnify and keep harmless the City of Cupertino against
s
liabilides,judgmc �I desPenses wti ay accmeagainst mid City
AIR I JANGLING UNIT (TO 10.000 CFM)
in consequence t granting of th tit,
9
AIR HANDLING UNIT (OVER 10.000 CFM)
Signe p :ant/ onl Dow
EXHAUST HOOD(WMUCI)
PAID 2 /_ �.- 72�� fi
�t�/D`Gle(q_j
HEATING UNIT (TO 100,1X10 BTU)
IIA DOUS MATERIALS DISCLOSURE
Receipt#
Wi capplica or future building occupant store or handle hazardous material
defined by the Cupertino Municipal CW., Chapter 9.12, and the HeA,h mal Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL: S 6'0m
VENTILATION FAN (SINGLE RESID)
Coda Section 255E20e19
Cl Yes 0_5�
Will lheapplicunlorfuture building occupanttemequipmemordevices which emit
tiadous coir contaminants as defined by the Bay Area Air Quality Management
ncR
all Yea Er]
BOILER - COMP 3fJP0R 100,000 BTU)
( )
PISSSU NUE DATE
N
FEB�(
EB 21993
BOILER-COMP(OVCR I(NI,IXq BTU)
NEW RESIDENTIAL MF.CIi. SQ. IT.
,
1 have mad the hazardous materials requirements under Chapter 6.95 of the
CaliforniaHwlth&Safety Cade, Scni5on. 25505 and 25534. filym toil that
ifthe builA' acs not currently have alit i. nyr nsibiliry to notify the
V
CITY Ur aur Cl'TI IIVIJ
(capon seymmmwlx mot r I ..oance of a CeniOwx of
'e
O
hemp.
y
ISSUED BY:. Te�hJL�/C'r.
o uuthrti igen Date
TOTAL:
U //,- v OFFICE.