25524APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIL tl II.UINC-F.I.ECI'RICAL
CITY
BUILDING C DIVISION APPLICATION/PERMIT PLUMUINC-MECHANICAL,
BUILDING PROJECT' IDENTIFICATION
PERMIT NO.
C C f� A
f� G J J G 4
BUILDING ADDRESS:
r UNIT# LOTp
SANITARY
JAPPILICATIONSUBMITTl. DATE
/0 /
OWNERS NAME: PHONE:
T ,Qr 1
CONTRACTOR'S NAME: LIC NO:
2.& 3
/C
CONTROL#
RJCIIITIeCT � GINEER: LIC NO:
A DRESS:
II �
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�i�l(` El El El
Z�Pw(�
1 �]
PERMIT ISSUANCE
LICENSED CONTRACTORRA
'S DECLATION
I hem by a(fi onNet I am licensed under pmv inions of Chapter 9 (commermi ng wi th
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7")of Divisaion 3 of the Business and Professions Cade, and my license is in
fall too
falllns can ffec)..
PANELS
Class il�C4 LIC.# 62338y
Claes,
UPT0200AMPS
Dae Conmaaor
-" 1, �•r•\V
- I" AMPS
RCHITECPS DECLARATION
I understand my plans shell be used as public records.
OVER
OVER 1000 AMPS
SQ. Ff. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL /
I N
Licensed Prnfcssionel
OWNER -BUILD DECLARATION
SPECIAL CIRCUIT'/MISC.
I hereby affirm Nfrom I am exempt Gum the Gonion Co License Lew for the
703Lmr, ainm andve.
Code:epairm orcountycture
TEMP. METER OR POLE INST.
which requires n
whichfollowing oresa Permit to demolish,
construct, alcor, improve, demolish, ar repair any rnuaem
4-.
e.alsoto
of r such the Copermiuo fileLice se La staemem
prime itsiensual pursuant to the previsions
9 (commencing is (icnw pursuem m00 provisions of the Ce Business ProfessionsaCode)
and Pro Law ns Code)
theeed
9thathisxemithominnt
POWER DEVICES
/ Q
SWIMMING POOL ELECTRIC IL
VALU ON
and basision3af
exemption. Any
onto 7031.empt Nemfrom end the Peris mit is thedlican civilp nattyation of
Section ]031.5 by any applicant fora permit subjecrx the applicanno a civil penalty of
OUTLET'S - SWITCHES - FIXTUR
not mom than ofthe rarery,,ormye00).
tlei(sole c0m,
❑ Lusnwrk,andepsanctu ormyempinyedorofweal
NEW RESIDENTIALELECTR _SQ. FT.
STORIES
TYPE CONSIRUCHON
will dnthewons and the sanctum Commnue for Business
Sec. R144, Business
License
andpro Professions Code: The Contractors License Lew docs not apply to an owner of
Law to
prnpemplhte,proviiimprovesalsu Nemon, and pmvementsumnsuchwd himrfemdthmugb his
employees provided avehimpmvemenuamnotiear dcdmpletiod Thr ale.
OCC. GROUP
TOTAL:
pr r-
however, the have the burdenaff mem is sold a didnone year or improv far the owner-
builder will hove the buMen ofproving that he did ret build or improve for puryou of
QTY. PLUMBING PERMIT FEE
ale.).
❑ I, asowncrofNepmperty,amexclmively contracting widrlimnsed conhacmnro
FLOOD ZONE
E-N
oaswct the project (Sec. 7614, Business and Professons Code:) The Conscience.
License Law does marthfi,or rn mx erofpmpmy whobiildsorimpmvestherecn,end
PERMIT ISSUANCE
whocomansm; forsuch projects with a contractors) licensed pursuenttothe Commetofa
License Law.
ALTER - DRAIN & VENT- WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this meson
BACK FLOW PROTECT. DEVICE
F
SANITARY Y N
RECEIPT#
Owner Date
DRAWS- FLOOR, ROOF', AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a certificate ofcoment to selfinsue, or a certificate of
Workew Compensation Insurance or a certified ropym0.
theof(See. 38Lab C.) which
SCHOOLTAX Y N
FIXTURES -PF,R TRAP
PARK
PARK FEE Y N
coven all employee's under this permit
Policy#
ET
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT'-
BUILDING DIVISION FEES
Com ny
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
'cnifted copy is hereby famished.
❑ Certifial copy is fled with Ne city inspection division.
GREASPIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM FA. 200FT.
ENERGY FEE
(This section need not be completed ifthe Permit is forone hundred dollars ($100)
or less.)
WATER HEATER W/V5NT/F.LECTR
I cenify that in the performance ofthe work for which this permit is issued, l shall
not employ any person in any manner ao as to become subject to the Workers
Compensation Lawsnf Califomia. Date
Applicant
WATER SYSTEMIMEATING
PAID
Dem Receipt
NOTICE TO APPLICANT: If, after conking this Cmificate of Exemption, you should
become subjecuo the WmkeTs Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
forthwith comply with such provisionxor Nis permit shell be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 hereby affirm Nat there is a construction lending agency for the perfommnce of
the work for which this permit is issued (Set. 3097. Civ. C.)
Lender's Hume
- TOTAL:
ELECTRIC FEE
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING PEE
1 certify that 1 have meed this application and state that the above information is
comet. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction. and hereby auNnire mpresentativesof Wsciry in emerupon the
above-mcn ioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(WO agree m save, indemnify and keep harmless Ne City of Cupertino against
lin 'udgmrnm,<osmandexprnus which ymaty ay accmcagainst said City
AIR HANDLING UNIT (TO 10,000 CFM)
to rn qurnc egranrng of thispemth.
S
AIR HANDLING UNIT (OVER 10.gp CFM)
Igoe are m CmarmG( Date
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT (TO 100,000 BTU)
Dae Recei t#
HAZARDOUS MATERIALS DISCLOSURE
material
Will the applicant orfuture building occupant Caperreor handle Health
as definN by the Cupertino Municipal Code, Chapter 9.12, and the Hcehh and Safety
L
HEATING UNIT (OVER I00,000 BTO)
VENTILATION FAN (SINGLE RESID)
Cada, Section 25532(e)9
0Yes ❑ No
lusWill theacormanincers rebuilding by the Bay Area Acre Quality a armati emit
District? air conuminants u defined by the Bey Arca Air Quality Management
District?
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
Pik p ' D
r Pi
BOILER - COMP (OVER 1(0,000 BM
❑ ❑No
limitations
I have read thelimitations materials requirements under Chapter 6.95 of the
(y�sp�.
n
vbl� 1993
NEWRESIDENTIALMF.CH. SQ.FT,
California Health & Safety Code, Sections 25505, M533 and 25534. 1 understand that
ifthe does currently h ve a the it notifytheof
CI I Y ear
1
_
aluirm w h must tsnl
cupnnt of the rcyuirememe which must be met prior b issuance of a Certificate of
0 iresponsibilityseana e
VVr Ci1111 J
Occupancy.
Sys i.f/
ISSUED BY:
Owner m authorised agem Date
TOTAL:
OFFICE