27113APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO, ^
L 7113
BUILDING ADDRESS:
U LOT #
SANITARY NO.
APPLICATIONNNSUBMITTAL DATE
V%_f
Q
E SNAME: PHONE:
OR'S NAME: LIC NO:
N/C
CON3ROLp
'ARC HhUPENGINEER: LIC NO:
AD ESS:
CONTACT: PxoNE: -
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG EL_ ECT PL EC
PERMITISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION
Z Thereby affirm thiol 3 of he sed Business and isionsmas Crier and mmecense with
y fallSecmsec tun) ofect. on 3 of the Business and Professions Code, end my license is in
full force and effect.
Licrnse Cluss Lic.#
Date Contractor.
APPLIANCES. RESIDENTIAL
1
PANELS -
UP T0200 AMPS
201- 1000 AMPS
Z ARCHITECTS DECLARATION
ns
I understand my plashall IS, used m public records.
j
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Lmenud Professional
SPECIAL CIRCUD/MISC.
OWNER -BUILDER DECLARATION,
1 hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC.,
following reason. (Section 7031.5, Business and Profce,iaw Code: Any city m cowry
which roquires is permit to consnua, sher, improve, demolish, m repair any spucmre
Prior to its issuance, alas, requires the applicant for such permittee file a signed statement
that he is licensed pursuant to the provisions of the Connectors License Law (Chapter
9(commencing with Section 7000) of Division 3 ofthe Business and Professions Code)
that
0 Sectio 7031. by aill refromnt f the perisforthe tsthedexemption. Any viohtion of
= Section ]031.5 by my dyed doll fore permit subjects the applicant m a civil penalty of
onot mom than five hundred dollars ($500).
❑ I,asownerofthepropeny,ormyemployeeswithwagesastheirsolecompensa6on,
will do the work, rod the swcmre is not imended or offered for isle (Set. 70okl. Business
VALUATIO
���
OUTLETS SWITCHES -FIXTURES ��
NEWRESIDENTIALELECTR _SQ.FT.
STORIES
TYPECONSTRUCTION
and Professions Code: The Convectors License Law does or apply to an owner of
property who builds or improves thereon, and who does such work himselfor through his
ownemployces,provided that such improvememsane rummendedoraffemd hostile. If,
however, the building orimprovement is sold within one yearofcampletion, theo oter-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
OCC. GROUPRES.
UNITS
��
QTY. PLUMBING PERMIT FEE
L PERMITISSUANCE
❑ I, as owner ofNeproperty, arnenclueively contraring with licensed conpacmrsm
onsuuct the project (Sec. 7044, Business and Professions Cade:) The Contractors
License Lawdoes not apply to an ownerofproperty who builds m improves thereon,end
FLOODZONB
APN
whmcrmacts forsuch projects with a conpactm(s) licensed Pursuant to the Compactors
License Law.
❑ I am exempt under Sec. , B & P C for Nia reason
sIi
ALTER - DRAIN & VENT - WATER BEA)
FEE SUMMARY
BACK PLOW PROTECT. DEVICE
SIDEFEES
YN
OwnerSANITARY
Date
WORKMAN COMPENSATION DECLARATION
i ❑ Thereby affirm thatlhuveecenifcam of wnsentmself-insure, arecenificem of
coar Warken'Caployee's makerhiistoracenifiedwpy thereof(Sec. 3800, LubCJ which
ars all employee's under this permit.
Policy #
DRAINS- FLOOR, ROOF, AREA, GOND.
RECEIPT#
SCHOOLTAX YN
RECEIPT#
FIXTURES - PER TRAP ��
PARK FEE Y N
RECEIPT N
GAS - EA. SYSTEMd INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - FA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
GREAS11MIDUSTRI. WASTE INTERCEPTOR
GRADING FEE
CERTIFICCOMPENE OF SATION INSURANCEON MOMORKERS' ��'"
C EPSE�RA� r^ Its", 11
>.
SOILS FEE
(This section need ambecompleted iftbeperotit is for one hunNed dpllers($100)
or less,)
SEWER SANITARY -STORM EA, 2Q)
P.NERGY FEE
1 nify Nat in th peKormance of Ne work for which this Permit is issued, I shell
no ploy any person in any manner ea m m bees, e pp e t to the War em,
A liensmirn la sof Cal' Date `u`
PP
WATER HEATER W/VVE /ELEC'[gs
/ "
- " " "
PAID
Date Receipt#
WATER SYS E N
NOTICE T) Aa CANT: IF, after making this Cenificam of Exemption, you sh Id
become subject m the WOA&s Compensation provisions ofthe Labor Code, you
forthwith comply with such provisions or this permit shell be deemed resulted.
SQ.
--�
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for Ne pea Iia ance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
SEISMIC FEE O
TAL
ELECTRIC FEE
Lenders Address
I certify Net 1 have read this application rad state Nat the above information is
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
ISSUANCE
correct. I agree to comply with all city and county ordinances and state laws relating toPERMIT
building construction,d hof
construction, enereby authorize representatives this city m enter upon the
shave -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless, the City of Cupenum against
liabilitice,judgmenis.costs radexpenses which may inany way accrue against said City
c of the of this permit.
MECHANICAL FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO II,000 CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER IO,glp CFM)
111,0696 r
�a
EXHAUST HOOD(W/DUCr)
lg erre ofA ploart/Con or Date
PAID
HEATING UNIT (TO 100,000 RTU)
HAZARDOUS MATERIALS DISCLOSURE
Dote Receipt is
Will the applicant or future building occupant store or handle hazrrdous material
as defined by the Cupertino Manicipal Code, Ch -per 9.12, and the Health and Safety
Code, Section 25532(.)1
HEATING UNIT (OVER 100,000 BTU)
TOT
VENTILATION FAN (SING LE RESID)
13 Yes El No
ceswhichemit
Will the applicamtrom, nBay
ISSUANCE DATE
BOILER- COME(3HP OR 100,000 BTU)
,building by the
hazardous air <onaminants as defnetl by the Bay Area Ah Quality Management
Am. Air unlit
Moo,'BOILER
- COMP (OVER 100,000 BTU)
❑ Yes ❑ No
PAy
NEW RESIDENTIAL MECH. SQ. Fr.
have read the hazardous materials requiremeals under Chapter 6.95 of the
Califomia Health & Safety Code, Sermons 25505, 25533 end 25534. 1 understand that
if the building does not currently have - tenant, that it is my responsibility to notify the
occupant of rhe napar mens which must IS, met prior to issuance of a Certificate of
Occupancy, a
jDI
® %t U
qct
! a
r� y5� n
$- t. J /
BY:
Owner or eothonzed ager Date/
T .: ISSUED
Of FIC