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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
IIUILDING PROJECT IDENTIFICATION
vERMlrrvo. 7 I
1
BUILDING ADDRESS: ���� n/F ✓1 i%/ /Vc� ��
UNIT# LOT
II iJC'ONTRACI'OR'S
SANITARY NO.
APPLICATION SUBMITTAL DATE
-II
O r&�wqlPHONE:
NAME: LIC NO:
NIC
❑
CONTROL Is
ARCHITECTIENO EER: LIC NO:
ADDRESS:
CONTACT: PHONE:
Gq] ^I///�O
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
B❑ LDG -ELEGY 'PLUM MECII
PERMIT ISSUANCE
I�{/�[• 1�3_g0
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby nffitmthet l am liudud undcrprovisions ofChapsor9 (commermmg with
APPLIANCES -RESIDENTIAL
B E CRIPfl0p1
' 1 I/,. %O 4 yam., II a s/
PANELS
5.....n 7(gm) of Di ' to the Bmine.a f yC•pd d items is in
W �I/i/ f
full three end effa %✓1
Lice 15 Lic.N pJ/l
UPT0200AMM
1Yfvf"A_]Ir`T,"A
r
Du Cnnrncmr (/I
HITECTS ATI N
1 undemm�d my plans shell be used as public records
201- 1000 AMPS
I •� (�'
OVER IOOOAMPS
SQ. FT. FLOOR AREA $/SQ, ff.
SIGNS ELECTRICAL
'
_
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIALCIRCUIT/MISC.
I hereby affirm thin 1 am exemptfrom the Contncmrs License Law for she
,
TEMP. METER OR POLE DIST.
following match. (Section 7031.5, Business and Professions Code: Any city or county
which requires a Permit to commuct, alter, improve, demolish, or tapir any structure
inform its issuance, also requires the affliction for such permitto file a signed statement
POWER DEVICES
Nat he is licensed pursuant to the provisions of the Contractor's License law (Chapter
9(commencing with Section 7") of Division 3 o the Business and Profescioru Code)
SWIMMING POOL EIPCTRIC
VALUATION '
Sectionat 703 escrepL5by thercfnmand she bmisforshea.egedexemption. civil carof
Section ,her vs, any dyed dent for $ 00). objects the apPiicanno a civil pdelry of
not ...,her five hunthopro dollar ($Sap.
❑ eroflM1e
gforWei(Sm.7om,Bmilon,
t �w
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR _SQ. FT.
STORIES
TYPE. CONSTRUCTION
will do s"cttmisnempcndM roffe
oaewe node: sh, Bminer
fmole(Sm.to
fework, Coreisnoti License awdo
and Professions Code: The tumr. Liana law dins an
apply lf an owner of
propown enywho improves ch or
own employees, ebu pmvid that such imprmementsnm not w
yees, pdamimprot suchinquove entimwho eanimende hrofferorsluoughde. If,
mpl feted for sale. Ir,
OCC. GROUP
RES. UNITS
TOTAL:
r improvement e fie
huilder ill havetie buren fmovin issold within n, year ofcirpoweion,far the Imposes, f
builder will have the burden of paving that hepid not build or improve for puryose of
ole.).
❑ I,pownerofthe plopeny,emezclusi_elyaonlnctingwiNlicenud conitaztonm
-'
QTY. PLUMBING PERMIT FEE
FLOOD ZONE,
"Nonswct
she project (Sec. 9044. Badrew and Professions Code) The Cmarecore
Lice se LawdoesnoruPplysomewnT/mfpmo nywhehuildsmimpmvesthercon,end
IF—
PERMIT ISSUANCE
who contract forsuch projects with amermactods) lic<medpoomentlothe Contractor's
License Law:
ALTER -DRAIN&VENT- WATIiR (EA)
- FEE SUMMARY
,❑ 1 am exempt under Sec. , B & P C far this mason
BACK FLOW PROTECT. DEVICE
D
SANITARY Y N
Owner DaleRECEIPfp
DRAINS- FLOOR, ROOF, AREA, GOND.
WORKMAN COMPENSATION DECLARATION' ''
SCHOOLTAX Y N
❑ Thembyaffirmthatlhsvmceni0cmeofCMMtIOulf-insurc,oraaNRcauof
Wm kers' C fed copy do ( 800, Lab C.) which
coven all employee' �crf�
Policy# "' r
RECEIPT
FIXTURES - PER TRAP
PARK FEE Y N
M
GAS - EA. SYSTEM -I INC. 4 OUTLETSRECEIPT
- BUILDING DIVISION FEES, .
Com Certified copy is hereby fumis ed.
OAS - FA. SYSTEM -OVER 6 (EA)
PLANCIiIiCK FEB
GREABPJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
"Clilificd cmpy is Bled with the city inspection division,
CERTIFICATE OE EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY HE
This section need not be completed if Ne Permit is forces, hundred duller ($100)
rales..)
WATER HEATER WIVENTIELECR C1
I certify Nat in dre perfomrdithe wants forwhich N pvmit is issuM, l.hall
not employ any person in any muuter so " t pecante bject to Ne Workui—L
PAID
Compenorion laws of Califomie. Date
_
WATERSYSTEWMEATING
Date Receipt#
ApplicantX111
NOTICE TO APPLICANT: rm C to of Ex e u
-
NEW ftESIDENIIAI. PLMB. SQ. FT.
-
- TOTAL:
become cubjecuothe Worker viaionsof N<La eauunt
cs
foMwishcmmplywithauc m upamit #�
-
BUILDING FEE
SEISMIC FEE
CONSTR ON LENDIN`q/s��a�+`,f��f'ae}_-
I hacby of lino Nm mere is reasur ion lend,Ii., a1e, for the performance of
Ne work for which Nis permit is issued (Sec. 3097, Civ. C.)
- p
ELECTRIC FEE
Lenders Nome
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address -
I certify that I have read this application and state Net Ne above information is
correct. l agree to comply with all city and county ordinances and slate law. relatingm
PERMIT ISSUANCE
MECHANICAL FEE
buildingconsruction, and hereby authodu upresenrliva of Nis city toenter upon the
above mentioned property far inspection Inaptness.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree m rave, indemnify and keep hanrdeu the City of Cupertino agaimt
liabi itim,jud r,co.Is andexpem.whichrvywrmywayacene... mstsadd City
AIR HANDLING UNIT (TO t0,o00CFM)
c nseq f the gmntin
/
-
AIR HANDLING UNIT (OVER 10,000 CFM)
E%HAUSTHOODOVIDUCD
PAID
Signature of Applican Gonuac V Data
HEATING UNIT 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSUREId
Date Receipt
HEATING UNIT (OVER 100.0110 BTU)
'1'nTAC:
Will the epplicom in furore building occupentsmrc mr handle hazardou
m defined by the Cupertino Municipal Code, Chapter 9.12, and the Health a
Care, Section 25532(a)7 -
- ❑ Yes ❑ No
VENTILATION FAN (SINGLE BUSED)
_ p
e M
Will theapplicunt orfuturehuildingmecupent useequipmentorreviceaw
- hazardous air conlmninanL m defined by the Bey Aren Air Quality Ma
District?
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter
DA TO -
•�'AI .••a^1
AIA $(
,'PTH 8 19,5
�s /asii `s�J
- VII y Ui
NNU
BOILER- COMP (111P OR 106,000BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ. Ff.
-
ety Code,
enifthe
J3 andsponsi Iumdenif
Hgdoes
uil of curentlybectiom255o5,255
the builJing roes nm curten0y have atenent, Not it it my responsibility m,pccupapt m s mem a ma hotmissucq.s�a Ce
7s,\Ja/,g_•_,cy, lel%s(%b (/Jl�/
ISSUEDBY:
O neeror au onzed qktL,,.�Date
- TOTAL:
OFFICE