25974APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONI v
CITY OF CUPERTINO BUILDING- RI AL
APPLICATION/PERMIT - PLumewG- MEcxnrvlcAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMITNO.
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BUILDING ADDRESS: /� /�� l�pt-"+-•-r^
/o� 3(� VfRV% L rte£ C)1'? DNITIk ... LOT#
SANITARY NO.
APPLICATIONSUBMTITALDATE
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OWN2R$; AME: PHONE: O
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CONTRACTOR'S NAME: LIC NO:
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RCHITECT/BNGINEER: LIC NO:
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oNTnCT: pHONe:'
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
B E E MECy
_
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION
L l hereby affirm that l am licensed under provisions of Chapter9(commencing with
J Section]WO)of Division3of The Business and Profess ions Code, and my license is in
force and effect.
License Class Li, It
AppL1ANCES-RESIDENTIAL
PANELS
UP TO 200 AMPS
TOB DESCRIPTION
n Data Contractor
ARCHITECTS DECLARATION
I underetand my plans shall be used as public records.
201. 1000 AMPS
OVERAMPS
FT. FLOOR AREA
S/SQ. FT.
CTRICAL
±ASQ.
6 0 L E D
Memod Professional
RCUIT/MISC.
L OWNER -BUILDER DECLARATION
hereby union Mat I am exempt from the Contramirs License Law for Tha
I� nCI
u, bioGo
ER OR POLE INS'r.which
VICES
FUOL ELECTRICVALUATI(�/a
SWITCHES -FIXTURES
followingreason (Section]03L5,Business and Professions Code: Any citymcounty
requires a Permit10 imotmct, alter, improve, demolish, or repair any structure
to its issuance, also requires the applicant for such pemit m file a signedstamment
that he is licensed pursuantto the provisions of the Contractor's License Law (Chapter9(commencing with Section](100) of Division 3 of the Business and Professions Code)
7031.byanyapplicntfPermtstsThnttocivilPnalty Section]031.5 by any applicant forupenni[subjects The applicannoa civil penalty of
not more Man five hundred dollars ($500).
o❑ I.asownerofthepmprty,ormyemployeeswithwagesastheirsolecompensafion,
will do the work,mr!the structure isnmimmndedorofferad forsale(Sec.](144,Business
gPrior
Ei
ENTIALELF _SQ.FT.
STORIES
TYPE CONSTRUCDON
and Professions Code: The Contractor's License Law does not apply an an owner of
property whobuildsorimpmves thereon,andwhodoessuch work himselforthrough his
ownemployees,pmvidMthatsucbimpmvememserenotintendedoroffendforsale.If,
however• the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
UCC.GROUP
RES. UNITS
❑ I, as ownerofthe property, amexclusively contracting with licensedcontraemrs to
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
Licenselawdoesnot aWlym a nownero£property who builds mimprovesthereon,and
PERMITISSUANCE
AL
whocnmracts forsuch projects with a convactor(s) licensed pursuant to the Contractors
License law.
I]1 em exempt under Sec. , B & PC for this reason
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTBID FEES
Owner to
WORKMAN COMPENSATION DECLARATION
❑ 1 hereby affirm that I have a certificate of consent to sel6insum. ora certificate of
orkere'Compensetion lnsumnceormaenlfied Dopy thercof(Sec.3B00, LabCJ which
covers nil employee's under [his permit.
M
-
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECEIPT M
SCHOOLTAX Y N_
RECEIPT is
FlXTURES -PER TRAP
PARK FEE YN
RECEIPT is
GAS - EA. SYSTEM -1 /NC. 4 OUTLETS
BUILDING DIVISION FEES
cmcPol,
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
0 Cert
❑ Certified copy is hereby famished.
❑ Cenifted copy is filed with The city inspection division
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
(This section need not be completed ifthe permit is forms hundred dollars(Sloo)
an less.)
SEWER - SANITARY - STORM M. 200FT.
ENERGY FEE
I certify that in the perfnounce of the work for which This permit is issued. I shall
not employ any person in any manner so as to become subject to the Workers'
Compensation Lawsrf Califomie. Dam
Applicant
WATER HEATER WNENT/ELECTR
PAID
Date Raeiptp
WATER SYSTEMGKEATING
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
forthwith comply with such provisions or this permit shall he domed revoked.
NEW RESIDENTIAL PLMB. SQ. FT.
-
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affimr that them is a construction lending agency for the perfmmaace of
SEISMIC FEE gstL
T
The work for which this permit is issued (Sec. 309], Civ. CJ
ELECTRIC FEE -...�
Lender's Name
Lenders Address
I certify That I have reed this application and sate That The above information is
QTY. MECHANICAL PERMIT PEE
PLUMBING FEE �•
PERMIT ISSUANCE
MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and state laws relating m
building construction, and hereby uuthon= representatives of this city to enter upon the
above- tinned property far inspection purposes.
ALTER OR AOD TO MECII.
CONSTRUCTION TAX
We) agree to save, i mnify and keep harmless the City of Cupertino against
I' ilities,judgments,cost d uses whichmay' y way accrueagniestand City
consequenceofthe Ispermi,.
AIR HANDLING UNIT (TO 10,000 CFM)
,
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCT)
PAID/ Z�6 � O
gnamre ofA icant/Contractor Date
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE -
De a Receip(M
Will the applicant in future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
Code, Section 25532(s)]
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
' El Y., 13 No
it
Willtheecormarinrats
BOILER- COMP(3HP OR 100,000 BTU)
,VS ICtPATE
jr+ 4C liJ/
m*definog by Bay Area it Quaevic Managemench t
hazaMeue yr conuminams ere'defined by the Bey Area Air Quality Managemnnt
District?
BOILER -COMP (OVER 100,000 BTU)
❑ Yes ❑ Na
nI��
JAN 2 31994
JAN
NEW RESIDENTIAL MECH. SQ. IT.
I haveHealth the hazardous materiels requirements under Chapter 6.95 ad the
California Health&Safetyently Sections 25533 and 25534. Iundemtand that
iRhe building does no[ currently have a tenant, that it is my responsibility to notify Me
occupant of the requimmems which as, be met prior to issuance of a Cenitimum of
Occupancy.
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CITY ur Gu-eriI
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BY:
gal
Owner or amhorized agent 1 Date
(� ISSUED
OFFICE
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