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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - r- - . - RICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINGROECTECHANIFIC
BUILDING PROJECTIDENTIFICATION
PERMIT NO.
2 O aI 8 '
G o 1 0 1
BUILDING ADDRESS:
SANITARY NO.
APPLI(WOONSUBMIIqTT-sA�LDATIf
(]
V R. UNIT# LOT
/ a�Qe.7,i'
OWNERS N % PHONE:
MLb a;Ii513 �
CONTRA R'S NAME r 6 3oICNO: �,
N/C
❑
COYIRQL#
ARCHIIECIENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ 9, ❑ IQ
�P`
n
PERMIT ISSUANCE h
LICENSED CONTRACTORS prow DECLARATION
1 hereby offDithat I amlicensed (commencing with
APPLIANCES - RESIDENTIAL.
JOB DESCRIPTION
Sx,iorell(adefDivisian3 of the Business wJ RoPoasimhs Code, end my license is in
inss and roftesions Coder and
fallLie force me eacm p
Cl...` C- 0 Lie.# J�
PANELS
UP TO203Q�
Date
Date ConTSD
ARCHITECTS DECLARATION
Wer
1 us,ond my plans shall he used as public records.
201-1000 AMPS
AMPS
OVER 00110 AMPS
SQ. PI'. FLOOR AREA
8/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby of Ian that I oro exempt from the Commnors License Lew for the
SPECIAL CIRCUIT/MISC. AAda
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair my structure
prior to its issuance, also requires be applicant fmsuch permit to file a signed statement
POWER DEVICES
chat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 (commencing with Section 7") of Division 3 of the Business and Rofessions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exemptahembern and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant m o civil penalty of
- - -
OUTSETSSWITCHESPIXTl1RE5
not mom than five hundred dollars ($500).
❑ I,asownvo0heprop ny, rmyemployceswithwagesm1heirsolecomp mmion,
NEW RFSIDENTAL ELECIR S . FT.
Q
STORIES
TYPECONSTRUCTION
will dothewons and the iamnde 7044, Bus
he Consent se Low
and Professions Code: The Corrientes Law dcea not apply to m owner of
does now apply
rid selme
propenywho b,pmviiimthmsuchimMvc=nts asuctendemmselforfw We.Ns
If.
ownwer,
OCC. GROUP
RFS. UNITS
TOTAL:
thms,pingorimproverimprovemema,e view oecropleemd The own
hnwder, wdl avec a burdenfor the owner-
will have the burden of proving the, he did not build or improve for purpose of
of proving that didnoaeyem or improve
QTY. PLUMBING PERMIT FEE
saltJcr
salt.).
withlicensed
❑ Loa owneraact
FLOOD ZONE
APN
(Sep (944, Business
the projm (Sec. nano nerofaa and Rohobure Code:) The Contractor's
s The Comment's
and Professions
construLicense
e tawdoes inana ofpropeny who end
met tovesthereon,
PERMIT ISSUANCE. -
sed purids
who contracts suchapply
c bac
wicensemctsforsuchprojedswithncomrmmr(s)licensee pumuanno,he Contractors
License Law.
ALTER IEA)
FEE SUMMARY
❑ 1 um esempl under Sec. , B & P C far this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FE -F.9
SANITARY YN
RECEIPTp
"Owner Dme
DRAINS- FLOOR, ROOF, ARFA,COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
❑ I hereby affirm that l have a certificate ofmnsent to self-imme. or a certificate of
Workers' Compensation lnsurmcearartifi
mortified copy thereof(Sec. 3800, Lab C.) which
RECEIPT#
FlXTURPS-PER TRAP
PARK FEE Y N
.
GAS - EA. SYSTEM -I I 4OUTLETS
Povamall employee
licyIT VD
RECEPT#
BUILDING DIVISION FEES
—Of
Company lr
>' Certified copy is hereby fumished.
GAS - EA.SYSTE VER4(EAT
PLANCHECK FEE
GREASrVI TRI. WASTE INTERCEPTOR
GRADING ME
❑ Certified copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
ORE AS AP
SOILS FEE
COMPENSATION INSURANCE
5 ER -SANITARY -STORM EA.!2WFT.
ENERGY FEE
Tllix section neeenotbe completed iflhe permit is faro. hundred dollars ($100)
orless.)
WATER HEATER W/VENT
I certify that in the perfrmnance offte work for which This permit is issued, l shall
not employ any person any mas=erso as to became subject ao the Workers'
PAID
CompensationLowsofCalifomin. Date
Applicant
WATERSYSTRIWAl G
Date Receipt#
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
NEW RESID I.
TOTAL,
becamesubject in the Workers Compensation provisions of The Labor Code, you must
forthwith comply with such provisions or This permit shall be deemed revoked.
BUILDING PEI:
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
L hereby affirm that Nthem is a connotation lending agency for e perfmirwomNe work for whichthis permit is issued (Sec. 3097. Civ. CJ
ELECTRIC FEE
lender's Name
Q MECHANICAL PERMIEE
PLUMBING FEE
Ieader'a Address
I certify That I have read this opplicmion and state that the above infommtion is
correct. l agree to comply with all city and county odinumm and nate laws relating to
PERMIT ISSUANCE d
MECHANICAL FEE
building construction, and hereby amo nm mpmmnt,ives of thia city tocmer.,a the
above-mentoned property for inspection purpose.
AL7ER OR ADD TO ME
CONSTRUCTION TAX
(We) agree to sive, indemnify and keep harmless the Ciry, of Cupertino agolnat
Iiahiliric,judgmemacosts and expenses which may in any way ucmewainat wit City
J
RHANDLING (TO 10,000 CPM) �–
in consequence of the granting of This permit.
AIR'ft#19WKGUNIT (OVER 10,000 CFM)
Signsumeof Applican4Cionscum - Data
EXIEAUST HOOD(W/DUCT)
q�
PAID /�^/7
tl
HEATING UNIT (TO 100,0011 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date eceipt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will the applicant or future building occupant Wore or handle hmardous material
m defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
FAN (BINDLE RESID)
If
Cole, Section 25532(o)7
0Y. )(No
K.No
BOILER-COMPOHPOR 100.00013111)1$SUANCE
DATE l
/_ t
Will theepplicmapplicant building occupant use equipmmmreeviceswhichemi,
BOILER - COMP (OVER 100,Dw BTU)
•h.dous air canmminanls as defined by the Bay Arca Air Quality Management
District?
❑ Yes No
P A G D
NEW RESIDENTIAL MECH, SQ. FT.
I have rend the hamrdous =,trials requirements under Chapter 6.95 of the
JUN 30 1995
California Health & Safety Code, Sections 25505.25533 and 25534. 1 undershond that
if the building does not currently haven tomm,,hat it is my responsibility m notify the
occupant of the requirements which must bo met prior to issuance f a Cenificme of
Oen Icy. P o
cil1 Ur Wr'" I'IN�l
ISSUE
Owner ar auNonzed agent Date
TOTAL:
OFFICE
j