24503APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO- , R A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
N, BUILDING PROJEC-TIDENTIFICATION
PERMIT NO.
/� A 5 0 /�
G 4 J JJ
BUILDING ADDRESS.
SANITARY NO.
APPLICATIONSUBMIITALDATE
/ate
% AlA I ` �++, V AQ V C A%44%_. UNIT N LOT#
V Ned
OWN RSSN k%4 PIIONE-���D
33FV+L`—
CONTRACTOR'S NAME: w n I.IC NO:
NIC
❑
CONTROL#
CHI'fECI'/FIJGINBL'R: IC NO:
ADDRESS:
CONTACT: PHONE,:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PLUMB MECH
PERMIT ISSUANCE
_ )O�g�{'SCRu If TION
C���L5CAR
LICENSED CONTRACTOR 'SDECLARATION
I hereby affirm thus am licensed underprovisiansof Chepter9 (cormnencingwith
APPLIANCES- RESIDENTIAL
PANPIq
Section 7000) Division 3 of the Business and Professions Cade, and my license is in
vON
mu force and affect.
License ClassL.ic.N
UPT02MAMPS
201 -1000 AMPS
Date Contractor
SQ.FEFLOCMAREA $/SQ.
ARCHITECTS DECLARATION
1 understand my plain shall be used ea public recoMs.
OVER I" AMPS
SIGNS ELECTRICAL
Licensed Prafessural
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 License Tow for the
M. thin 1 en exempt from the Comics
TEMP. MFTF.R OR POLE. INST.
Cs
followingreason,(Section 7031.5, Business and Professions Code: Any city or
ngherebymason
which requires Issuance, permit to io. then alter, improve, demolish, or repair any snunurc
structure
to ftleasigned statemem
,bio me ilamed
POWER DEVICES
pstartur$a prviuman.1' be Copeman
the Cnmmcmr's and Pro Lew(Chapter
thinmhe is lacing with Scenes
9 (commencing withh ecoan ]000)Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
err that he is sxempubcrelmm and the basis for the allege exemption. Any violation of
he
Section 7031.5 LS by any applicant subjects the applicant to civil Penalty of
�O l
OUTLETS - SWITCHES - FlXTURES
IS5ermit
t rethanrafbemt rtllarmyem).
campemsiness
eiewrk.
NEW RESIDENTIALELECTR —SQ.
Q
STORIES
TYPE CONSTRUCTION
suaheproperry,arm otimenyedorofwagesasthe(Sim.
ill ahewons anda:
nureisnotimendese
fices not
La do
ad Professions Cade: The Contrerem, License Law done not apply to an owner
iZ apply to
is
own erywyers, pdsrnimprovsatheteanendentimassuchwork himselnonbmugh M1if,
employees,ldin i that for sole. If,
nuarcnot ear
OCC. GROUP
RES. UNITS
TOTAL:
or Improvement sold cu ompleerrd
bowevsq Waas the arImprovemem issoldwithin aneyear or improve for thrower-
builder will hove the burden of proving thin he did nm build or improve far purpose of
QTY. PLUMBING PERMIT FEE
ale.).
❑ 1. as awnerortna propery.em eanaaivelymmaaamg who bamlea aamnemrs,o
FLOOD ZONE
APry
answer the project (Sec. I0a4, Business and Professions Cade:) The Contractors
License Low does not apply to anawner.E.,ertywho bolldaorhmproves thereon,and
PERMIT ISSUANCE
who contracts for such projects with a cormorant) licensed pursuant to the Contranos
License Law.I
ALTER - DRAIN &VENT -WATER IRA)
FEE SUMMARY
❑ I am exempt under Sec. , B & PC for this mason
BACK FLOW PROTECT MY
DE -
ANI rj\jf Y N
RECEIPT,
CII L A YN
Owner Dem
DRAINS - ILOOR, ROO ,AR ,C ND. ^ �'
WORKMAN COMPENSATION DECLARATION
❑ I hereby anion that l have a certificate ofemsem to self -insure, or a certificate of
Workets'Compensationlmuranee orecertifiW espy therenf(Sec. Jglp, L.hCJ which
covers all employes under this permit.RECEIPT#
Policy#
� f� RECF.IPI'p
PA Y_N fq
FIXTURES - PER TRAP ,
1 I I
GAS - EA.SYSTF.MdI .40UTLETS
BUI DING DIVISION FEES
CnmpanY
GAS - EA. SYSTEM -OV 4161) F11C
KFEE
❑ Cenilied copy ix hereby fumisheA.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ CeniBW ropy is Bled with the <iry inspation division
CERTIFICATE OF EXEMPTION PROM WORKERS'
GREASETRAP
SOIhs FEE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA. 200FT.
ENERGY FEE
(This aeutictimed net be completed ifthe permit is formalumared dollars ($100)
or less.)
WATER HEATER W/VENIELECIR
a
I certify that in the performance ofthe work fm which this permit is issued, I shall
not employ any person in soy manner so as to become subject to the Weaken'
PAID
Compensation Lawsof California. Date
WATER SYSTEWREATING
Data Receipt it
Applicant
NOTICE TO APPLICANT: If, after making this Carnivals of Exemption, you Mould
NEW RESIDENTIAL PLMB. SQ, PT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Cods, you most
forthwith comply with such provisions or this permit shall be clamed revoked.
a
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a construction lending agency for the performance of
the work for whichthis permit is issued (Sm. LHP, Civ. Cy
TOTAL:
ELECTRIC FEE
Lenders Name
QTY. MECIIANICALPERMIT FEE
PLUMBING FEE
Lenders Address
I certify that I have read this application and state that the above information is•�
correct. l agree to comply with all city mad county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construclion, and hereby authorize representatives coma city teener upon the
aMve-msnrimaxi properly for inspection purpsxes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree m save. indemnify and keep harmless the City of Cupertino against
liabilities,judgments, amts mdexpensss which may in any way acerae against said City
AIR HANDLING UNIT (TO 10,000 CFM)
mfthegmmingopcnn
iaconscqueo fthisit.
- 4.
11 ^ K`v��
^Crr
AIR HANDLING UNIT (OVER IU,OpU CFM)
HXHAUSTHOOD(WIDUC)
r
PAID
`
S�Ra me�rc actor Dam
HEATING UNIT (TO 100,I0(19TU)
HAZARDOUS MATERIALS DISCLOSURE
Date Remipt#
Will the applicant or future building occupant store or handle rancorous material
as deCovert.. fined by the Cupeno Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
T L:
Code. Section 255]2(.)?
❑ Yes 11 No
VENTILATION FAN (SINGLE. RESID)
ISSUANCE DATE
Will the applicamorfuture buildingacupant tiomquipmetnardeviceswhich emit
BOILER- COME (THE OR 100.000 BTU)
BOILER -COME (OVER 100,000 BTU)
hmmilm, air rmh m mala as defined by the Bay Ana Air Quality Management
imria?
NEW RESIDENTIAL MECH. SQ. FT.
13 yes C3 No
1 have read the hazardous materials regairensom under Chapter 6.95 of the
1ti L9 /Ak
California Health & Safety Code, Sections 25505,25533 and 255]4. I understand that
i� Ft1 LL'l
if the building does not correrttly have a tenant, that it is my responsibility to notify the
occupant of the reyuiremens which most M met prior in issuanre of is Cerifinm of
Occupancy.
ISSUEDHyt
Owner or authorized agent Dane
I IT atia-
�s WWI OFFICE -