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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'CITY OF CUPERTINO•- nLRMICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING• MECHANICAL
BUILDING PROJECT IDENTIFICA'FION
PERMITNO.
/�
L 877
ILDING ADDRESS:
SANITARY NO.
APPUCATIONSUBMTITALDATE
1 4 G� H K� QI Aa G'i
UNIT# LOT#
�?
NF.RS NAME: P
V
C NTRACTOWS NAME: 4 -IC NO:
P ✓L
CONTROL #
BUILDING PERMIT INFO
ARCHITECI'/ENGINF:IiR: LIC NO:
0N/C
S L VS M 0/1rS r3 L v
// '
QTLY, a '. GEEE C If FEE
.d r'
CONTACT: PHONE:
/ CC [,
15 OIS .-2 ff V ss- 5-291 ry
BLDG E PLUMB MECH
� D�
N
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARA'OON
I hereby affirm that I am I iceazed under previsions of Chapter 9 (commancing with
APPLIANCES- RESIDENTIALis
ES RIPfO
PANELS
UP T0200 AMPS
Smimn 70(10) of Division 3 of the Business and Professions Code, and my license is in
full Lt..force and effect- JO
License Class G Lic. N._
I.
_..
Dated Conuuror ✓��
ARCHITECTS DECLARATION
1 understand my plans shell M used as public retards.
!r1cT/�1�1_GC/A-
201- 1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
SRQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER BUILDFA DECLARATION
SPECIAL CIRCU1T/MISC.
I hereby n. (Se that 1 urn exempt from the Co Professions
Co License law for thefollow
rag reason 703 L5, io Cade: Any city treasury
arneae andove,
TEMP. METER OR POLE E4$T. I —
which Permit to t, de li repair any tate ent
which its issuance,
n permit re censused, alta, Improve, demolish, file
prime its Neapplrcmrfor such
pp
P. a
.. .. ..
POWER DEVICES
mint. the La (Chaltnt
that he is licensed putsuam m the provision of Ne Convener a License Lew (CTapttt
uselms License
9(commencing with gmd.n 7000)of Division3ofNe Business and Profesaione Code)
SWIMMING POOL ELECTRIC I
ALUATION
ser Nm he is enempnhemfrom and rhe buil fmthe alleged exception. Any violation of
Section 7031.5 by my applicant for u pertnir aubjecu rhe applicant in. civil pevhy of
r
OUTLETS-SWITCHES-FlXTU S
r marc than five hundred dollen ($500).
❑ 1,uownerofNepmperry,ormycmploy«swiN wzgesurheirmlecompensedon.
NEW RBSIpF/J'f1AL ELECTft . FT.
STORIES
TYPE CONSTRUCTION
will do the work, and the rructum iz not rounded or offered foreds (Sm.7044, Businesa
and Professions Code: The Commemrs License law does not apply to an owner of
propertywhaburldsorimproves Nereon,and whodom suchwork himselforman lihis
ownemployms.pmvidedihetsuchimpmvemenuamnm intendedmofferedforsale. If,
OCC GROUP
RES. UNITS
however, the building or improvement is sold within one yearafeompletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale)_IY;t
❑ 1.asownerofthepmpeny,emexclusivelyconuuaiagwiNlicenudconu wmw
-
QTY.-.� PLUMBING PERMIT FEE
FLOOD ZONE
APN
The Commodes
construct the project (Sec. 7044, Business and Professions License
LicenLaw does organdy pman owner of propany who bur Id s or i m proves Merton, and
PERMIT ISSUANCE
whacontracts for such projects with a contractorad Branded usuanuurhe Contracers Law.
Liven.
ALTER - GRAIN &VFM-WATER (EA)
FEE SUMMARY
❑ l am exempt under Sec. , B & PC for this mason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPTp
Owner Dote
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Ihertby.ffirm Natihavcacertificete of tunsenteself-itasure,macenrfacaRof
WorkeFlXTURFS
e.,e. s'Comp.,'iond"I, Insurance
permit. ifrdcopy thcmof(Sx.7g00, Lab C.) which
avers all employee's under Nis permit
Policy #
RFCEIPT#
- PER TRAP
PARK FEF, Y N
RECFIPTN
GAS - FA. SYSTEM -1 INC. 40UTLE1'S
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(G)
PLANCHECK ITE
❑ Certified copy ra hareby famished.
GREASMNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenifedcopy is fled with Jen city inspection division.
CI?RTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not be completed Blind permit is for ane hundred dollars(SI00)
orleas.)
WATER HEATER W/VEN/ELECTR
I certify that in the performance of Ne work for which Nis permit is issued, i shall
not employ any person in any mountain m u in become subject to the Workers'
PAID
Cmd,mds1md Lawsof Caifmnia. Date
WATER SYSTEM/IRFATING
Dau Remit,#
Applicam
NOTICETO APPLICANT: If, after making this Cerifeueof Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become mbjecfto the Wmkee, Comisomm n provisions of the labor Cade. you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm Nan the. is a canstmetion lending agency fm she perfomumm of
,he wmk far which this permit is issued(Sm 3097. Civ. C.)
TOTAL:
ELECTRIC FEE
Landers Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that 1 have mad this application and nate Nes the above information I.
correct. I agree m comply with all city and county ordinances and amu laws neleung do
PERMIT ISSUANCE
MEC1{pMCAh FEE
building construction, and hereby sunburn repruenuuves of Nis city merrier upon the
.hproperty
.hove -mentioned far inspection no,dres.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree ro save, indemnify and keep harmless Ne ns
tof Cu A ait
ag
liabilities.judgments,cpe it
osuundexnxswhichmayinanyy;
AIR HANDLING UNIT(TO 10.0x) CFM)
in .asequence of the granting of Nis permit.
I
AIR HANDLING UNIT (OVER IQOIXI CFM)
Signut 0fA VC mixer Dare
EXHAUST FOOD UVMUCT)
PAID
HEATING UNIT(TO 100,000 BTU)
HAZARDOUS MATERIALS SURE
Date Recerp#
Will the applicant tar (mart building ac mar handle havrdous material
as defined by the Caliendo. Municipal Code, Chapter 9.12, and Ne Health and Safety
HEATING UNIT (OVER 100,00) BTU)
TO
Cade, Section 25532(a)T
❑ Yea ❑ No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
WillNeapplicmmrfmurt buildingoccupem uRequipmemordeviceswhichemis
BOILER - COMP (3HPOR IfN1,000 BTU)
BOILER - COMP(OVER 100,(100 BTU)
haMose. air conwminairs m defned by the Bay Asea Air Quality Management
District?
sou [k
P L`y
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yes 11No
I have mud the haszrdous materials requimmenu under Chapter &95 of the
California Health &Safety Code, Sections 25505, 25533 and 25534. I undmnn
ed Nat
�uG171994
i
Natrirs myresponsibilityenmify the
rfthebuildingdocsnotmeents yhaveast
cupam of the rtquircanenu which must he met prior m issuance of a Certificate of
he
Occupancy. �
y .1
CIT
ISSUED BY:
Owner or authorized agent Dare
TOTAL:
OFFICE