T 28074APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
HICAL
CITY OF CUPERTINO x am H - MEC ANICA
BUILDING DIVISION APPLICATION/PERMIT PLUMPING � MECHANICAL
BUILDING PROJECT IDENTIFICATION
No. O 0
O 4
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATE
Da UNITN �/ LOT IT
OWNERS NAME: PHONE: ass -q/00
CONTRACTOR'S NAME: x LIC NO:
f
NIC
CONTROL#
ARCHITLCT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC ARMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
ya prop ( gwi0
IhereM1 ffirtn thmlam licensed under sinnsMChe ter9 commencin
Section 7") of Division 3 of the Business and Professions Code, and my license is in
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
`
full farce enA effect.
License Class _ Lot4
UP T02W AMPS
Date Imametor��,,//
ARCHITECTS DECLARATIONrj Yao6//G
201 - I" AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER Hot AMPS
1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
"
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
Law for the
I hereby affirm.(Se That I am exempt from the Contractors e: An, city
following reason.(SectionconstruBusiness and Professions Code: Anycity
_
TEMP. METER OR POLE (NST.
epee improve, demolish, m repair any structure
structure
which requires a permit to quires the file signed statement
prior to its rsuchthe
POWER DEVICES
licensed pursoret to the pr visio sof
Co puter's Lice
that9(c he islicensedwith Section of previsions the Computer's License Law (Chapter
9 (commencing whh Somlon ]000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt mrefmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant fora permit subjects the applicaano a civil penalty of
OUTLETS -SWITCHES -FIXTURES
not morethan rive hundred dodors rmyem).
❑ I, wok,
NEW RESIDENTIALELECTR_SQ. FT.
STORIES
TYPE CONSTRUCTION
Business
The inaleproperty,ormyemployixictohwagesavhei(Sec. 70,4 LB Business
will do[hewons
and Professions Code:'fhe Contractors License Law does not apply m an owner of
and Code: Th Coreisnetimendederofwdoes cut apply
property whobuildsor improves thereon, and whodoes suchwork hineselforthrnughhis
own employees, Movidedthat such improvements Tracor intenshdmefferedforsale.IL
OCG GROUP
RES. UNITS
TOTAL:
however, the bulldingor improvement is sold within one yearofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
tele.)'
❑ I, asownerofihe property,Tm exclusively contracting with licensed contmcmrsm
construct the project (Sec 9044, Business and Professions CmRJ The Contmmors
License Lawdoesnotipply to enownerefpropeny whobuildsorimprovesthereon, and
PERMIT ISSUANCE.
who contracts for such projects with a contactors) licensed pursuan[mtheContme[or's
License Law. ,
❑ I am exempt under Sec. , B & P C for this reason
ALTER - DRAIN & VENT - WATER (PAT -
FEE SUMMARY
BACK PLOW PROTECT. DEVICE
OUTSIDE FS
SANITARY Y N
RECEIPT#
Owner Date
DRAINS - FLOORROOF, AREA, COND.
, ,
SCHOOLTAX Y N
RECEIPT IT
WORKMAN COMPENSATION DECLARATION
(hereby affirm that l have a cenlficate ofewasent to self-imare,ora cartificeteof
Worker.,'Compensation Insurance or a cenified copy thereof (Sec. 3800, Lab C.) which
ars all employee's under this IT it lArtif=tt
Policy#
PIXTURPS - PER TRAP wt
.. »+m.^!^-"' tri^'+"P"'
PARK FEE Y N
RECEIPT#
'6'A '-SEA. SYSTEM -I INC. 4 OUTLETS I'
BUILDING DIVISION FEES
Company rax—_
❑ Cenifiedcopyishoebyfumished, p ,r
❑ cenified copy is fled with the cityimpection division.'t5
GAS- Y EM ) :I
Sl
PLANCHECKFEE
LEADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS'
GREAk$OILS
FEE
COMPENSATION INSURANCE
SEWER -S RY-S Heyo
ENERGY FEE
(Thissection need no[be completed ifthe permit is Redone hundred dollars($100)
in less.)
I verily that in the performance of the work for which this permit is lesdeQ, l alittl
LECTR rl
not employ any person in any mammy so as to become subject m he Works
Compensation Laws of California. Date
PAID
Date Receipt#
y,.'
_ WATER SYSTEMGrREATING, ,�ppw;;ipxNVtt'"Ttt'
APPlic.,
NOTICE TO APPLICANT: If, after making this Certificate MExemption, you shdEMA
Ifl'¢u "NEWI2 1DENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be, deemed revoked.
BUILDING FEE
SEISMIC FEE "
CONSTRUCTION LENDING AGENCY
1 hereby offmt that there is a compaction lending agency for the pMom arce of
the work for which this permit is issued (Sec. 3097, Co. C.)
TOTAL:
ELECTRIC TEE
QTY. ,. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Name
Under',, Address
I verify that I have read this application and stare that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby amhodae representatives of this city to enter upon die
above-mentioned property for inspection purposes.
ALTEROR ADDTO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFM)
(We) agree to save, indenmify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any ayaceme agaiensaid City
AIR HANDLING UNIT (OVER 101" CFM)
in consequence of the gryptin ,x
or
EXHAUST HOOD(W/DUCI')
PAID
Signarmid'Applicant/Cmucactor Date
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
- Date Receipt#
HEAPING UNIT (OVER 1 W,Of10 BTU)
TOTAL:
Will the applicant or future h ildiag occupant erre or andthandle Health a material
t b
as defined by the Cupertino M pal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)]
❑ Yes Nn
ISSUANCE DATE .
Will heapplicad or future building occupantuse equipmentmrdeviceswhich emit
BOILER- COMP(SHP OR 100,000 BTU)
1/
PAID
brooders air contaminants as defined by the Bay Area Air Quality Management
BOILER (00,000 BTU)
'
DistricIT
NEW RESIDENTIAL MECH. SQ. M.27
11 Yes ID No
1995
1
n�uN
I have read the beauteous materials requirements under Chapter 6.95 of the
(a s7J
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building dcesnTt curtentiy have etenanh that it is my responsibility to notify the
Ur IJU
occupant o�nts w " must he met prior m hivan Cen}�cat, of
OccupaR`y , � � �/J�
TOTAL:
Owner oofala dagent �DDaate
ISSUED BY:
OFFICE