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1PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO UfLBINC�:LF.CTRTCA
APPLICATION/PERMIT PLUMBING- MECHANICAL,
BUILDING DIVISION BUILDING PROJECT IDEMfIFICA1 ION
PHRMITNO. 1
f� C A C
G V G J
NILDING ADDRESS:
SANITARY NO.
APPUCATI�ONSUBB`MIITTALDATE
ZZLS UNIT# LOT#fg!!91��
l►��
3WNERS NAME: s PH NE_�_
S ►
CONTRACTOR'S NAME: IC O:
b45
NIC
❑
CONTROLNI
1RCHITF.CT/FNGINEPR: LIC NO:
a'
ADDRESS:
&kII
"ONTACf: PHONE
"
" +"' t ^ "
QTY. - ,.L Y,kGLE(TRIC, PERMIT,"- FEE
is ..kf<k r.. Z. WC•?.
BUILDING PERMIT INFO
BLDG ELECT PLU MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed underprovisionsofChepmr9(wmmwemg with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTIO
PANELS
Section 0000)of Division 3 ofthe Business and Professions Code, and my license is in
full to. and effect.
License Class Lic. N
UP TO 200 AMPS
-
201- 1000 AMPS
Dam Con'.
ARCHMTS DECLARATION
I understand my plans shall be used as Public records.
OVER 1000 AMPS
SQ. FT. FLOOR
$/ Q. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 License Lew for the
that 1 .m exempt from the Camionex
TEMP. METERORPOLE INET.
Cs
followingreusoa.(Section
ngherebyma n. (Se Code: Any drymwunry
onstruBusiness endue,
which itsissanpermit re construct,ahem improvgdemolish, fimpeigned structures
construct,demolish,
prior es requires theapplicantforsuch filets signed statement
SOWER DEVICES
lisenses!,ulso mumtt Comermitm
Licand Pre Lew (Cheater,
that be is IicensW d, recti m the proviai isi of the Ce Business
9 Division 3oflhe Business end ProfyviolaCode)
ixem it
SWIMMING POOL ELECTRIC
VALUATION
tSeeiromandthe
that he is
smith 7031.5 by yapplimrdthe hasPeriat subjeasegedexcmpti to My violation of
L5 by n dent for n Permit subjects the applicant a civil perlry of
OUTLETS - SWITCHES - FUTURES
no amn than u dred
ern m1,..a.fi,.f undreddollormyem).
❑ I,m, fthepropeeum,
NEW RESIDENTIALELECfR _SQ. FT.
STORIES
TYPE CONSTRUCUON
I..tmaindimm.flaed for ia(Sele 014, Bunion,
.,k, a of Business
is
will Bothework, ands:
he Coeisnot
License La
end Profusions Code: The Contractor License Law does not apply lf am owner of
does apply to an
property who buildsorimprovcathcreon,anti whodaee such workhimselforthroughof
wn evert.yea,p v Threats.
iearoftd
OCC. GROUP
RES. UNITS
TOTAL
mpletired
ingori praurmonis soldwithinone r.
however, theavet a arimprovementishat he id nt build or improve
builder will have the burden .[proving that he did not build or improve for purpose of
omm eforthrpose of
"
Q �' .� PLUMBING PERMIT FEE
ole.).
❑ I,asownerofthepmNny,umexclusivelycontrectingw ffilicwsedconv tomto
FLOOD ZONE
APN
construct the project (Sec. 71 , Business and Professions Code:) The Con manor's
Li cense Law does not apply to r ow net of property who builds transitions. thence, and
PERMIT ISSUANCE
whocontracts ferauch projects with acontmchms) licensed punumt man, Cometin's
License Law.
ALTER-DRAIN&VENT-WATER(EA)
FEE SUMMARY
❑ I am exempt under Sm. • B & P C fm this reason
BACK MOW PROTECT. DEVICE
TSD E S
SANITARY Y N
RECEIPT p
Owner Data
DRAINS- FLOORROOFAREACOND.
, , , .
ORKMAN COMPENSATION DECLARATION
SCHOOL TAX V N_
RFlyi
lJ (hereby eWmtthetlheve ecenificate of cmtsmtm self -insure, ore cenificem of
�Yvrrse Comprradioo Insurance or a cenifiad cagy thereof (Sec. 3800, Lot C.) which
acne Ilemployaiunder this permit.
'Policy N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE RECEIPT# N
GAS - FA. SYSTfiM-I INC.4OlITLEfS
BUILDING DIVISION FEES
Company
GAS -G. V
PLANCIIECK FEE
❑ Ceni0ed copy is hereby furnishes.[3Cenifiest
'REAS US A U AS INT�RCE t
GRADING FEE
copy is Filed with the city inspection division.
CERTIFICATE OF EXEMPDON FROM WORKERS'
GREASE " f
SOILS FEE
COMPENSATION INSURANCE
(Thissectimimadi not bccompleted lfthe Finanot ie fomes hundred dollars($100)
SEWER - SANITARY - STORM EA. . /
ENBROY FEE
or leu.)
WATER HPA
I certify that in the petfneam. of the work for which this permit is issued,[.hall
not employ any person in any mems, an o to became subject to the Workers'
PAID
Comperosation Lawaof Califrinia. Data
WATER SYSTEM/CREATING -
Date Receipt#
Applicam
NOTICE. TO APPLICANT: If, after making this Cer ifiate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker! Compensation provision of the Labor Code, you must
forthwith comply with such provision or this pard, shall be domed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affrso that them is a construction lending agenry, for the performance of
he work for which this permit is i ... ad (Sec. 3090, Civ. C.)
sill
ELECTRIC FEE
QTY,": `' MECHANICAL PERMIT FEE
PLUMBING FEE
Leder. Addrcu
I cenify that 1 have read this application and statetort the above information is
contact. l some mcomply with all city and county ordinances and state laws mlming to
PERMITISSUANCE
MECHANICAL FEE
buildingcmuuvction, and hereby authoris repremm atives of this city toemer upon the
above-mentioned propery for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(WO) agree to save, indemnify mW keep hamtless the City of Cupertino against
liabilities,judgments, costs and exp,was which my in any waymeme against said City
AIR HANDLING UNIT TO 10," CFM)
in;n�ting of this PantT�• (/Lsc1G.�►
i
AIR HANDLING UNIT (OVER IO,OW CFM)
EXHAUST HOOD(W/DUCO
PAID
T,inatu of Applicam/Coatractor Date
HEATING UNIT (TO IOLO00 BTU)
I IAZARDOUS MATERIALS DISCLOSURE
Dom Receipt N
HEATING UNIT (OVER 100,000 BTU)
T
Will the applicant or future building occupant store or handle normal nuesserial
at definad by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION PAN (SINGLE RE$ID)
Code, Section 25532(.)1
❑ Year El No
BOILER - COMP (3HP OR IO ," BTU)
ISSUANCE DATE
Will the apPlicent ar (mart building wcupenmx equipment or devi<er which emit
BOILER-COMP(OVER 100.011) BTU)
ibazmdous air contaminants Out defined by the Bay Area Air Quality Management
Diann"?
NEW RESIDENTIAL MECH. SQ. Fr.01
.11
❑ Yes ❑ No
1 have teed the hazardous materials requirements under Chapter 6.95 of the
qq
r A ! D
California Health It Safety Code, Sections 25505, 25533 end 25534. 1 understand that
Win, building dcex.1 uren0y have a term,thut it ie my tesponxibility to notifythe
occupant of the requirements which must F< met prior to issuance of a Certificate of
Occepancy.
JV
o91'
ISSUED BY:
Owner or mthoticed agent Data
TOTAL: