27790APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - VILEURICA)'
APPLICATION/PERMIT PLUMBING - MECHANICAL.
NUII,DING DIVISION BUILDING: PROJECT IUF,NTIFICATION
PERMIT NO. O
BUILDING ADDRESS
SANITARY NO.
APPL.ICA'DON SUBMITTAL DATE
%:
14� S/�ZiI C s/a" UNIT# LOT
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l
O NERS NAME: PIIONF.:
CONTRACTOR'S NAME: LIC NO:
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❑
CONTROL #
Z In h s
ARCI 11'ITCT ° INEER: LIC NO.
ADDRESS:
CON'T'ACT: PHONE :
QTY.' ELECTRIC PERMIT FEF,
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION
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I hereby affirm that l am licensed underprovisions ohapter9(commencingwith
Section 7000) of Division 3ofthe Business and Professions Code, and my license is in
fall farce andeffeet.
License C13N.s Lic.#
Date Conwmor
APPLIANCESRESIDENTIALTOB
DESCRIPDON
Jf,._f
ll.� ITq-Vy
PANELS
UP TO 200 AMPS
201-1000 AMPS
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OZ-0
SNF j
ARCHITECTS DECLARATION
l understand my plans shall be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
$/SQ. PT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MISC.
�$J
yce<
xp.
tn3 ay
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Commarm's License Irma for the
following mame.(Section 7031.5, Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
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KW�S
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which requires a permit to construct, alter, improve, demolish, or repair any tantrum
prior to its issuance,alsorequires the applicant borauch Permit o file a signed statement
that he is licensed pursuant to the provisions of the Convectors License Law (Chapter
9(commencing with Section 7000)of Division 3 of the Business and Professions Cod,)
o that In, is eacmpt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more th:m five hundred cellars; ($500)
❑ 1,asowncrofNepropay.ormyemployeeswiNwagesstheirsolecompensation,
will do thework, and the mucdm isnm intended oroffcml forsale(Sce. 7014. Business
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS- SWRCHES -FI%TURES
NEW RFSIDFNTIALELGCfR _SQ. FT.
STORIES
TYPECONSTRUCDON
and professions Code: The Contractor's License Law docs not apply to an owner of
propenywhobuildsor impmvcsthereon, andwhodeessuch work himselforrhrough his
ownemployces, providedthat such improvemeutsare not intendedorofferedforsale. If,
I
OCC.GROUP
RES. UNITS
however, the building or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did on build or impmve for purpose of
'TOTAL:
QTY, PLUMBING PERMIT FEE
sale.).
❑ I,asowneroftheproceny,amexclusivelycontractingwithlicenudconimctorsm
Fl.00D ZONE,
gpry
construct the project (See. 7044, Business and Professions Code:) The Convector's
License Lawdocs not apply toanowccrofpropenywho buildsm impsov<s Nc=,.d
PERMIT ISSUANCE Z-%Q
who eomractx forsuch projects with acnmractor(.$) licensed pursuant to the Contractors
License Law.
pLTER-DRAIN & VENT- WATER (EA)
FEE SUMMARY
❑ 'andexempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE,
OUTS) F FEES
Date
1 r WORKMAN COMPENSATION DECLARATION
hereby affirm that l have a certificate ofcousenuo self-insure, or a certificate of
ers'Compermankn Insurance ora certified espy thcmof(See 3800, Lab C.) which
en all aind,ec's unde,this permit.
Policy #
DRAINS- R. ROOF, ,COND.
SANITARY Y N
RECEIPT#
SCHOOL TAX Y_N_
RECF,IPT9
Fl%TUR' -PER TRAP
FEE Y_N
RF,CEIPT#
GAS .SYSTEM-IINC.40UTL S
BUILDING DIVISION FEES
Company
❑ Certified co ix hereby
AS-EA.SYSTEM-OVER4(EA)
NHECK FEEpy
th the ity❑ Cenifed copy is filed with the city Inspection division.GRFASFANDUSTRI,
WASTE INTERCEPTORADING
FHT:
CERTIFICATE OF E- CMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRA
SOILS FEE
(This section need not be completed ifthe Permit is bounce hundred d (SIM)
or Tess.)
SE 'R-' T Y-STORM .200FT.
ENERGY FEE
z
(•^ N
�?
Icenify thar in the perTorrance ofthe work fimwdch this pe tis issued.)shall
not employ any Person in any manner so as to become subje t to rhe Worker'
Compensttm Lawsof Califontie. Dam
Applicant
NOI'ICE 'IOAPPLICANT: If. after making this CertificmeefFxc tion, you shoo
become subject m the Worker's Compensation provisions of Ore lobo ode, you m
forthwith comply with such provisions onhis permit shall be decmedr eked. G
l WAT 1' TF.R W/VEM'
V
PAID
Date Recciptp
SYSTEM?R
N;W RESID 1 B. SQ, FT.
TOTAL
(
p
BUILDING FTSE
Q
Z
U O
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the pedo ce of
the weak for which this permit is issued (Sec. 3097, Co. C.)
Lendera Name
SEISMIC FEE
.n
TOTAL: A
ELECTRIC ME
U.
O U
Ir" 0.
C�)
U Z
Lenders Addressrti
1 certify that I have red st
athis application and ate that Ne above inrmmatian is
correct. I apace to comply with all city anal county ordinances and some laws relating to
building construction,and hereby authorize representatives ofthis city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep handless the City of Cupertino agaiut
liubilitles,judgments. costs and expenses which may in any way acconagainsr said City
nonpoi eof the'eminnull.
TY. MEC NICALPERMIT FEE
PLUMBING FEE .O/%
—PLIMMISSUANCE
MECHANICAL FEE
ALT' ER OR ADD TO MECII.
AIR HANDLING UNIT (TO 10,011) CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT IOVER I0.000 CFM)
Signmurc al'Applicnnt/Comramorl Date
EXHAUST] IOOD(W/DUCT)
PAID SSZ71
HEATING UNIT(TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building occupied store or handle hwWous material
.�B
Date Rmcipt #
TOTAL ep
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(o)R
HEATING UNIT (OVER 100,000 B'TO)
VENTILATION PAN (SINGLE RESID)
El Yes 0N
Will theapplicanmrfumre building morepamuse equipmemordeviesswhichemit
BOILER- COMP QHP OR H1Q0W BTU)
1$SU l[E&TE
Y Ya 11 Cull
haaardous air contaminants as defined by the Bay Area Air Quality Management
Di'mol
BOILER -COMP (OVER 100,000 BTU)
❑Yes 0N
T�
IIflflD 1 O IQ�q
MAR L 1v v
NEWRESIDENTIALMECIL SQ. PIL
1 have read the hassrdous materials mquiremems under Chapter 6.95 of the
California Health & Safety Code, Sections 25505,25533 and 25534. 1 understand that
if the building does not cunemly have a tenan6 that it is my ruponsibility to notify the
occupant of the requirements which most be met poor to issuance of a Cenificare of
CITY Vr �ur�nIIIVU
Occupancy.
BY: VN�IL��✓Y G4KW
Owner or aathonndagem _. Data
TOTAL ISSUED
OFFICE