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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL,
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
iN �]J oOO�
J
BUILDINGADDRESS'.
SANITARY NO.
APPLICA ON SUBMITTAL DATE
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OWNER'S NAME: PHONE:
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CONTRACTOR'S NAME: LIC NO:
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9 E /ENGINEER, LIC NO:
ADDRESS:
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CONTACT.
BUILDING PERMIT INFO
'y1�` ^�fPHONE
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El Consultant Fees Paid by Applicant (Initial)
PLU - MECH
BLDG 2e, ELECT PLUMB
I� Va IlO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 an, licensed ander previsions of chapter 9 (commencing
..
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 7000) of Division 3 ofthe Business and Professions Cade, and my license is
in full force and effect.
Licence Class Co
Data— Contractor
PERMIT ISSUANCVMS
SFDWL ❑KITCHEN REMODEL
El ADDITION ❑PLUMBING RE -PIPE
[]MULTI -UNIT EI STRUCTURAL
MODIFICATION
APPLIANCES - RESIDENTIAL
DECLARATION
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
PANELS
UPT02MAMPS
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT L] SWIMMING POOLS
Licenced Professional
201-IOMAMPS
OWNER-BUILDERm DECLARATION
o far ,be
1 hereby a(Sect met 1 am'exempe from the Cessions Co License city
followingreason (Section ] and Professions Code: Any city m county
❑ BATH REMODELREPAIR ❑DEMOLITION
❑OTHER
OVER IWO AMPS
SIGNS ELECTRICAL
construct. attess
which requirea a permit m improve, demolish,
or repair any tamaureprior
sthealter,
t
mcensece,also re Permit LicensFile ae ned
of fortuthe
the
SPECIAL CIRCUIT/MISC.
Com
that to Law
licensed pursuant m the of Divisio of the a Business License Law (Chapter 9
provisions
that he is commencing of of Profession,A.,Cnde)or
ommah
TEMP. METER OR POLE/NSTCOW
R I L
ire.1c,cdcssasd
anion] ad basis Et
that he is exempt therefrom anJ me basis Entire alleged exemption. Any violation of
that
W BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more then five hundred Jnllars (850d.
thepmparty,mmyot
Lothe
ANT L] FOOD SERVICE
4=PROVEMENT
SWIMMING POOL ELECTRIC
work, ]1144, Business
will do the work, and the[ numeeswithwngexmthei(Sec. 0o 1.B sines,
is not Intended o
�p HER
OUTLETS - SWITCHES -FI%TURES
Law dos not apply.
and Professions Code he Cont License Law does not apply to an owner of
ove, meram and w1Or does such tinte himself or through
.ar improve,
properly who builds Orr improves thouch
his own employees, provided that tach improvements are not intended or offered for
i
side. If, h.wever, the building., improvement i -old wi,binoneyearofa,mplelion, the
..a,,huilder will have the burdesof proving that he did nut build or improve for Pur-
have as alae
❑I,uownerofthe Sea 70,emexclusively contracting with liceneeCoommcmas1-
construct the Professions Cadei The Contractor Li-
not (Sec. ]044, Business and
NEW RESIDENTIAL P.LF.CTR SQ PT
SQ. FT. FLOOR AREA
KN�,♦
1,11/1 n��n id#b
/ 7 /,y.
ATL'.'7i•
$ISQ, FT.
t^� go
Y r Q
2 [ 6 7
es rty who
c se Law doe or inch plymts with
er ac lowbmywcOrsedpds rrant in the Continuator
whOr comrucafor,uch projects with acnmmcmr(s)IicensW pursuammlhe Cnntmctnfn
License Law,
❑Inco exempt under Sea Cfor this reason
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
0 C•
44_0S0
n Data _ll
war ARI iR'S COM PENs� 'IO DECLARATION
IherehyalTrmunderpemlty of pFga Orme of the following declarations:
ALTER - DRAIN & VENT -WATER (EA)
UATION �J r
POO
A3S 0OO
O
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.RIES
"❑lhaveandwilltnaintainaCetificatevf Cancemtoself-insurefor Workers Compen-
series, as provided for by Section 37W of the Labor Code, for the performance of the
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES - PER TRAP
❑ I haveand will maintain Work,,', Comp evaiti.m Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which,his permit is issued.
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC.GROUP
APN
y Worked, Compensation Insurance Cama and Policy number are:
Eads: Policy N.:
GAS - EA. SYSTEM -OVER 4(EA) _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASF/INDUS'TRL WASTE INTERCEPTOR
B.D1N
(VISI is
(This section need not he completed if the Permit is for one hundred dol lars IS 100)
or less.)
Icetify from,any on as .aI wF, a which this permitis iscucd,Ishall
not employ any person in any man er xOr as m become suhjett m the Workers' Cumpen-
GREASETRAP
LA^CFFj'�K FEES DD /
BNFiROY PBE '
SEWER -SANITARY -STORM EA. 2W FT
WATER HEATER WNENTELP.CTR
sof Law -sof Gl la. are
plicnm ��� �' a�L1-�
GRADING FEE
OTICE TO" PPLICANT: ,after making etificae of Exemption y. u sh Tld
ob tro m the Workers Carepensati operli.m of the Labor Code, you all
WATER SYa rEMIfREALING
��home OR 'LOW-
PAID s
On RecelptN
f.thwimcomply will, such powisirnsonhi,pennit shall betleemedrev.ked.
CONSTRUCTION LENOINC AGENCY
I herebyaffirmThi that there iasued(Sconstruction lending agency for the performance of
the work for which this permit is issued (SOC. 3097, Civ. C.)
WATER SERVICE
NEW RESIDENTIAL FLUB. SQ. Flt
� O Y
Lender's Name
-
TOTAL:
Lender's Address
I certify that I have read this application and ,tate that the above information is
rou'rearl. l agree to comply with all city and county ordinances and stale mw, relating to
building consomme, and hereby amhmlze,epreaesmtive, of this city to corer upon me
TOTAL:
BUILD/ ,
QTY, MECHANICAL PERMIT FEE
SETS .F -3(10
PERMIT ISSUANCE
EL RIC EE Z 3 IU f
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO MECH.
PLU GFEE O r
Iiabilities,judgments,costs and expenses which may in anyway accmeagencia said City
inconsequence of me gaming of this permit.
AIR HANDLING UNIT IO,WO CFM)
MECH /CAL PEE 23 Of�e
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
$OURC REGULATION..
AIR HANDLING UNIT (OVER 10,1X10 CFM)
CONSAUCTION TAX ( 5
I
Q
/AL2 11
11
Name I
Name of Applicant/ .drucvu Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WMUCT)
HOUSING ITIGA ON FEE
HEATING UNIT (TO I offol0 BTU
Will the appliveramfcore buildingacuper,c am handle hawed-, material
as defies d by the Capetian Municipal Code, Chapter 9.12, and the Health and Safety
Code Section 25532mr?
HEATING UNIT (OVER I W,OW BTU)
❑Ya ❑ No
PAID Data Rec "
VENTILATION PAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,0010 BTU)
Will the aI, comm Or future building by the B use equipment of devices which
emit hazardous sir comuminanu as refined by the Bay Area Air Quality Management
District?
Yes ❑No
BOILER- COMP (OVER IW,(1fN1 BTU)
BOILER
ZI f
AIR CONDITIONER
1 have read me hmaNnm materials requirements ander Chapter 6.95 of the Cali-
famed Health & Safety Code. Sections 25505, 25533 and 25534. I understand that if fire
building fines no mens yheve s t. mat it is my msponslbilitymvodfy me.ecupam
oft erequarm tswhichmust 'a, in issuance ofd Cetif c.f Occu rye
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
s
-LL
—hQ
ISSUED BY:
TOTAL
amhovzod used,Dnte
v OFFICE