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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO '-"
APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO. ^ ^ I
L b l
BUILDING ADDRESS: (�1 UNIT# LOT#
SANITARY NO.
APPLICATION SUBMITTAL CAT
WNERS NAME: (N O _
1143
C RA OR'S NA ' LIC NO
n�
Nrc
❑
CONIROLN
I ARCHMECT/ENGINEER: LIC NO:
DDRES ^
.-1111
CONTACT: PHONE:
On. . ELECTRIC PERMIT FEE
Q
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
❑ ❑ ❑ la
�1
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that I am licensedunderpra konsof Chapmr9(eemmencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section 701 of Division 3 of the Business and Professions Cade, and my license is in
fol rens sad erre
J Liten�Cmm
Date Canvass r�nlT
PANELS
UP TO200AMPS
201 _IOW AMPS
ARCBITECTS DF,CLARATION
� 1 understand my plans shall be used as public records.
J
SQ, FT. FLOOR AREA
E/SQ. 4T.
OVER IM AMPS
SIGNS ELECIRI
J Licensed Professional
OWNER -BUILDER DECLARATION the CATION
License Ism for the
1 hereby affirm Nm I an caempt from the Cosions
SPECIAL CIRCUIT/AHSC.
TEMP. METER OR POLE INST.
a
following reason. (Section ]OJLS, Business and Professions Code: Any city meounry
which
7 which'quire a permit reconstruct, Wee improve, demolish, m rcpaiT any sruclnre
pane,the petmiuo
thevisios
0r suchhe
slicensed
POWER DEVICES
deal he La (Chapterlaveracto
j that is licensed pursuantto the
the provisions of the Contractor's
ofCo License
Liana (Chapter
es i
a with Section
with Section and)he Division rus the ed!caasand Professions Coda)
..,
9 thin he i,
Section731.5banyap mmanf the Permit sbjeasegedexemption. Anyviaatipn of
Section]OJ LS by any applicant fora Permit subjects Ne applicant to+civil Penalty of
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
more than five hundred dollars ($500).
❑our ml.asownemDhepropeny,ormyemployeeswithwagesu Neirsolecompensadw.
will dothework,and the cruor,isnot atended.reffcred forsale(Sec. 7014, Business
NEW RESIDENTIAL ELECIR SQ�FT
YPE CONSTRUCITOs
and Professions Gale: no Contractor's License Law does not apply to an owner of
Property whobuildsorimprovesthemm,andwhod.easuchwork himselforNrough Ns
own employees, provided that such improvementsarc not intended.(offered tenants. If.
however, the building or improvement is sold within one year ofeempletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose or
We.).
❑ Laz esclusis nlrazviesur
OCC.RES.
NZONE
UNITS
TOTAL
TY. PLUMBINGPERMITAPN
Q FEE
the Project (Sro70a,L Codcenaedc.ohacr.rst.
construct the project (See. ]044, Business end Professions Code:) Th< Convectors
and
eL spplyman. n pn.pcnildsn.thereon,
PERMIT ISSUANCE
who, ctsfmsochpmjarswihaoniwemga)[icenedPursu=twhCowemes
License Law.
El Iam exempt under Scc. , B & P C for this reawn
ALTER - DRAIN ffi VENT. WA'T'ER (FA)
/
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE ZEES
TARY YN_
Owner
D+
WORKMAN COMPENSATION DECLARATION
ION
❑ ers Co affino Na11 Insurance
covers al Cnmpensminn Insurance oracertidcd copy, Nercof(Sec. JBW.Isb C.)whi<h
ora cer+pf consent reef( (Sec. Lab C.) which
h
colics allypplgyeydt;r\hic+cnnis. ,
Company_ W d- CJs�l
Company l�siYJ1k�F\
DRAINS- FLOOR, ROOF, AREA, COND.
RECEIPT#
SCHOOL TAX YN
RECEIPT#
FIX9'URES-PER'TRAP
PARK FEE Y_N
RDIVISIOK
GAS - GA. SYSTEM I INCA OUTLETS
BUILDING DIVISION IEFS
❑ Certified copy is hereby furnished.
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
Certified copy is filed with the city inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
GREASETRAP
SOILS HE
This section need nos bearmplevd Bron Permit is fm one hundred dollars(SIM)
.rle".)
SEWER - SANITARY - STORM HA. 20017.
ENERGY FEE
I certify that in Ne Performance ofthe work for which this permit is issued, l shall
not employ any person in any moment so as ,n become subject on the Workers'
Compensmlon Lowsof California. Date
Applicant
WATER HEATER W/VENT/EL
WATER SYSTENITREATING.1�
PAID
Dam Receipt#
NO'T'ICE TO APPLICANT: If, after making Pits Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
NEW RESIDENTIALPLMB. SQ.PT.
TOTAL:
forthwith comply with such Provisions or this permit shall be domed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a consovction lending agency for the performance of
the work for which Nis permit is issued (Sec. 3000, Civ. C.)
I<nder's Name
SEISMIC FEE
TOTAL:
ELECTRIC TEE
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE a
1 cenify that I have mad this application and smte that the above information is
rerl.I.9re m comply withall till and caunry.ndinancnandstate laws nelson,,.PERMIT
building construction, and hereby authorizereirmserhaver of Nis city memerupon the
above-mentioned properly for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cupenino against
habilities,judgmems,cosss andexpectses which may inanywayaccrue against said Ciry
of the m6rentingo thispnit.-AIR
ISSUANCE
\/
MECHANICAL FEE
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10.010 CFM)
HANDLING UNIT(OVER 10,04(g) CFM)
RKnance
`-t
ef Apphc.m/C.nome Date
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO IW,IXX)BTU)
HAZARDOUS Ming an"LS DISCLOSURE
Will the io Toole building acapa store or handle hHcrhh s material
Dmc Receipt
TOl'AL:
the Cope ici a
as defined by the Cupertino Municipal Code, Chapter 9.12, enmd the HeWhacM Safety
p
Code, Section 25532(.)?
HEATING UNIT (OVER IW,WO BTU)
VENT HATTON FAN (SINGLE RESID)
ElYes No
Will thea licuvinrfmurcbuildin it
pp by
hazardous air contaminants as dchncd by the Bay Area Air Quality Mwagemcnr
the ay Ana Air or Jevi Management
District? �
BOILER- COMP(3HP OR 100iO00 BTU)
ISSUANCE' �E' D
O.x
BOILER 100,1X)0 BTU)
<No
I have mad the hhaaachas materials reyuirrnsms under Chapter 6.95 of the
California Health ffi Safety Code, Sections 25505, 25533 and 25534. 1 understand Wt
if the building does nm etmmly have .tenor, Nat it is my responsibility,. notify the
a r the rc,inmems whichkrary be met poor 1. i"OrIg of e CerrOum of
(`j]
OCTYes
�/1 1993
CIIi UI- ul Lh=H IIIVU
NEW RESIDENTIAL MECH. SQ. FT,
CL
BY: +^ ♦ 1
O n amhnrized agent Data
TOTAL: _� ISSUED