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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOA
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENT'IF'ICATION
PERMIT NO.
25537
BUILDING ADDRESS: `
ZI UNIT# LOT#
SANITARY NO,
APPLICA IION SUBMIT] AL. DAD
�� )
OWNERg,Nph1F,:
LIC NO
ncyil
NIC
❑
NT
COROL # #
'ARCH] 'ITC 'I' /ENGINEER : G CNO:
ADDRES_3', �^ O /i �r
�<
1
CONTACT': PHONE:
QTY. ELECTRIC PERMIT//C
FEE
BUILDING PERMIT INFO
�LDJy FlECT PLUMB MECH
PERMIT ISSUANCE
I�fJ(� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby zffirenthat l am licensed underprovigions of Chapter9 (commencingwid,
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
J Section of Division 3 of the Business add Professions Codc, and my license is in
full forcea add and of Di t
License Class Lie.#
I).& Contractor
PANELS
UPTO200AMPS
201 - 1000 AMPS
1 undcrswnd my plans shell T used DECLARATION
ARCIIITECTd as pub.ARAords.
ATIO.
9
OVER 1000 AMPS
c� .[,fin $/SQ'I'1'
Y6./1 9^VY I
T� p It TER R
P qU pL_�
SIGNS ELECTRICAL
Licensed Professional
= OWNER -BUILDER from DECLARATION
License Lew for the
1 hereby affirm that 1 am exempt from the Conions
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
n Cs
whfolich respcmon. (Sectionatito ecand0. Business and professions Cole: Any city or coumy
whim reyuires a cennir to suer, improve, demolish, or repair any
my
tavnerc
t.i. t e i
S prior toils issuance.alsordtoteprvisios firestinh Co permit's Licele a se
D that he is licensed pursmnt to the policies of the Contractor's License Law (Chapter
9(commrncing with Section ]000)of DivisionJofnce Business and Professions Code)
n or that he is exempt members 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
J not mom than live hundred dollars ($500).
c ❑ I,asownerofthe properly, ormyemployeas with wagesasthei...lecomcensation,
wi l l do the work, and the strua ure is not imtended or offered for sale (Sec. 70a.4. Busineas
POWER DEVICES
SWIMMING POOL ELECTRIC
' AIr
25tiD—`
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECfR 5 . FT.
Q
STORIES
TYPE CONSTRUCTIOD
and Professions Code: The Contractor's License Taw does not apply to an owner of
property wbobuildsorimproves thereon, and whodoessuchwork himself«mrough his
own employees, provided that such improvementsarc not intendelor offered tonight. If,
OCC GROUT'
RES. UNITS
however. the building or improvement is sold within one yearofcompletion. be owner.
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
QTY. PLUMBINGPERMIT FEE
sale.).
❑ I,asownerofthepmpery,emexclusivelycontractingwithlicenacdmn=wmto
FLOOD ZONE
qpN
onmmct the project (Sec. ](144, Business add Professions Cade:) The Contractors
License Law doeanot apply toun ownerofpmpeny who builds or improves thereon, and
PERMIT ISSUANCE
who contras for such projects with acmntrector(s) licensed pursuant to the Contractors
Lierme Law.
❑ 1 am exempt under Sec. , B & P C for this mason
ALTER -0RAIN&VIiNT-WATER HLA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE I171LS
SANITARY YN
Owner Date
DRAINS- FLOOR, ROOF. AREA, COND.
RECHIIT#
I WORKMAN COMPENSATION DECLARATION
El Coalfirmthmlhrance or reearoo(copy1hvvfScsure,or Lab C.) which
Worker: Compensamon Insurance oracertified copy thereof (Scc.3g00, Lab C.)wM1ich
ralersall cmptpy� it 0,
rcy# f // `�.1 G(JT•
nmpany��l�r�
SCHOOLTAX Y N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE YN
RECEIPT N
GAS GAS-EA.SYSTEM-I INC. OUTLETS
BUILDING DIVISION FEES
Certified copy is hereby furnished.
GAS - EA. SYSTEM -OVER 4 EA)
pLANCHECK FEE
❑ Cmi6al copy is fled with the city inspection division.
GREASI;/INDUSTRL WASTE INTERCEPT OR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE MAP
SOILS FEE
(This section near not be completed ifthe pemtit is Jerome hundred dollms(SI00)
or less.)
SEWER -SANITARY -STORM EA. 200FT.
ENERGY FEE
I certify that in the performance ofthe work for which this permit is issued, l shell
not employ any person in any manner so as to become subject td the Workers
CAo peneemime Lawsof Cnlifnnia. Data
pv
WATER HEATER W/VENT/ELECTR
PAID
Date R«eiprp
WATER SYSTEMaREATING
NOTICE TO APPLICANT.If. diet making this Certificate of Exemprion, you should
became subjectto the Worker's Compensation Provisions of the labor Code, you must
forthwith comply with such provisions or this permit shell he deemed revoked.
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
BUILDING ME �—
CONSTRUCTION LENDING AGENCY
1 hereby affimr that there is a emedri lion leadingagenc, far the perfomtamce of
the work for which this pemdt is issued (Sec. 3097, Civ. C.)
Lenders Name
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Leaders Address
1 crony that I have read this apprcadon and .In that the otiose information is
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEE
reel I agreeit) comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree ro save, indemnify and keep harmless the City of Cupertino against
liabilities,jadgma"N, costs and expenses which may many way sucipreagau . r)lsollity,
a scyuenceo -grant got 's it.
ALTER OR ADD TO MECH.
W AIR HANDLING UNIT 10,OCFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,0(10 CPM)
Signature of Applicanr/Commemr VDa¢
L% HAUSTHOOD(W/DUCTt
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building recupunt store or handle hazardous material
Date Receipt#
TO
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Ilealth and Safety
Code. Seen.. 25532m)?
HEATING UNIT (OVER I00,000 BTU)
VENTILATION FAN (SINGLE MID)
11 Yes 0 N
Will the applicanmr fuwrc huilding arm upuuse equipment or devices which em
BOILER - COMP OHP OR 100,000 BTU) '
ISSUANCE DATEit
hamedous air contaminants as defined by the Buy Area Air Quality Management
❑ Ycs ❑ No
BOILER -COMP (OVER 100,001) BTU)
1 have read the harammus materials reprimmenrs under Chapter 695 of theSEp#SCelifomiaIlealth&SafetyCade,S«tioms25505,25533and25534. 1undersandtonr
if the building does not currently have a tenant, tlmt it is my responsibility to notify theecupan of the rcyuirementa which mart tin mot prior to issuance of a CeniOeme of
Owneror
`J 1993
Cwty.
V 1Owner
aNEWRESID�IALMECH._SQ.FT.
in
m amhonzW agent Date
TOTAL: ISSUEDBY