26091_ ,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO msms.DiNG= MAIL TRRIA -
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION BUILDING PROJF.IIT I I ENTIF'ICA'IION
PERMIT NO.
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BUILDIyypylf]D ��� � UNITp�
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SANITARY NO.
APPLICATION SUyB/M��I PTALDA'0?
3�- ILf
OWNER PHONE:
CO I'RACTQR'S NAME: LIC NO:
1/-JI/GJ- ON IA,,L
NIC
❑
CONTROLp
CRL II' I?C'/ENGINHER: LIC NO:
ADDRESS:
..
ONTACT: PHONE:
..
QTY. 17LECTRIC PERMIT FEE
BUILDING PERMIT INFO
L ELECT PLUMB MEC
PERMIT ISSUANCE
}Y�s�I�V
pyr
LICHNS CONTRACTOR'S DECLARATION
Ilowd,afftem Osatl a licensed under provisionsofChapmr9beourmencingwith
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
VJ00
y��i1F
Section ]000)of Division ofthe Business and Professions Chair. and my license is in
Poll Rmmr awd effect.
PANELS
6y WVjs)
License Class Lic.p
UP TO 20IAMPS
201 - 1000 AMPS '
h6 h
Uate Common.
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ARCHITECT'S DECLARATION
1 undersand my plana shall be used ns public retorts.
OVER TWO AMPS
SQ. FT. FLOOR AREA
VSQ. FT.
SIGNS ELECTRICAL
F�
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P� O V
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt man the Contractor's License Law for the
following reason. (Section 7031.5, Business and Prafeasimm Code: Any city or county
which "wrox a permit to construct, alter. improve, demolish, or repair any structure
prior a its issuance, dm reyuircnhim lieanl forauch pennluo file asignedwammmm
that he is licensed pursuant to the Provisions of the Contractors License Law (Chapter
9(wmmania, with Section]000)rf Division 3ofthe Business and Professions Code)
ordain he is aempnhemnom and the basis farthealleged exemption. Any violminn of
Sation ]031.5 by any epDlicant fore permit subjects the epplicanmoecivll penehy of
not mote than five hundred dollars (1300).
❑ Las Owat(OflhepfOpeny.Ormy CmplOYCe9001111 WagCaef lhClr SolCtompeommoa,
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
l
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECfR S .FT,
-SQ.FT.
TYPE CONSTRUCTION
ywill
do the work, and the stmcmm isnotimmnded proffered formic (Sm. 7=, Business
and Prnfussians Cade: The Cantmcar'a License Law dues not apply m an owner of
property whobuildsorimpoves themon.and whodoessuch work himselforthrough his
own employem,povidW that such Impmvemermame not intendedoroffered fmsale. If,
G RES. UNITS
TO "
however, the building orimpmvement is sold within am yearo eximpletion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
t
QTY, - PLUMBING I''IiRMIT
le.).
❑ Lasnwnerora<pmperty,nm exclusively wmmningwith licensed contmeama
construct the project (Sec. ]044, Business and Professions CaleO The Comruam's
License law does not apply town ownerof pmpeny who builds or improves flonew, and
/I>t z e APN
6
pERMTT{SSUANCP.
whocantmcts fmsuchprojects with acantraetor(s) Remand pursuartothes Contracar's
License Lew.
ALTER-DRAIN&VENT-WATER (EA) -
FCC SUMMAR
❑ 1 ore oxcmpt under Sec, , R & PC for this reason
BACK FLOW PROTECT. DI?VICEf
DF. FTF.S
SANITARY - Y N
RECE11'I'a
Owner Date
DRAINS - F1.00R, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Ihemhyeffimt that l have a cmificate ofcoment to self -insure, or a cenifiateof
Worked ComDensztiun lnsumnceoracerifiedcopymereof(See. 3800, Lab C.) which
RECEIPT#
FIXTURES-PHRTRAP
PARK FTE Y N
coversall employee's under this Permit.GAS
Pollcyk
- EA. SVSTI?Md INCA 0UI'LF,TS
10`7.CHIPT #
B L IVIS T-.-
GAS -EA. SYSTEM -OVER 4(EA)
Company
mp
PLANCHECK
❑ Ceniliedempy ishembyfumdshed.
GREASE(INDUSTRL WASTE INTERCEPTOR
GRAUINC
❑ Certified copy is filed with the city impeclion division.
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
GRFASETRAP
SOIL I''
SEWER - SANITARY - STORM EA. 200FT.
OeNERIVIrr
(This section need not lx completed Hire permit is for one hundred dollars (1100)
odess.)
WATER METER W/VEM'/ELECTR
I certify that in the performance of the work She which this permit is issued, l shall
not employ any peraan in any owner so as to become subject to the Workers'
PAID
ZCm,wihimn
z 0—
Lowsa(Celifnmia. Dote
Applicant,
NOTICETOAPPLICANT:If,wfwlr ingtNs Cenificnemffxemptian,youshould
WATER SYSTE?MGREATING
NEWRESIDENTIALPLMB. SQ.FT.
Um Rccciptw
TOTAL:
F" VJ
1
Z
U (]
D. r
C)IU+
become subjeuathe Worked Compensation provision of the Labor Code, you mow
fordwim comply with such provisions in this pemtil shall be domed revoked.
LENDING AGENCY
construction
I hereby affirm that there is a consction lending agency for the performance of
the work for which this permit is issued (Sm. 3097, Civ. C.)
Lender's Name
Lenders Address
-
BUILDING IEE �•
SEISMIC R?E
TOTAL:
ELECTRIC FEE
QTY. MCCIIANICAL PERMIT FEE
PLUMBING IEE
FA.
rA
U z
I certify that 1 have noel this application and state that the above information is
torted. I agree to comply with all city and county ordinances and state laws relating to
building construction, and herchy uatbariae rcprescnatives ofthis city to emeruDnn the
above-memioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupcnit a against
PERMIT ISSUANCE
MECHANICAL FRE
ALTER OR ADD TO MECH.
CONSTRUCTION TA
,juJgoen¢,costsiwdcxpwmea which may imanywwywccmengainst said City
AIR HANDLING UNIT (TO 10,000 CFM)
im cn acnes of the gmming of this pertnit.
Y G
AIR HANDLING UNIT (OVER 10,(WCFM)
_abilif
Signaaoof App' am/Coutremor Deter
EXHAUSTHOOD(W/DUCf)
PAID
HEATING UNIT (TO 100,00(1 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipts
Wi 11 the applicant Air future building cecupart same or handle humrdmus material
as dermad by the Cupeninn Municipal Axle, Chapter 9.12, send the Health wW Safety
HEATING UNIT (OVER 100,0181 BTU)
T 1
Code, Section 25532(x)?
11 Yes Cl No
VENTILATION PAN (SINGLE RFSID)
Will the upplicanmr fears building occupant use equipment nr levices which emit
ISSUA EDAT
oOILER- COMP (31 IP OR 100,000 BTU)
BOILER - COMP (OVER 110,IIfIfI BTU)
dons or contaminants as defined by the Buy Area Air Quality Management
mct?
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
I have mead the betatrons mweritls rtquiremems under Chapter 6.95 M the
California l health &Safety Cade, Sections 25505,25533 and 25534.. l understandingr
A D
P1 A
'
if the bui lding does not currently have a termal, that It is my melnmsibi lily In moti ry the
.cc upum of the reyairememx which roust he mea prior a issuance of a Cerificute of
Occupancy.
ISSUED RX:,
Owner or auth unzcd agent Date
TOTAL:
OF