27361APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY QF CUPERTINO U'lu'lNirRIAPTI 17AI'
BUILDING -DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
BUILDING PROJECT OWN'1'IFICAT'ION
PERMITNO.
- 70C
1 JU
BUILDING ADDRESS:
SANITARY NO.
TTE
APPLICAION SUBMI'PI'AL DA
\�`]"],f- ] `�j/
`161- •o �/T+� Y,L UNIT# LO I'll
Z
OWN PHONE:
CO LIC NO:
NIC
❑
CONTR L#
ARCHHTCI'/ENGINBER: LICNO:
ADDRESS:
'ONTACf: PHONE:
:' }'"'t -'
Q'PY. ,a,EL mRIC PERMIT PEE
BUILDING PERMIT INFO
BLUG ELECT PLUMB MI?CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affil that 1 um licensed under prnvisionsof Chepter9 (eommencingwith
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
PANELS
UP T0200 AMPS
Section 7") of Division 3 of the Busainess and Profusions Cade, end my license is in
full forcend effect.
I Lictume Class Lia. N'
1
^ I l \
i Dam Contactor
281 - 1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used u public records.
OVER I" AMPS
SQ. FT. FLOOR AREA
IVSQ, FT.
SIGNS ELECTRICAL
3
j LiunseA Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby the I am exempt from the Contractors License L.w for the
TEMP. METER OR POLE INST.
folloj c.(Se and Professions Code: or county
whichiequireoa(Sution]ommod,Business
or repair
1 which its requires a permit to cm. t et.,lu improve, demolish. or repair any structure
thevisionsofor file treatment
thitherslicensed
POWER DEVICES
palsnretoth La
licensed pursuenno the provision of the Convectors and Pro Law (shaper
The Contractors License
j 9that (c he is (commencing
9(commcncing with Semion]f#I(1)of Division 7ofthe Business end Profusions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for e permit sub*.,ha applicant m a civil penalty of
GIJTLEI'$- SWITCHES - FIXTURES
not more than five hundred dollars ($500).
❑ I,saawncofthepropwy,ormyemployeeswiihwagesutheirwlccompenuuon.
NEWRESIDENTIALELECTR _SQ.F7L
STORIES
'1'YPH CONS'IHUCI'ION
will do the work, and the strucmm is not intended or offered for We (Sec. 70f4, Business
and Professions Cade:'De Cotumnnr's License Law does not apply to m owner of
pmpcny whabaildaosimproves therean,and whodoes suchwark hinsselfor through his
con employees, proviAeA that such impnrvemems me not imrnded or offend for sale. If,
OCC. GROUP
UNITS
TOTAL:
however, the building or improvement is sold whhinaneyearofcompletion, the owner-
builder will have the burden ofproving thehe did not build or improve for purpose of
PLUMBIN0 PERMIT FEE
a Ia.).QT'Y'
❑ gwith eontrecmnr's
and
FLOOD ZONI.PN
EA
constructthe project(Sec. 704 , Businessde:) h
Business end ywhobiam Cade:) The Centeses
Professions
License the does net (gee. to an
-
PIiRMI'1'ISSUANCP.
whocoLawdursuchpplyewaownerafpropertywhnsed pumGnprovu@crcomonA
whocalaw. for suchpmjauwithecammemr(#licensed pursuanumhe Convectors
License law. I
AUFER-DRAIN&VENT-WATER CA
(')
PEE SUMMARY•
❑ 1 am exempt underSec. , B'& P C for this reawn
BACK FLOW PROTECT. DEVICE
�Y F IS
Owner Deter
pRA1N5-FLOORROOFAREA,
,, ..
SANITARY -N-
RECETPI'#
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Thereby altirm that l have a cenificam ofconsent to self-insurs, ora ocnificate ofRECEIPT#
Compensation h¢urunce orecertifiW copy thereoflSu.3800, Lab CJwhichx
'
FIXTURES-PERTRAPWorkrni IPARK
FEE YN_
GAS - EA. SYS OUTLETS
overs all etaployee'a under this permit.
Polley #
RECEIPT
BUILDING DIVISION FEES
Company
AS -P TF. ER4(LA) /
PIANCHECK FEE
❑ CeriEulaspyisherebyfumished.
N NDUSTRL ST I? PIPOR
GRADING FEE
❑ Cenified ropy is filed with the city inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
R SET
SOILS FEE
S. ER -SA ARY-STORM EA. 2WFE
ENERGY FEE
('T his section need not be completed if Ne permit is forage hundred dollars ($100)
or less.)
WATER HEATER WIVENTIFLECTR
I certify that in the performance ofthe work for which This permit is ounce, l shall
not employ, any Jarman in way manner w on m become subject a the Widmer
PAID `
Corri'mationlawsof Califrmit. Date
Applicant
WATER SYSTIEWMEATING
Date Receiptp
NOTICHTO APPLICANT: IL after making this Certificate of Exemption, you should
became subject o the Workers Compensation provisions; of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FE8
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hcmbyeffitm thattbee iso conswction lertdingageacy far the performance of
work for which this plumb is issued (Sec. 309'1, Civ. CJ
Linder, Name -
TOTAL:
ELELTNIG PER
LendreaAddress
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
I certify that I have mad this application end stme that the above information is
correct. l agree to comply with all city said county ordinances said state laws relating to
PERMIT ISSUANCE_
MECHANICAL. FEE
building construction, and hereby authorize representatives of Nis city toenterupon the
shove-manom ed property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify ward kap headdress The City of Cupertino against
liabilities,judgments. costa and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO l B" CFM)
in co sof elm Bmnun of Nie permiL
P
AIR HANDLING UNIT (OVER 10,000 CFM)
igomumof Applican enactor Dae
EXHAUST HOOD(W/DUCIT
PAID
HEATING UNIT (TO 100,000 BTU)
HA7ARDOUS MATERIALS DISCLOSURE
Dae Receipt #
Will the applicant or Powe building acaupaat mare or handle horrendous material
u, refined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Solely
HEATING UNIT (OVER IW,O(ID BTU)
T T 1
Cade, Section 25532(e)T
❑255yes 11 No
VENTILATION FAN (SINGLE RNSID)
Will the applicant or future baildingw upeatuwe uipmenwrdevicn whichemit
hazallous air ematu looms as defined by the Bay AreAir Quality Management
strict?
BOILER - COMP (311P OR 100,IXN1 B?v)
ISSUANCE DATE
�
ra
PAID
A I D
BOILER - COMP(OVER 100,ODBBTU)
❑ Yea ❑ No
I have read the hevrdous materials requirements under Chapter b.95 of the
pa#aa,'
�s `i #M9 -1995
NEW RESIDENTIAL MECI I. SQ. FI'.
California Health & Safety Cale, Sections 25505.25533 and 25534. I understand that
ifthe building doeaam emmedy have.edam, that it is my responsibility to deify the
F
C�IY U` /.��
occupum of the ed,immems which man be met prior to issuance of a Cenifieata of
V�
fhcuPuncy. �,
ISSUED BY:
Owaerancy. iud cogent Dole
TOTAL:
OFFICE'