24995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
jBUILDING
Y OF CUPERTINO - - PERMn'No.
APPLICATION/PERMIT PLUMBING-MFIDENTIIC24995
DIVISION BUILDING PROJECT IDENTIFICATION
(NNGG ADDRESS: }� SANITARY NO. APPLLCATIONSUBMITTALDATE
v �I UNITOf LOTH RS NAME: P OE: LICNO:CNO: N/C CONTROLN
TECT/ NGER: LI NO: VACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I i r-r L L(r EC7' PLUWB MGCH
PERMIT ISSUANCE LY�) P(LU f
LICENSED CONTRACTOR'S ionsof ATION APPLIANCES-RESIDENTIAL B
Qz4z Thereby of
mision 3 ofthnsedinss it Profession,
Carlo,
9nd(commencing with
Off—
POO Section]000)of Division 3 of the Rosiness and Professions Code,and my license is in PANELS
fol sand elle ��
IQ„Z can 1 Lic.N UPT0200AMPS
m Q Dae s Contractor 201-1000 AMPS
Z O y ARCHITECTS DECLARATION OVER 1000 AMPS- SQ.IT.FLOOR AREA $/SQ.FT.
O Z—O I understand my plans shall be used as public records. ,
P,k W SIGNS ELECTRICAL
baa LicwedPopusiona
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
k3 N 1 hereby affirm that 1 am exempv from the Conuacwrs License Isw for[he
tel following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
fJ which requires a permit 0 cmnswcq elle,improve,demolish,or repair any sbuctme
� Y
presto its issuance,alsorequires the applicant for such permit to file a signed statement POWERDEVICES
y( Q p that he is licensed pursuenuo the provisions of the Contractors License Law(Chapter
0.gorL 9(commeneing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALL44iON
or he is exempt herefrom and the basis for the alleged exemption.Any violation ofG✓
6
Section 7031.5 by any applicanm
tfar.perit subjects the applicant to ecivil pertelty of OUTLETS-SWITCHES-FIXTURES �1i11A
not more than five hundred dollars yempl NEW RESIDENTIAL ELECTR _SQ,FT. -STORIES TYPE CONSTRUQT10N
❑ Laework,oftheproperty,mmotin lnyed orofwagesns le(Sm.compensimss I 9I
^p willdo the work,and the s0ucwre is notintended oroffered(orsale(Sec.]M4,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property who bui Ids or improves thereon,and who does such work himself or through his
employms,provided Natsuchimpmvementsarcnotimendedorofferedforsale.If, P R ND'S
however,the buildingor improvement is soldwithin one yearofcompletion,Neowma- T E i'
builder will have the burden of#raving that he did not build or improve fm purpose of
sale.). QTY, PLUMBING PERMIT FEE FLGGIy�ON ApN 1
❑ Iuct the project progeny,amendusivelycorofesiions C licensedc Commorsw T `
Licconense the project(Sec.oaro Business and Professions Code:)The Contractor's PERMIT ISSUANCE '� W IE `
License Lawdfin ionsuch
apply mawithac ofpropertywhnsedpsouant in the thereon,and
whocontmctsfor such projecuwiNacununetor(s)Iicensed pursuant in the Conuucwfs ALTER License Law. FEE SUMMARY
❑ I em exempt under Sec. ,B&P C for thio reason BACK FLOW PROTECT.DEVICE UT IDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR. COND. RECEIPT#
, , . .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have a certificate ofcoment to self-insure,or a certificate of �I RECEIPT#
orkera'Com ration firemance orscertifiedc FIXTURES-PER TRAP
pe copy thereof(Sec 3800,Lab CJ which PARK FEE Y N
f covers Of employees under this permit. a GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPTN
4., Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER PLANCHECK TEE
El Certified copy is hereby modified.
❑ Certified copy is filed with the city inspection division. GREASFWNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This
seetionneed notbe completed ifthepemtit is for one hundrnddollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of thework for which this permit is issued,I shall WATER BEATER W/VENT/ELECTR
not employ any person in my manner so a to become subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTEMiTREATING Date Receipt If
C) Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Ceoificare of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
W) become subject in the Workers Compensation provisions of the Labor Code,you must
a ' forthwith comply with such provisions or this penNt shall be deemed invoked. BUILDING FEE �a
ACONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby option that there is a construction lending agency for the performance of ELECTRIC FEE
V O7-. the work for which this permit is issued(Sec.3097,Civ.C.)
w rr Lender's Name PLUMBING FEE
L^ Lender's Address QTY. MECHANICAL PERMIT FEE
O W co I certify that 1 have read this application and some that the above inf zonation is MECHANICAL FEEF. a sect.I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
V) building construction,and hereby authorize representatives ofthiscity m enterupon the CONSTRUCTION TAX
L) Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. -
(We)agree to save,indemnify and keep harmless the City of Cupwino against
liabilitles,judgments,costs andexpenseswhich 'navy way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
Eof the rantingofthis permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signamm of ApplicanYContmenor ate I EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE - HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as defimW by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)R
El Yes ❑No VENTILATION PAN(SINOLB RB$ID)
ISSUANCE DATE
Will the epplicaomrfumm building ocwpemueeequlpmemordeviceswhlchemis BOILPR-COMP(311P OR 100,000 BTU) PAID ezardom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A C
..Yw ❑No NEWRESIDENTIAL MECH.—SQ.IT. //qT
I have read the hazmdous materials requirements under Chapter 6.95 of the - APR 221993
„ifomia Heahh,
Safety Code,Sections 25505,25533 and 25534. I understand hint y W
the building does not currently have a tenant,that it is my responsibility to notify the
oupant of the requirements which must be met prior to issuance of a Cortifoam of v' W)'t f("1Yu
opancy.
-or authorized agent Date TCLO ISSUED BY:
.. "jf