25651APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO'-
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL L
p .. .. BUILDINI: PN(IJP:LT IDF.NI'IFICA'I'ION
PERMITNO.
25651
BUILDING ADDRESS:
AV IGc_G- UNIT# LOT#
SANITARY NO.
APPLICATIONSUBMITTALDATE
OWNERS NAME: PHONE:
CONTR CTOR'S NAME: LIC NO:
N/C
CONTROL p1
❑
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
I"RI?:ry
QTY. ; ELECC PERMIT ;'. PEE d �I'^
LIC.' B!}ILDINGPERMIT INFO
BLDGE CT PLUMB MECH
PERMITISSUANCE
�I
LICENSED CONTRACTOR'SDECLARATION
Ihemby affirm@edam licivsed under proviaionsof @epmr9 mm
(comcingwith
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7000)of Division 3ofthe Businus and Professions Code, arta my licenu is in
full force end effort.
PANERS
License ClassLh,Is
UPT0200AMP5
sv ^~
rTl q ,-.r10V
Date Contract
` �[��V
201 -1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER 10011 AMPS
SIGNS ELECTRICAL �I
SQ. FT. FLOOR AREA $/SQ.
FT.
LimmudProfessi... 1
OWNER -BUILDER DECLARATIONTEMP.
LCIRCUR/MISC,
1 hereby affirm Net 1 amexempt from the ConnacbtsLicense Lew for Neconstruct,
TEMP. METER OR POLE INST.which
Ift,
following meson. (Section 7031.5, Business and Professions Code: Any city or county
requires a permit to consct, eller, improve, demolish, or repair any structureprior to its ismumm, also requires the applicant(orsuchpemnita, file a signed statement
IE ,
POWER DEVICES
that he is licensed pursuant to the Provisions of the Contractor's Licenu Lew (Chep...
9(ommnemcing with Section 700o)of Division 3ofthe Business and Prof,miam Code)
SWIMMING POOL ELECTRIC
VALUAT(Q
or that he is exempphere(mm and the basis far the alleged exemption. Anyvioledonof
Section 7031.5 by any applicant for a permit subjeea the applies. no a civil penalty of
OUTLETS-SWITCHPS-Fl%IVRES
Nan five hundred dollen ($500).
e,ofthepro,Kny,ormyemployeeswithwMmmtheirwlecomp radon.
NEW RPSIDFNTULL F.LECfR S . FT.
Q
STORIES
TYPECONSTRUCDON
Illd.du Work, and"h ctumisnotin.endMMofeR forsMc(SU.7W.Buinms
u d Professions Cash: The Coneacmis License Lew does not apply to an owner of
property whobuildsm improves thereon, and whod.es such work himself., through his
n employees, provided Not such improvements ore no. i mended or offered for sale. If,
OCC. GROUP
RES. UNITS
however, the buildingor improvement is sold withinaneyearofeampletion, the owner-
builder will have the burden of pwving.hat he did not build or improve for pterpwe of
T
Q 'PLUMBING PERMIT FEE
sale.).
❑ I,mownerofrhepropeny,em exdusivNyconwming with licensed convacmnm
FLOOD ZONE
APN
construct the project (Sm. 7W. Business and Professions Code:) The Cnneectofs
Licenu Lawdmsnmopplymmownerofpmp nywhobuiidsmimpmvesthereon,end
1 �.
PERMIT ISSUANCE
who conwcn fmsuch prvjecta witha<onwctorts) licensed pumuant to the Conwc[ot^s
License Law.
ALTER -DRAIN &VENT -WATER (FA)
FEESUMMARY
❑ 1 am exempt under Sec. , B @ P C for Nis owmnID
PACK FLOW PROTECT. DEVICE
E
SANITARY Y N
RECEIPTp
Owner Dam
pRAINS- FLOORROOFAREACOND.
, , , .
WORKMAN COMPENSATION DECLARATION
SCHOOLTA% YN_
❑ Ihembyaffimr than have scomficateofemsent mself-insure,oramnifieemof
Worker%Compensetion lnsurence onccnified copy thcrwfLm
C.) 3800, LCJ which
RECEIPI'N
FIXTURES PER TRAP
PARKFEE YN_
GAS - EA. SYSTEM.I INC. 4 OUTLETS
covers all employee's under this permit
I
Policy NBUILDING
RECEIPT #
DIVISION FEES
Company
GAS - FA. SYSTEM -OVER 4EA)
PLANCIECK FEE
❑ Certified copy is hereby famished.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is Ned with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER- SANITARY• STORM EA. 200FT.
ENERGY FEE
(Thissection need notbe completed ifthe permit is(orone hundred dollars ($100)
or less.)
WATER HEATER W/VBNT/LLECTR
I certify that in the performance of the work for which this Permit is issued. I shall
not employ my person in any mouser so es to become subject to the Workers'
PAID
Compenm.ion Lawsof California. Date
WATER SYSTEM/TREATING
Dam 0.eeeiptN
Applicant
NOTICE TO APPLICANT: If. after ranking this Certificate of Eumption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to Ne Wmker'r Compensation Provisions of Ne Lehr Code, you most
(atbwith comply withsuch Provisions or this pewit Kali be, deemed revoked.
BUILDING FEE .s
CONSTRUCTION LENDING AGENCY
SEISMIC FEE CD
I hereby affirm that them is a construction lending agency for the perfurmenca of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lcialm's Name
TOTAL:
ELECTRIC FEE
Lenders AddressTY�>±`.;
,. -�MECHANICALPGRMIT+: FEE
PLUMBING FEE
1 certify Not I have rad this application and state that the shove informed. is-
correct. l some to comply with all city and county ordinances and sum laws relatingha
PERMIT ISSUANCE �'
MECHANICAL FEE
building construction, and hereby mthmize repreaenlatives of this city to enter upon the
above-mentioned property for inspection putposea.
ALTER OR ADD TO ME•CH.
CONSTRUCTION TAX
(We) agree 10 save, indemnify and keep harmless the City of Cupertino against
I abilitics,judgmenn.costs and expenses which may in any way accrue against said City
A IR HANDLING ONI'1'(TO I B" CFM)
in consequence of the antin8 o(ths permit
/d Gh
AIR HANDLING UNIT (OVER 10,1100 CFM)
`Sigurea Applicant/Contnrchar Data
EXHAUST HOOD W(DUCT)
PAID
HEATING UNIT (TO IW Wq BTU)
. HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt N
Will the applicant or future building occupant share or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9. 12. and the IIcahn and Safety
I HEATING UNIT (OVER 100,W0 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
Code, Section 25532(gP
❑ Yes ❑ No
Will Ne appli<antor(mure buildingoccupantuxequipment mdevices which emit
housuM.s air contaminants as defined by the Bay Area Ab Quality Management
Di,onct7
BOILER -COMP (3HP OR I Wp00 BUD,
ISSUANCE DATE
P A f D
PAID
BOILER - COMP(OVER 100,0I10BTU)
i% ❑ Yes ❑ No
1 have mad the hmnrdous materiels under Chapter of the
OCT
V I M
NEW RESIDENTIAL MUCK. SQ. IT.
5505, M 33
. Safety Cody. Sections 25505, 25533 and 25534. 1 undentond Nat
understand
California buling due.
i(thebuildingd«snm..costlyhave amnsm,thanitis my n brtf. notify the
occupant of the requirements which most met poor to issuancec.o. oof a Cenificem of
r '
C�IY Uh !r[y
Occupancy.
—V
ISSUED BYt�_
Owner or authorized agent Date
OFFICE