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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELMIRTCM'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMH'ND'
i % 0 G �i C
27025
L r J
BUDING
IL., AOIIRFSS:
SANITARY NO.
cAAPP�PLLICATIO�LN� S_UBBMGTAL DATE
UNffO LOTH
I
tRUU--�sN�AAMMl/R
�%
p r:J S��
CONTNA ME:
O
NIC
❑
CONTROL
'ARC ,Cf'/FN NEER: LIC NO:
AD 15
l
CO TACT PHONE:
QTY. E4PCTRIC PERMIT PEE
BUILDING PERMIT INFO
BLDG PLUMB M'
ilj/TJ\I
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licennaltrderprovisionsnfa,ier9(,manumeing wird
Sect ion ]naB of D' Businev end syrrsC dmylicenae isN
full fnrteand off in ai qde, /n
p Licrnse Cloa LIC.N ! -ILII(/^./V�
D'uw Contractor
ARCHITECTS DF,C
I understand my plans shall be used m public records.
APPLIANCES - RESIDENTIAL
10B DESCRIPTION /
,�1�• `�'�_'
L44\
ppNBUq
UP TO 2W AMPS
I"AMPIS
OVER InODAMPS
SQ. f. FLOUR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Ucensed Professional
i OWNER -BUILDER DECLARATION
4-1 SPECIAL CIRCUHDMISC.
I hereby affirm that 1 am exempt form the Convector's License Lew far to
following reason (Section 7031.5, Business and Profeastmn Cade: Any city orcomry
TEMP. METER OR POLE INST.
which requires a permit to construct, alter, improve, demolish, m repair any structure
prior to its issuance, also re ime the applicant for such permit to Ne a signedstalement
1
POWER DEVICES
that be is licensed pursuant to the provisions of the Contractors License Law (Chapter
( 'J (annmencin th Seninn](KKlof❑ivision3ofthe Business anJ Prnfeasinna Code
8wi ) )
Ortho 7031. by rric refromand the basis subjects thedeaemptt to civiny 1plelion of
Section ]031.5 by my permit subjects the applicant m a civil penalty of
dollars
SWIMMING POOL. P.LECTRIC
0
e ALUAO'ION
�.✓
OI1l1ET5-SWITCHES-FIXTURE <
t r )
dyed
t mnrc than five hundred dollen (5500).
($
n❑ I,eeownerof thepropedy,ormyemployeeewithwagnmtheirsolecompeneetlan,
RI 'TYPE CONSTRUCHON
NEW RESIDENTIAL ELECIR S : FR I
will do the wnrk,andthestmcmrcis not imendedoroffetW fer.R(Sce.7044, Business
and Professions Code: The Conunttola License Law does not apply to an owner of
t,
pmpenywhabuildsorimporvesthemon,andwhodoasuchwoh MmselfonhmughhisOCC.GROUP
ownemplUess, providedthat such improvementsarenot intendedaroffeteiltr We. If,
FS. UNITS
TAL:
however, the building or improvement is sold within one yearof completion, the comer -
builder will have the burden of proving that he did rot build or improve for purpose of
QTY, PLUMRINGPERMIT FEE
side.).
❑ I,asownerofthepmpM,emexclusivelycontrectingwithlicensedcontracwnm
FLOOD ZONE pPN
amaruct the project (Sec. 7044, Business and Professions Cade:) The Conhectors
License Law does not apply w an owner ofpropedy who builds or improves thereon, and
PERMIT ISSUANCE.
who contracts for such projects with a comractor(s) licensed pursuant to the Commoner;
License Law.
ALTER. BA
( )
FETE SUMMARY
❑ I um exempt under Sec. , B & P C for this meson
BACK FLOW PROTECT. DRVICE
OUTSIDE
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
SANITARY Y _N
RECEIPTN
WORKMAN COMPENSATION DECLARATION
❑ Ibemhyaffmrthatlhaveecertificamofconsentwself-insum,oracwificam°f
Workers Cr�aatio surenceorec 'fird co f(Sec. 3800, Lab C.) which
SCHOOL TAX Y N
RECIe1PTN
FIXTURES - PER TRAP
PARK FEE Y N
GAS -FA. SYSTf:M-I INC. 4OUTLETS
coven allemph cs '•'hSiad%•ijferAl,
Policy p
RECEIPTN
BUILDING DIVISION FIi1S
Company
❑ tfied copy is hereby fumisl
GAS - EA. SYSTEM-OVER4(EA)
PLpNCHECK FEE
GREASEBNDUMI, WASTE INTERCEPTOR
GRADING FEE
Candied!copy is filed with the airy inspection division. 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This secticanecdnot becampletad ifthe permit is for am hundred dollanaHH00)
or lees.)
WATER I IFATER WNENT/ELECTR
I codify that in the performance ofthe work for which this permit is issued. )shall
not employ any person in my manner so as to become subject to the Worlori
Cumpcnsatinnl.awsaf Cnlifomie. Date
Applicant
WATER SYSTRMRMEATING
PAID
Date RcceiptM
NOTICE TO APPLICANT: if, after making this Certificate offleemption, you should
become subject to the Workers Compensation provisions of the Lobar Code, you must
NEW RESIDENTIAL PI.MR. SQ. FT.
TOTAL;
forthwith comply with such Provisions or this permit shell he deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hemhy affirm dust them is a construction lending agency far thepo formunon of
the work for which this permit is issued (Sec. 3097, Civ. CJ
Dander's Name
TOTAL:
ELECTRIC FEE
Q�
Lmder'a Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 unify Nat 1 have read this application and edam that the above infomtetion is
m comply with all city anal county ordinations and sum laws relating w
PERMIT ISSUANCE3
MECHANICAL. FEE
ed porpedy far inspection Purposes.
ommotion, and hereby authorize tepreaenmuva ofthis city toerner upon theZPAID
ALTER OR ADD TO MECH.
N TAXtit
qc.t.gme
u ec as save,indemnify and keep harmless a City of Cupertino against
mends, casts and eaprnses whichtoyi ywayeccru again said City
AIR HANDLING UNITOO 10.000CFM)
c fthe granting 's permit,
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCf)
is V ontmctm ate
MATING UNIT(TO JOB000 BTU)
e ReceiptN
HAZARDOUS MATERIALS DISCLOSURE
Willtheopplicmt or future Raiddingocnupmt store or handle heurdousmaterial
so defined by the Cupertino Municipal Cade, Chapter 9.12. and the Health and Safety
BEATING UNIT (OVER 100,000 BT1nTOTAL:
O .0
Code, Section 25532(0)?
11 Yes C3 No
VENTILATION FAN (SINGLE RESID)
Will the applicmtorfulurebuildingoccummuse equipmemordeviceswhichemit
BOILER- COMP OIJP OR IOg000 BTU)
ISSUANCE DATE
haardom air comaminmu as defined by the Bay Area Air Quality Management
Distda?
BOILER - COMP (OVER I W,IXp BTU)
❑ Yea ❑ No
NEW RESIDENTIAL MECII. SQ. Ff.
I have read the hazardous materials requirements under Chapter 6.95 of the
SEP 16 1994
Cnlifomin Health & SafetyCode, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
rwcupunt of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
UI' VV(L-f1'IpI1V
ISSUED BY:ziDi If
Owner or uuthorizr4 agent Dem
TOTAL:
16= 7