24457APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT EN ONLY
OFFICE
CITY OF CUPERTINO n 1 1 -ELhc a1cAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJEC FIDENI'IPICA'I'](IN
PERMITNO.
/I /I C�
C NJ 4 4 J
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATH
/n^D/ 0nre&IG
- UNITN LOT#
OWNERSJJAM : PHONE:
CO CfOR'S NAME: � LICNO:
�•
N/C
❑
CONTVROLp`
ARCIIIILCCCf/FNGINEER: LIC NO:
ApRL$S, l6rv�w< *)C �
/6 /
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MHCHn
•Vt ` G Gsn
CRMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffrm the, I. licensed under provisinexofChapter9 Bmarmaroal with
Section 7001 Division 3 of the Businemand Professions Codgand my license isin
full forcennd effort. G� '2•
APPLIANCES - RESIDENTIAL
❑Cz
m00
tFp•W
JOB DESCRIPTION
PANELS
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Liccnse Clas LigN �J 7
Date Convenor_ C—
ARCHITECTS DECL RATION
I understand my plan shall be used as public records.
UPT02N
!ial,
40
Y`/�
201 - I"AM
GVHR I(JOUA S
SQ. FT. FLOOR ARP.A
f/IQ. RI'.
/
SIGNS L'LECT ICAL/
Licensed Professional
OWNER'BUILDER DEC ON
I hereby affirm that I am exempt from NContra
e GoLicense lafar the
following reason. (Salina 7031.3, Business and Professionsnion w Coo de: Any city or county
which rcquirts a p[mtil to constmc0 ober, improve, demolish, or rtpair any swnurc
pd., to it,isamnce,misorequire., Ne Npplicant forauuh permit m fileaxignedautemem
that he is licensed pursuanno the provision of.he Contractors Lisorm w(Chepter
9(commencingwirh Socims7") of Division 3ofthe Businessand Professions Code)
or that he is exempt herefrom and the bois for the alleged exemption. Any violation of
Section]031.5 by any applicant for a permit subjects the applicantto a civil penalty of
not mom than five hundred dollars ($5W).
I,mownernfthe
❑ pmperry,ormyemployenwiNwagn as N<inolemmpensmiun,
will dothework, and the structure is not lntendedoroffered formic(Sec.]044, Theocrat
SPECIAL CIRCUIT/MS
oy
fOyFF.
I30.y
RJ' Oce
sM7
jC00
a:00
CZa
F
e' ❑
Co
,
'$ELME. METER OR PAhINST.
POWER DEVICES
SWIMMING POOL URIC
VALUATION
O
OUTLETS -S CHES-FIXTURES
NEW, $DENTIA$. ELECIR 5
STORIES
TYPO CONSTRUCTION
and Professions Cale: She Correctors License Low does not apply to an owner of
_
property who builds or improves lhercon, and whodoessuch workhimxelforthrough his
menemm
ploy,ee,provided that such improv entimanotimendedoroffered formic. If,
O OUP
RPS. UNITS
TOTAL.
however, the building or improvement is sold within one yearofcompletion, the owner-
builder will have he burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT
s 1e.7.
❑ ].ax ownerofthe pmpmY,amexeluxively contracting with licensed contractors to
FLOOD ZONE
AI'N
construct the project (Sec. 7044, Business and Professions Code:) The Cmnructims
License Law (m$ mol apply to on owner of property who builds or improvca forma,and
PERMIT ISSUANCE
whocommels for such pmjecta with acontranor(s) licensed pursuant othe Contractor'n
Li'mor, Low.
ALTER HA )
FEESUMMARY
❑ 1 am eacmpt uWer Sec. B & P C for $his rcasmn
BACK FLOW PROTECT. DEVICE.
OUTSIDE Mq
SANITARY Y N
Owner Dam
DRAINS- FLOOR, ROOF, AREA, COND.
RECLIPTN
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
❑ $hereby offirm Nm lheveacertificate of conumto elf -inure, orattrtiRcme of
Worken'Compareation Insurance aacenified ropy flumen Sec. 3800, Lm CJ which
RECEIPT
FIXTURES - PER TRAP
PARK FEE Y N
- EA. SYSTEM -1 INC. 4 OUTLETS
coven all employee*,under this pemtil.GAS
Policy N
RECEIPT N
BUILDING DIVISION FERS
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
(:I Cenifiedcopyishcrebyfaniiii
GRFASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ C,nified mpy is filed with the city inspeNon division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ORF.ASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This action need not be completedHNe permit is (orae, hundred dollars 1$ 00)
or less.)
WATER HEATER W/VENT/ELECTR
I comity that in the performance of the work for which this permit is issued, l shell
wt employ Iny y manner sn gy�,po �ytbject m the Workers
PAID
WATER SYSTRM/TREAnNG
Data Receipt#
6 9
Cnmpcnsmin fCW�Jrmlu. / "i.�
pplicam !
to
NO'T'ICE TO 'the Wmk:If, after Cornfakinion pr Certificate of Lmor iode,yshould
as,
become objcomp to the Wuch
Coons this pravisio. of theelfbed Latasr Code, you must
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
�;
Pro to
fnnhwiN comply with xuaM1 provisions eer this pemtil shall be deemed revoked.
BUILDING FEE
»
4 Q
Q z
O
U
CONSTRUCTION LENDING AGENCY
Ihereby affirm thanker, is a construction lending agency for the performance of
the weed for which this permit is issued (Su. 3097. Civ. CJ
Lender's Name
SEISMIC FEE
O
'TOTAL:
ELECTRIC FEE
Lenders Addrea
QTY. MECHANICALPERMIT FEF.
PLUMBING FEE
4
rA
7
I certify that I have read this application and stale Nat Ne above information is
correct. l agree to comply with all city and county ordinances and stale laws reloting to
building construction. and herebyauthonee repreunutivesof Nis city to enter upon the
shove -mentioned property fee inspection purposes.
PERMIT ISSUANCE
ALTER OR ADD TO MCH.
MECHANICAL FEE
CONSTRUCTION TAX
F7
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabumes,jud ment"wasand expense hichmayinanywamcmeagainstuid City
AIR HANDLING UNIT(TO 10,00(1
in co sex ufthe renting of hie it.
AIR HANDLING UNIT (OVER 10,000CFM)
tgnmurcof Ap,hram/Cmmct Date
EXHAUST HOOD(W/DUCf)
PAID
IIIfikTING UNIT (TO 100,00) BTU)
Date Recei t#
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as dented by the Culxnino Municipal Cade, Chapter 9.12, and the Health and Safety
(EATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
Code,Scati 25532(n)'I
❑
ElYes 11 Na
lot
Will licanlmfumrcbuildin ruse
pp gbythe equip Air Quality Management
Iu m-fri? air contaminants as delved by the nay Area Air Quality Management
DisVlLl.
BOILER -COMP(3BPOR 1W,t10) BTU)
ISSUANCE DATE
r., B
pOILP.R - COMP (OVER IOO,OW BTU) a
❑ Yea ❑ No
1 have mad the haardmu.s materials raptircments under Chapter 6.95 of the
California Heath @ Safety Codq Sections 25505, 25533 and 25534. 1 understand that
ifthel ildm does rat currently have a remain, that it is my responsibility m notify the
p
®� 6 1901,2
CITY i ' 1r ��//(v
i
NEW RESIDENTIAL MECH.—SQ. F3'.
oceruuppaaral of a req/uiirmcco s which must be met prior to issuance f a C{`'nificate mf
0, 'e�,,i IY�
V LI/T-CT
ISSUED BY:
O r uwihortud aB�mt —Dam—
TOTAL:
OFFICE