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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�T `". h'Lhu r A .
CITY OF CUPERTINO1
BUILDING. DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECIIDENTIFICATION
PERMIT NO. ^ O
BUILDING ADDRESS: /AA•'��y `
d&/r- UNIT# LOT#
SANITARY NO.
APPI-CATTIION,SUUBBjMIITTTTALDATE
�k
- �V
OW ERS HAMA; PHOW:
CO OR'j IS LIC NO:
Sc
NIC
❑
CONROL#
RC1 iCT/ENOIN EH: - / LI NO:
/Sa
A ESS: r. d. ` t , /
IW " �6 ✓ v
Co ACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ELECT PLUMB MECH
❑ ❑ ❑
4ttJ— 4{J
PERMIT ISSUANCE
LICENSED CONTRACTOR'S ionsof RADON
Ihembye(Tirm thalium licensed underprovisiomo(Chaptar9(cammencinB wird
ppp1.IANCES-RP.SIDENTIAL
• s
DES �
Section�R00) of�4j"kW�n 3 ofthe Businessan Professions Code, and my license is in
full force and effect. .A ' 1
License Cl illi'' Lie.#
PANELS
UPT02MAMPS
Data Contraamr
RC1 {I0 CP'S DECLARATION
1 turnaround my plans sha11 IK used u public records.
201. IWO AMPS
OVER IWO AMPS
SQ. FT. FLOOR AREA S/SQ. FT.
SIGNS EPIC
Licenced Professional
OWNER -BUILDER DECLARATION
SPECIA. R /MI C.
I am exempt from the CantnnoYs License law for the
1 herebyai affirm thatn.
n.. Anycity or county
followingo saPermiinn]03Lmr,a5. im,
TEMP. OR I S
which to consumer, eller, improve, demolish, or
improve, repair any structure
its mere n e, ex
prior to its eh.applicant for file
Permit soLiceseLad stamment
PO '.VICES
,hot he is Ilene w p Sectio to the) ofDi om of 3 of Contractors License Law (chapter
the Co
9(commeis exemith Sectiora7000)ne bisision3aftll Business add .A., ionsCode)
onto h7031.5 by themfrocant road f the permfanheallegedexempsion. civil pinion of
Section byany applicantfornpermit subjttb the epplicumroocivil penalty of
SWIMMING POOL P. RIC
VALUATIONvO
OUTLETS.SWITCH PII -FIXTURES
than
net more five hundred dollen ($5110).
[II,mownownemfshepraperry,ormyemployees withwagesulheirmlecompensation,
NEW RESID[N7JAL ELECTR _SQ. PI'.
STORIES
IYPP. CONSTRUCTION
will do the work, mel im stmctme Israel intended or offered for mle (Sec. OW, Business
and Professions Code: The Comment's License Law does not apply to an owner of
pmpenywhobuildsorimpmves thereon, and whodoes such work himmlforehroughhis
own employees, provided thin such improvements ere ms intended or offend far sale. If,
OCC GROUP
RIS. UNITS
TOTAL:
however, the buildingor improvement is sold widdnorae yearnfcompletlon, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
El I, mownerofthe property, umexclusively consracia, with licensed contractors m
ILOODZONE
APN
comwn the prajecs (Sec. 7044, Business and Professions Code:) The Contractor's
License lawdramosapply ton ownerofpropany whobu f� pthe d
whucnnvane Gorsuch prnjecse wish nconvucum(s)liccnse peirau6ntn "i Cdnet r�'e
Licenm law.
MIT
S .�
I
R
R VGNT-WATCR (PA)
FEP. SUMMARY
❑ I am exempt uMet Sm.N & P C hai re soman
l ly
tl C TECf. DEVICE
O ,IDE
SANITARY Y -
RECEIIO' p
N -Owner Dale
R, ROgP, AREA, COND.
WORKMAN COMPENSATION DECLARqTJQOyL.�..,
SCHOOL TAX YN
it ❑ Ihembyaffimtheilhave acenific I of canss��Ito self Jl;b
Workers'Competnatica Insurance or a cen'!E d copj4hurof(Sec.3g00. La w rc
RECEIPTN
CR TRA
PARK FEE Y —N -
coven all employee's under this permit.
Policy It
RF EIPTM
GAS - EA. SYSTEM-IINC. 4 OUTLETS
BU ISION FEE
Company
OAS - EA. SYSTHM-OVER 4 (EA)
PLANCHP.0
t O
[ICertified copy is hereby famished.
GRFASMNDUSTRL WASTE INTERCEPTOR
GRADIN MIS sississia
❑ Certified cap, is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASF.TRAP
SOI
COMPENSATION WSURANCE
SEWER - SANITARY - STORM EA, 200FT.
ENERGY FEE
(finis section need not be completed iRhe permit is far one hundred do]].($HOO)
or less.)
WATHIS HEATER WNENgELECTR
PAID
1 certify that in the performance of she work for which dl', ' issued, l shall
not employ nn pe n m stunner so as to fi n e ®A a Workers
4
WATER SYSTEMiTREATING
Coar;,i i (Cut'a Date
Data R t t
p f J
Applicant
NOTICE L NT: ,nBer na;i this Cenificam of P.xemption, you should
NEW RPSIDENTIALPLMIL SQ.FT.
TOTAL:
become subject m the provisions of the Labor Code, you man
forthwith comply with such provisinru or this permit shell be deemed revoked.
such provisions;
BUIL # '�
SeKXCFEE L41 CAD I
CONSTRUCTION LENDING AGENCY
1 herehy affirm that there is a cansounfo r lending agency for On, pe icra ce of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's
TOTAL:
ELECTRIC FEE
Name
Lenders Address
QTY. MECIIANICALPERMIT FEE
PLUMBING FEE.
1 certify that 1 have mad this application and stem that the above information is
comet. I agree to comply with all city and county ordinances and stale laws relating to
PERMIT ISSUANCE
MECHANICAL.
building cannmetion, and hereby authorim representatives ofthis city to anter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
C S X ZOO
(We) agree to save. Indemnify and keep harmless the City of Count.. ugaimn
liabih1mx,' nn, costs and capenres which may in any way ace,u egemit said City
AIR HANDLING UNIT (TO 10,M CFM)
Si ft renting of th'
{A,�/.`
� 1
AIR HANDLING UNIT (OVER IO,OMCFM)
EXHAUST GOOD(W/DUCD
IL
PAID
Signatum of Appman Contncmr F Vale
HEATING UNIT (TO IM." BTU)
HAZARDOUS MATERIALS DISCLOSURE
am Receipt It
Will Me applicant or future building occupant nom or head]. hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IOO.WO BTU)
TO'f
Code, Section 25532007
El Yea 13 No
VENTILATION FAN (SINGLE RFSID)
WillNee licamorfutumbuildingaccu ruse
pp pan equipmir
BOILER- COMP(3HP OR IL'B4OBO BTU)
ISSUANCE f�
? AB
BOILER. COMP (OVER IOE,000 BTU)
na=erdnus air conmminann az defined by the Bay AtPa Air Qualify Mesmgelslrnl
Quality
rDlnriet)
Yes No
C313H.1993
1�
12
NEW RESIDENTIAL MECSQ. FT.
1 have mad the hazardous materials requirements under Chapter 6.95 of she
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does nae currently hove a moan., ramify Ne
it Ir my nuance
Aur,
-r�f fa I�tf j )IV1%
C� L I U�' V V
oflfry a
Occupant of the requirements which must be met prior to issuance of a Certificate of
et
V
Occupancy.
ISSUED BY:
Owner at' authorized agent Data
TOTAL:
err-ict