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CITY OF CUPERTINO PUH• •..
APPLICATION/PERMIT PLUMBING -MECHANICALIDENIICA
PERMIT NO. O
L 37
• BUILDING DIVISION IIUII.UIN'!: YRUJF.Q'IUEN'"1'14'1!;A9']ON
BUIL D'N(: /a DD�F55�
SANITARY NO.
APPLICATION SUBMITTAL DATE
UUII//YY�w// UNIT# LOT#
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OWNERS H' PITON' CONT E: jz
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CON TROL#
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RCIHIEC 1'/ENGINEER : LIC NO: ADDMS w
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'ON'1' (-': PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE DO
ENSED CONTRACTOR'S DECLARATION APPLIANCES - RESIDENIAL
,DESCRIPTION
Matz
!hereby affirm that l am licensed under pmvisionsofaapter9(commencing with
Business andprpfessipns God and myli<ense is in PANELS
SOF
full fto a)eff c.�oR3yd.)he
'(7//V�� /�1 f/{,r,JY q(/I�fL� UPT 20 OO AMPS
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License Class
,<o.
co
F -D
Oam ConOocmr 201-1000AMPS
ARCIIH ECI"S UECI,
SQ. FT. FLOOR AREA
$/SQ. 4T.
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I understand my plvts shall he used as public records. OVER 1000 AMPS
SIGNS ELECTRICAL
LicrnsW Pmfaslonsl
6y$;
OWNER-,UILDER DECLARATION SPECIALCIRCUIT/MISC.
:W.6
E O W
I hereby affirm that 1 ern exempt from Ne Contractor's License Law for the
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following reason. (Section ]031.5. Business and Professions Code: Any city or county TEMP. METER OR POLE MST.
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which myuires a permit to construct, alter, improve, demolish, or repair any structure
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prior loitsi.... ace, also mquices lheapplicant for such Permit o file. signed smmmant POWER DEVICES
,,, C C O
that he is licensed pursuanto the provisions of the Connectors License Law (Chapter SWIMMING POOL ELECTRIC
VALUATION
dao
9(cocncing with SaWB)nf tion]Division 3 of the Business and Pr.fcssions Code)
mm
WMm
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of OUTLETS - $WITCHPS -FIXTURES
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Seal 7031.5 by any applicant fora lwmut subjects the applichnno a civil penalty of
-a
S p
d
nnnnnrethhn five hundred dollars($500). NEW RESIDENTIAL ELECTR _9Q. FT.
STORIES
TYPE CONSTRUCTION
m
❑ I, asowncrof Nepropeny.ormyemployees with wagesastheirsolecompensition,
will Jo thework, and the structure isnot intended oroffercd forsale(See. 901 Business
and Professions Code: The Contnemr's License Law does not apply to em owner of
property whobuildsorimproyes themo%anJ whodonsuch work himselfer through his
OCC.GROUP
RIS. UNITS
wnemployees. provideadd at such impmvemenmarenot imendedoroffeced formle. If, r
however, the building or improvement is sold within one year ofcompletion, the owner- TOTAL:
builder wil I have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE
MOOD ZONE
APN
❑ 1,avownernfthepropenXamexclusivelyconv tingwithlicensedcuntrvcimto
the project (Sec. 9014. Business and Professions Code) The Contractor's
Linstruct
icense Lawdocemm apply to on owneroTrapeny whobuilJsnrimpowasl anon,and PERMIT ISSUANCE
who contmelsfor such projects with aconnacmr(s) licensed pitacenuo the Contractor's pL'f1iR-DRAIN&VENT-WATER (F,A)
FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. . B & P C for this reason BACK FLOW PROTECT. DEV ICE
OUTSIDE FEES
SANITARY Y N
Owner DateRECF.11'T#
WORKMAN COMPENSATION DECLARATION GRAINS - FLOOR, ROOF,A ,GOND.
SCHOOL.TAX Y N
�❑
1 hereby affirnh that l haves cenificmeofconsmnr salt-iscum. m is exrtificamof FlXTURES - PER
RECEIPTp
PARK FEF. Y N
RDIVISION
Workers Compensation hvsuren�.cc�P )s cutifiWcopythe (Sce. 38W, lab C.) which
Pule, all employee'solul./sA't�}e/rt��j%'7 l GAS -F STEM -I INC.40t1'rLETS
BUILDING DIVISION
Policy#y[JyG _I✓ srI!iU
IT'yb A -E
Comport {��G—p, �— GA. SYSTIiM-OVER4(FA)
PLANCHECK FEE
1/���
❑ ,Had copy ishere, m
GRADING EEC
Cerlilicd copy is fled wird the city inspection division. EASFIINDUSTRI. WASTE I RCEPTOR
CERTIFICATE OF IiX1IvnON FROM WORKERS' REASE'1'RAP
S FEB
OILF:RGY
COMPENSATION INSURANCE s.
me
(This adios need not becomplctcd ifthe permit is for one hundred dollars ($100) EWER - SANITARY - .2WFT.
or leu.)
I certify that in the perfomahce oftht work for which this permit is issued. I shall AT HEis /ELECTR
not employ any person in my marcher s. as, to become subject to the Workeri
PAID
Corop etatimi-maxof Califomia. Dam n :M/IRG G
Dam Receipt
Z
Applicant
Q 0
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should N WR IpE ALP B. SQ.
TOTAL:
fry
become subject to the Workers Compensation Provisions of the Labor Code, you must
F-'
�?forthwiforthwith
such provisions or this pershall be deemed revoked.
comply with mit m
BUILDING FFE
SEISMIC FEE
0. [�
CONSTRUCT ION LENDING AGENCY
ELECTRIC FIE.
Z
I hereby affiant Nat there N o construction landing agency for the perfunmmee of
TOTAL:
O
the work for which this permit is issued (Sec. 3097. Civ. CJ
ndr's Nance
F
lender. Address QTY.ERMIT FEE
La
NM
PLUMBING FEF
C) U
I I have this that dee above information is
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unify that read application and stare
laws w PERMIT ISS Z/
MECHANICAL FEE
correct. I agree to comply with all city and county ordinances and state relating
CONSTRUCTION TAX
F-'
building construction. and hereby auNmiu representatives of this city to enter upon the
L.I Z
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We) ogre msec e, indemnify and keep hamcWs the City of Cupertino against
hahilioa,,jud ms, sw and expenses which may in any way accr�ea ins said City AIR HANDLING UNIT DO 10,000 CFM)
in cunscyuPet Rh c ting.fthla permit.
AIR HANDLING UNIT (OVER 10,WO CFM)
PAID
Silicono[A1 s1i nt/ t Date EXHAUST HOOD(WMUCT)
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('1'O 100.0001 BTU) /
Data Receipt#
TOTAL:
WilltMapplicmt or future building occupant since., handle hevmdmis material HEATING UNIT (OVER 100.001 BTU)
u defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(.)? VENTILATION FAN (SINGLE RESID)
❑ Yet ❑ No
ISSUANC DATE
BOILER- COMP (311P OR IW.WO BTU)
r A I I,f
Will the licantor future buildin fusee taNeviceswhichemit
pp goy 9uu
Ir`
the Air
hvurdnur esu contaminants as def neJ by the Bay Area Air Quality Management BOILER - COMP (OVER 100,01)(I
DkvicQJUN
❑ yes ❑ No NEW RfiSIDEN'TIAL M[CII. SQ.191
27 1995
1 have mad the haemdeas materials requirements under Chanter 6.95 of the
Cod%Sections 25505, 25533 25534, !understand that
CII Y Ur- (;Url"-'
Califomia rdth& .fety and
ate
o
if the buil dins of currently have a lemon, thm it is my res oas bility o nify the
cupam c ems which must be met prior to iss , e of e C 'ficme of
;,w
Occupm
ISSUED
Ownermc
0 '
t Date TOTAL: r�
OFFIC