25873APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO A
APPLICATION/PERMIT PLUMBmG-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMITNO.
C 0 7 O
JO / J
B!UII�LDDIINNG ADDRESS:
SANI'T'ARY NO.
APPLICATIONSU/B�MIITTA�ILDATE
( / 11 D UNIT#
i
O ERSNAME: PFIONB:
NTRACTOR'S E LIC NO:
N/C
❑
CONTROL#
A CIII'fF.CT/ENGINEER: LIC NO:
ADDRESS:n n �/ (1� `' /SK�
j2C5
ONTACT: PHONE:
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QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MF,CH
PERMIT ISSUANCE
fel v' 1 w 2� `Ag Wim+
LICENSED CONTRACTOR'S DECLARATION
l hereby affirm that l am licensed underprovisions of Chapter9(commervingxvida
Section 7")of Division 3 of the Business and Professions Code, and my license is in
APPLIANCES -RESIDENTIAL
PANELS
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TOB DESCRIPTION
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full mocernlJ1act.
Liccnsc Class `—'-3� Lic.# �SS�iA
UP T0200AMPS p
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Dm Contractor
ARCH IT ECTS DECLARATION
I understand my plans shall be used as public records.
201 - 1000 AMPS
SQ. FT, FLOOR AREA
\ j J
8/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I ton exempt from the Contractors License Law for the
101—ingremon.(Section ]U3LS, Business and Professions Code: Any city or county
which requires a permit to consumer eller, improve demolish, or repair any structure
no, its issunnvainkorequlres lM1eappliwm formeh permit m flea sq,tedstammeat
that he Is licensed pursuant to the provisions of the Commences License Law (Chapter
9(wmmcncing with Section ]O(10)o[Division3of the Business and Professions Code)
of that he is exempt therefrom and the basis for the alleged exemption. Any vielationof
.5 b,m, applicant for. permitbjamts theapam m plica civil penalty,(
Section]031su
no, more than live hundred dollars ($500).
❑ I,asowneroflheprop ny,ormyemployccs with waSesastheirsolecompcnsadon,
wJlrLdnework,andmc,"Oureisnol intended oroffcred 0m.,cile(See.]044, Bunions
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECI'R — SQ, FT.
STORIES
TYPE CONSTRUCTION
and Professions Coage: he Comranor's License Law does not apply I an owner of
property, who milesor improves thereon, and who does such work himselforthroughhis
own employees, provided that such lmprovemems are not intended m cdfiered for subs. If,
OCC.GROUP
RES.UNI'1'S
TOTAL:
however, the building or improvement is sold within one year ofcompletion, theowner-
builder will have the harden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FF I,
FLOOD ZONE
APN
❑ I, as owneroRhepropuny, nm exdusivelywntraming with licensed contractorsm
onstruct the project (Sec. 7014, Business and professions Code:) The Contractor's
License Law does not apply wanownerofproperty whobuildsmimarmacihereogand
PERMIT ISSUANCE
who contracts nonsuch projects with a moraemr(s) licensed pursuant to the Contractor's
Liccnsc Law.
PETER - GRAIN&VP,NT - WATER (BA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FF,LS
❑ I em exempt under Sec. B & P C for this reason
SANITARY Y N
JWork
RECEIPT#
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ Thereby of l have a scomeme mfconsent U,elf-insure, ora certificate of
Compensation Insurance or acernified copy thereof(Sw.3800, Lab CJ which
roversall employee's under his pctmiL
Policy # _ 14 s[o /
SCHOOLTAX Y N
RECEIPT#
¢ FIXTURES - PER TRAP
/
PARK PP.E Y N
RECEIPT#
GAS -FA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Cenifedcpy is hereby famished.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ CernillrA copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Thissomion radon be completed Knot p—it is foronehundred dollars($100)
or lees)
WATER ITLATER W/VENDELECPR
Icenify that in the performanceofthe work for which this permit is issued, Ism[]
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not employ any Person in any manner so as to become subject to the Workers
Compensation Lawsof California. Date
Applicant
NOTICE TO APPLICANT: if. after making this Certificate of Exemption, you should
PAID
Date Receipt
WATER SYSTEMNREATING
NEW RESIDENTIAL PLM. SQ. FT.
TOTAL:
V)becm
>
become subject to the Worker's Compensation provisions of rhe Labor Code, you must
Forthwith comply with such provisions or this Perrot shall he Deemed revoked.
�O
BUILDING IEE
SEISMIC FEE
i Q
CONSTRUCTION LENDING AGENCY
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O
F
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Q0
hereby affirm that there is a construction lending agency for Be performance of
the work for which this Perrot is issued (Sec. 309], Civ. CJ
Lenders Name
O L:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. l agree In comply with all city and county ordinances andstam laws relating to
building construction, and hereby aallmdm representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wc) .,.at save, indemnify and keep Irani the City of Cupertino against
tubi ldes,judgments.cnsix and expenses which may in my way acerueagainsl said City
PERMIT ISSUANCE
MECHANICAL FEF.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
active. heg tin, Ihulwored.
Ks
EXHAUST HOOD(W/DUCT)
PAID
Date Receipt#
Sioneurcof Apph pC tractor Due
\ HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
T
Will the applicant or future building occupied store or handle hasurdoue material
s defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
art
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)'?
E3 Yes ❑ No
ff-
ISSUANCE DATE
Will the applicamorfumm bullmngoccupant use equipmemn ordeviceswhich emit
BOILER- COMP DHP OR I00,000 BTU)
BOILER- COMP (OVER 100,W0 BTU)
�huaardons
ate contaminants us defined by the Bay Arca Air Quality Management
District?
py p D
NEWRESIDENTIALMECH. SQ. FT.
❑Yes ❑ No
Y Pry
1 have read the hu,no s mammals requirements under Chapter 6.95 of the
Culifomta I Icalth a Safety Code, Sections 25505, 25533 and 25534. I understand Nat
FEB1
if the building does not currently have a tenant, that it is my raedmr iblllty to notify the
f G
of the requirements which must be met prior to issuance of a Carl 6cme of
Ooccupant
ccupancy.
, �y1{1 I INU ,
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1h
ISSUED BY:
Owner m salatoxed agent Dam
TOTAL:
OFFICE