27267APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OF CUPERTINO - ' b
APPLICATION /PERMIT PLUMBING. MECHANICAL
LDING DIVISION BUII .DINGPROJBLTIDF:N9IF'ICATION'
PHKMI'f NO.
7 [�
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GADDRESS: I�-�
s7 oR ,6AP 'p GI a
E
SANITARY NO.
APPLICATION SUBMITTAL. DATE
NAME: / I O P ONL'y
aVl S
CONBACTOR'SN LIC NO
SIC
❑
CONTROLp
ARC IFFECT/ENGIN LER: LIC NO:
ADDRESS:
CONTACT: PHONIC
QTY.
EiLECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT MECH
LUMB
PERMIT ISSUANCE
El El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed underprovisions of Chitl (commencing with
APPLJANCES - RESIDENTIAL
JOB DESCRI 'ION
PANELS
Section ]000) of Division 3 of the Business and Professions Code, and my license is in
I ull force and effect.
License Class Lic.a
UP TO 200 AMPS
201 - 1000 AMPS
Date Contractor
ARCHITECT'S DECLARATION
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$ /,SQ. FT.
1 understand my plans shall he used as public records.
P fan
SIGNS ELECTRICAL
Littnu4 Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am encnmt Isom . the the Commences License Law for mTollnwing reason ,(Seminn1U3L5, Business and Pnessinns Code: Any city or county
SPECIAL CIRCUR/MISC.
^
TEMP. METER OR POLE INST.
which requires a pemtit re wnswm, applicant improve, demolish, file repmr any swemre
pd., 1. requires the evisis for such statement
a
POWER DEVICES ,- I
r 1 IJi `
Comment's License
that m is Beene w pursuamuo the) of Diinm of the Ca Hanna's License Law (@voter,
pursuant
9(commcncmg with Section l000)of DiviaionJofthc BYalme9 and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt herefiom and the basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a pemhit subjects the applicant o a civil penalty o!
OUTLETS - SWITCHES - FlXl lJRES pp 1
1 �I"a
not more than five hundred dollars (ESOI)1.
❑ me In..cnffthndred ry,m m$500). yecswith wages its theicwlecompensmion,
NEW RESIDENTIAL ELECFR I '—SQ. FT.
STORIES
TYPE CONSTRUCT ION
will do the work, and the smicwre is not intended or offered for sale (Sec. 7014, Business
and professions Gale: The Commenar's License Law dos not apply to an owner of
prapeny who builds or improves thcmon, and who draw such wank himself or trough his
con employees, provided that such improvements e not intended or offered for We. If.
m
OCC. GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within are year ofcampletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
QTY.
PLUMBING PERMIT
FEE
FLOOD ZONE,
APN
sale.).
❑ I.as osvnerof dw propay, um exclusively onamaing with licensed contractors to
nnswct the project (Sec. 7044, Business send professions Code:) The Contreetor'a
License Law does not apply loan ownerofpropany whobuildsor improves Haan , and
PERMIT ISSUANCE
who crammes for such projects with. comumelo(s) licensed pursuenuothe Conwanr's se law.
Lice m
ALTER- DRAIN &VENT- WATER(G)
FEE SUMMARY
[3 I am cacmpt under Sa. , B & P C for this onamn
BACK FLOW PROTECT. DEVICE
O bIDL FEES
SANITARY Y N
RIiCEIPI'a
Owner Date
DRAINS - Fl,OOR, ROOF, ARIiA, COND.
WORKMAN COMPENSATION DECLARATION
❑ 1hereby affirm that I have a cenificxteofemervaun self - insure, or a certificate- of
Worken'Compcnsation Insurance ma cenified copy thercof(Sec. 3800, Lab C,) which
covers all employee's under this permit
Policy a
SCHO(X.'I'AX Y N
RI:CIilPfa
FIXTURES - PER TRAP
PARK FEE Y N
HECEIFT p
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
�"�
BUILDING DIVISION FEEg
Company
GAS - EA. SYSTEM -OVER 4 (PA)
PLANCHECK FEE
• CenifieA copy is hereby famished.
GREASEANDUSTRI. WASTE INTERCEPTOR
GRADING FEE
• Certified copy is fled with the city inspection division.
CERI'IFICATEOF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM PA. 2041
ENERGY FEE
(This metionnced.1 becomplated iftbe permit is far one barometrical]. ($100)
or less.)
WATER HEATER WNENT/ELECTR
I certify that in the perfermarme fthe work for which this permit is issued, l shall
not employ my person in any manner so as to become subject to the Workers
Cnmperentian Lawsof Califnmlz. Date
WATER SYSTEM/TREATING
PAID
Dam Reccipta
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such musicians or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a construction lending agency for the performance of
the work for which this permit is issued (See 3097, Cn. C.)
�
ELF,CfRIC TEE
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
Lender's Name
Lenders Address
1 certify that 1 have read this application and alma that the above informed. is
correct. l agree mamply with all city and county ordinances and atate laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building eamwnlon, and hereby authmrm repramutives ofthiscity meraccirpoa the
above mentioned pupeny for inspection forposa.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,(1!1) CFM)
We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway averucagm hod y
AIR HANDLING UNIT (OVER 10lNIO CFM)
in �n fit gr ti gof this manna. 1{'
c // 1
I L I
EXHAUSTHOOD(W/DUCD
PAID
na reof ApplicintlContmcmr ate
HEATING UNIT (TO 100,001D BTU)
HAZARDOUS MATERIALS DISCLOSURE
rii,
Date Reccipta
HEATING UNIT (OVER IW,OBO BTU)
TOTAL,:
Will the applicant or future building occupant store or handle hvallous maleral
defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
VENTILATION PAN (SINGLE RESID)
Code, Section 2553240?
❑ Yes ❑ No
Will theapplicanmrluturebuildingmcupamuse equipmentardeviceswhichcmit
BOILER -COMP (3HP OR 100.(100 BTU)
�3�.1,�'CE DATE
h ardour air commo nanu as defined by the Bay Arco Air Quality Matrimonial
istrict? ❑ Yes 1:1 No
BOILER - COMP (OVER 100.000 BTU)
NOV
- - s 8 19agA
NEW RESIDENTIAL MECH. SQ. FT.
I have read the havardnus materials requirements under Chapter 6.95 of the
CITY Ur
California Health & Safety Code, Sections 25505, 25533 and 25534. ( understand Nat
uurttt l IIVU
Uthe building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requiremenu which must he met prim to issuance of a Cenificae of
Occupancy.
ISSUED BY
Owner or malimi'eed agent Date
TOTAL:
OFFICE