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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO IHTIIAINf: hLf:CIRICA] .
APPLICATION/PERMIT PLUMBING- MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIF'ICAT'ION
PERMIT NO.
2 5 2 3 2
BUILDING ADDRESS: r
SANITARY NO.
APPLICA'110N SUBMI'I]'At, DA' 11:
OFF UNIT# LOT If
J
O ERSNAMH: PHO -i
A G l 1 V 9
CONTRACTOR'S NAME: LIC NO:
010i'(/
SIC
❑
CONTROLp
ARCHI .CHINGINF.ER: LIC NO:
ADDRESS:
4av
CONTACT:
ELECTRIC PERMITF1313
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE:
❑ ❑ -ifi ❑
1 CENSEDCONTRACTOR'SDECLARATION
Ihembyaffn that l am licensed underpmvixions ofalipter9(commencing with
APPLIANCES - RESIDENTIAL
10—B DFS^CRIPI'ION
Sceb )oft v mnJnf the Busineav and Prolcssions Calc, and my license ix in
Seniorce
I'ANIi1,5
^
full rccandeffc 0ts
an
license Cls""yy"y/PPb�� Li<.p
UP TO 200 AMPS
II✓"
Dale TECTS D!
is \ ARCHI'IECI'$DECLARATION
AMPSS
IDI - Bill AMPS
SQ. FT. 4100E AREA b/SQ. PI'.
OVER Ill
1 undera d my plans shall be used a. Public rtcods.
-- —
A L C D 1 l
� C I
SIGNS F,LECTRICAI.
u
LicensedPotlessionul
OWNER -BUILDER DECLARATION
I hereby effort that 1 am exempt from the Contractor's License law lin the—CM
following reason.(Section 0031.5, Business and Professions Code: Any city or county
which rtyuires a perrnit to construct, alter, improve, demolish, or repair any swctu e
pricrmitsissuance,also ma,mo,lhe appfiered for such permit. fileasigned x ... era
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter
9(commencing w'nh Section 7")of Division 3 of Ne Business and Professions Crde)
SPECIAL CIRCUIT'/MISC.
u—
ttJ � n n U T
E
TEMP. METER OR POLE INSr.
POWER DEVICES
SWIMMING POOL ELECTRIC
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 0031.5 by any applicant faro semii, subjects the uppi team to a civil penally of
OUTLErS-SWITCI IHS - FIXTURES
not more than five hundred dollars ($500). ❑ I.mowncrofthepropeny,ormycmployecswithwagesmtheirsolecompensation,
NEW RISIDFNTIAL ELISCIR —SQ. 1-7.
STORIES
TYPE CONSTRUCT 'ION
will do the work, and the structure is not intended or offerM for sale (Sce.7W, Business
and Professions Code: The Commoners License Law doer not pply to an owner of
property who builds or improves thereon, and who docs suc h wink hi msel f or through h is
ownemployees, provided thmsuch Improvements arcno lntcadedorolTercd frrsale. If,
OCC GROUP
RES. UNI'T'S
TO'IA :
however. the buddingar Improvement is sold within one yo orsdownpletior. thmrwner-
builder will have the burden of proving that he did not build or improve for purpom of
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
aelc.).
❑ Lasowncrnfthep.pcny,amcxdusivdyconwcting with licensed conVKroram
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
Licenu Lawdas not apply roan owner ofp.peny` Int builds or improves theater.and
PERMITISSUANCE
whocontracts forsuch projectswirh aconuxtogs)Iiansedpursuutto Ne Contractors
Licenm Luw.
ALTER- DRAIN & VENT. WATER (FA)
FEE SUMMARY
BACK ROW PROTECT. DEVICE
OUTSIDE 4hLh
❑ I am exempt under Site . B & P C for this rca.n
SANITARY Y N
RECEIPT'#
Owner Dale
DRAINS. FLOOR ROOF. AREA, COND,
WORKMAN COMPENSATION DECLARATION
❑ Thereby affnn the those acmificem of coram toselGinsurc, ora ceni0ce¢rf
Workers' Compensation hemariceoracertifed copy thereof(Sec. 380), Lab C.) which
cresm.11 croto cc'n undertbis #etent.
Polls, p
SCHOOL'I'AX Y N
RECEI1Tp
yXTURES - PER TRAP ��
PARK FEE Y N
RFCEIPT#
GAS INC.INC40UTLETS
BUILDING DIVISION FEES
C ny
GAS -EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
nificd cnpy is hereby famished.
T
GRFASIVINDUSTRL WASTE INTERCEPTOR
GRADING IEA?
❑ Certified wpY is fill wird Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SHWER SANITARY - STORM EA. 2001T.
ENERGY FEE
(This scnlon need not be completed ifthe permit is for one hundred dollars($100)
m less.)
WAT° W/VHNT/ELECTR
I certify That in the perfomnnceafrhe work for which this permit is issued.I shall
not employ any Person in any manner so as to become subject to the Workem
Compeoustirenlawsof Califomia. Dare
PAID
Dae Recciptp
ATE SYSTE RPATI NO
Applicant
NOTICE TO APPLICANJ:If, after making this CeniOcam of Exemption, you should
'W RESIDENTIAL TIME. SQ. IT.
TOTAL:
bcrome.subject a the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
Ne work for which this permit is issued (Sec. 3097, Civ. C.)
TOT
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL, ITE
Lender's Name
Lenders Address
1 artily that I hast, mad this applicntion and state that the above information is
neer. l agree m comply with all city and county ordinances and state laws relating to
TERM I ISSUANCE
building construction, and hereby authad'm rtprtsenrarivts of this city teener upon the
above-memlonad property for inspection purposes.
ALTER OR ADD TO MSCIL
CONSTRUCTION TAX
A W HANDLING UNIT (TO 10." CFM)
(We) agree to save, indemnify and keep haradess the City of Cuprnino against
Ii abilities, judgments, costs and expenses which may in any way accrue against said City
AIRHANDLINGIO,gq CPM)
inc yuencethe granting of this pent>>>'1.
atj o( ,a /J
) f0
'actor /1_ Date
HOOD
EXHAUST HOOD (WNUCI]
PAID
Signawrc Applicant/Conrmmor Dae
C
HEATING UNIT (TO 100.00() BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT' (OVER 100,000 BTU)
'
Will the applicant or future building occupant store or handle haamdous materialTAI.
as defined by the Cupertino Municipaltad Code, Chapter 9.12, the Health and Safety
Codi,. Section 25532007
❑ Yes ❑ No
VIIN'I'HAI ION FAN (SINGLE RESID)
ISSUANCE Difrr
Will the applicant arfmumbuildingacupantuu ectuipmentordeviceewhichemit
hmardoue air compositions as defined by Ne Bay Area Air Quality Management
BOILER- COMP CHPOR I00.000 BTU)
BOILER -COMP (OVER 100,000 BTU)
/� p.
P A D
Dome?
NEW RESIDENTIAL MECII. SQ. FT.
❑ Yea ❑ No
I have read the hazardous materials reyuimencros under Chapter 6.95 of the
J�1M 2
California Health & Safety Code, Sections 8505.25533 and 25534. 1 understand that
Bit.building does not currently have a tenam, that it is my responsibility to notify Ne
curcom of the rcyuirements which must be met prior to issuance of a Certificate of
6�/Y ur k- fir 4•
„ , s�
Occupancy.
\\�� //y'�1pC(//�/y���"�
ISSUEDBY: � I%� � /
OwneroranNmiadagcm Date
'TOTAL:
UI -riot