25777APPLICANT TO FILL IN INFORMATION WITHIN RED LINES . USE BALL POINT PEN ONLY
CITY OF CUPERTINO °IcrsB.°-RLeCTa'TCz'
BUILDING DIVISION APPLICATION/PERMIT P.MECHANICAL
IIUII.DINGPROJECI'IDEN1II+ICA'11(IN
'
PERMrc ND.
25777 5 7
BUILDING ADDRESS: /./��-Pik
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SANITARY NO.
APPLICATLONSUBMI'1 'ALDATE
Ar )`I/ UNIT# LOT
'RS NAM� PHO E: f/O
CO CfOR'S NA LIC NO;
NIC
❑
CONTROL#
0 to
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RCHITEC (ENGINEER; V LIC NO:
A G•SS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
HIM ELECT PLUMB MECH
�f� 0 El
(B
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION
1 hereby.M m that lam licensed underprovisionsofChapter9(commencing w700(lSection 700(Division Sof the Holmes, end Professions Code, unit my license is in
APPLIANCES - RESIDENTIAL
PANES
�IO DESCRIPTION
full force lass effect.
�P
�
License Class Lic. p
UP TO 200 AMPS
yTyf��j�
Dae Contractor
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used as puf�lic ,oaths.
OVER 1000 AMPS
SQ. FT. FLOOR AREA fi SQ. FT.
SIGNS ELECTRICAL
Licensed Pmfasiannl
OWNER -exempt R DEC,
SPECIAL CIRCIIIT/MI$C.
Cornmeal
1 hereby affirm that 1 em exempt from fie GonCo License Lew for she
follwhich remmason. 7031.5, Any
smpr Professionsh,
TEMP. METER OR POLE INST.
ors.peation yrcaunsy
crashed,
which requires n permit re construct, alcor, improve, demolish, or repair nay swcture
orraman
to s pemdno fileaseIza, statement
,provision,
POWER DEVICES
thatheor of fe Co
licensed palaoct to the
,has he is licensed Pursumt,o she provisinu of Ne thenaectofa License law (Cheam,
the Division Darthe Business andFord ions Code)
9that exemwith Section7").f
SWIMMING POOL ELECTRIC
VALUATION
heir and
msha h7031.5byary.pt efromaed the bodpronitrrthet. thedppica exemption. AnyvioWionaf
.Any
by applicant soacivil prnelryof
ore
OUTLETS - SWITCHES - FUGURES
northan dolllfor. ($500Ltsubjasthe
not come than five hundred dollar (5500).
hundred
❑ Lmownerofthepropeay,ormycmployeeawithwaguessheirsolecompensadon,
NEW R[SIDENI7AL ELECTR _SQ. FT.
STORIES
TYPF:CONSTR CHON
will do the work,and shestrucmre is not imeadedoroffued for sale (Sec. 7044. Business
and Professions Code: The Conuacter's License Taw does not apply to an owner of
propertywho buildsorimprovesshemon, and who met such worlchimselforthrough his
ownemployees, provided thutauch improvements mmminsendedorofferd formic. If,
OCC. GROUP
RFS. UNITS
TOTAL:
however, the building or improvement is sold withinaneyearof completion, the owner.
builder will have the burden of proving that he did nos build or improve for purpose of
QTY, PLUMBING PERMIT IFI'
° • •
ante.)'
❑ Luer with sed
ILOODZONE
APN
pcl ( (Ser. 7044,m raclusivelyconvacting s
L�msvuct the project (Ser. 7(b4, Business and professions Code:) The Cnmmemre
'he The Corrector's
icense Law does not apply to an ownerofpropeay whobuilds or improverfloomn,nod
PERMIT ISSUANC
who contracts for such projects with a consraceds) licensed Furnace to the Convector's
License Law.
ALTER-pRA1N& ENT Pi I
FEE SUMMARY
❑ I am tamed, under Stns. , B & P C far his reason
BACK FLOW PRO VI E
S�
UTSID .is
ITARY YN
RECEIPT#
Owner Dose
DRAINS -BOORROOPARF.A, COND.
. ,
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
❑ Thereby affirm thmlhave scenifuma(canunsmselFinsure.on ttnificem of
I Worker Compensation lnsurcenaor a terrifiW copy theral'Sec. 3800, Lab C.) which
RECEIPT#
FIXTURES-(RTRA
Af Y N
coven all employee's under this permit
Policy 0
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPT p
BUILDING DIVISION FESS
Comy
[I Carolled copy is hereby furnished.
GAS - G. SYSTEM -OVER 4(FA)
PLANCHECKFEE
GREASEBNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with theciry inspection divisimi..
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not becompleted fire permit is for Cort hundred dollar1$100)
or les")
WATER HEATER W/VENT/ELECPR
I ready that in the performance ofsbe work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers'
PAID
Compenss,ionlawsof California.Date
WATER SYSTEM/TREATING
Date Receipt#
Applicant
NOTICETO APPLICANT: If,site, making this Cenifiver, of Eacmcon, youahnuld
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
beeume subject o the Worker's Compensation provisions of the Labor Code, you mus,
forthwith comply withsuch provisions or this permit shall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that dome is a construction lending agency for the performance of
,he work for which this Permit is issued (Sea. 3097, Co. C.)
Lender's Name
TOTAL:
ELECTRIC FEE
Leal Add..
QTY. MECHANICAL PERMIT FEF
PLUMBING FEE
I really that I have .0, this application and sum Bus the above information is
,rat, Iag¢e to comply wi,l all city and county mdfsunm aW state laws relasingso
PERMIT ISSUANCE
,
MECHANICAL FEE
built ingcousuuction, and hereby endemic representatives ofthis city menter upon ft.
abovcmemimexi property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUC ION TAX
We) agree to save, indemnify and kap bombs the City of Capetian against
liabilities judgments. toss and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
in asequence of the granting of thi is.
a OO T
AIR HANDLING UNIT (OVER 10,000 CFM1•,
ignaurc of ApyKantiountractor nm
[%HAUS3'IIOOD (W/DUCf1
PAID
HEATING UNIT (TO 100,000 BTU)
I IAZARDOUS MATERIALS DISCLOSURE
Date Recciptp
Will the applicant or fpmre building occupant store or handle hazardous material
as defined by the CuPin inn Municipal Cade, Chapter, 9.12, and me Humb and Safety
HEATING UNIT (OVER 100,WO B'TU)
T014 .:
Code, Sttti 25532(u)7
0Yu ❑ No
VEN'T'ILATION FAN (SINGLE RESID)
BOILER- COMP(3liP OR 100,000 BTU)
ISSUANCE D E
Will he npplicamarfummbuildingoccupan, oseequipmem ordevices whichemi,
BOILER - COMP(OVER 100,OLID BTU)
heramcua air commoners ones m defined by the Day Arca Air Quality Management
Dishier?
❑ Ya ❑ No
A B
W
NL'W RESIDENTIAL MECH. SQ. FT.
I have read the haterell materials requirement under Chapter 6.95 of ,he
California Health & Safety Code. Sections 25505, M533 and 25534. 1 understand that
NOV
if the building docs nm m
currently have a nem, that it is my responsibility to notify the
accurate of the requirements which muss be met prior to issuance are Certificate of
Occupancy.
n
1
ISSUED BY: Nil
Owner nr nahorized egem Date
TOTAL:
OFFICE
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