25405APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO•'
BUILDING DIVISION APPLICATION/PERMIT
-
PLUMBING - MECHANICAL
BUILDING PEO.IECI' WENT IFICATION
PERMIT NO. O
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITI'ALDAT'E
C
-I.-
UNIT# LOTH
O NERS,c[,MNAH: PHONE:
y1) -
COM RACTOR'S NAME: LIC NO:
N/C
❑
COMTEOL#
1ARCHITEC ENGINHR: LIC NO: ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
B ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaffinn that I um licensed underprovisions of Chapter9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7000) of Division 3 ofthe Business and Professions Code, and my license is in
full force and effect
PANELS
1 x
License Class Contractor
Date GOal'S
UP T0200AMP5
- 1 AMPS
/
IVfN` OI�
\ sl
ARCHITECTS DECLARATION
D
I understand my plans shell M used as public records.
OVER Has
OVER 1000 AMPS
p�\� ppp pppppQE-&p& [,q
ATL E b '
SIGNS ELECTRICAL
O V 6F_
B M
g�
Licensed Professions
OWNER-BUILDERD ECLARATION
IAL ID
Zvi y phi_
I hereby affirm that I em exempt from the Contrnnore License Lew for the
,�..(l
following reason. Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to consumer, alter, improve, demolish, or repair any structure
prior[, its issuance.alsortquirestheapplicant forwch parml to filevsigndsamenent
TEMP. METER OR POLE INST.
POWER DEVICES
that he is licensed pursuatuo Ne Provisions ofthe Contracmfs License Law (Chapter
9Lminmencing with Section ]BO,T)nf Division 3ofthe Business and ProfaiomsCade)
or lbathe is exempt hereltom and the basis for alleged exemption. Any violation of
Section 7031.5 by any applicant for v permit subjects the applicant to a civil penury of
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
0 O yVV UAI
not more than five hundred dollars ($500).
❑ I,aaownemDhepropeny,ormyemployceswith wagesmthcinolecompcvahon,
NEW RFSIOPMIAL ELELTR _SQ. PT.
STORIES
TYPECONSTRUCIION
willdo the work, and the structure isnot intended reoffered formle(Sm.]044, Business
and I'rolessions Coshes T c Cmnvacads License Law Joos not apply 10 as owner of
property whobuildsmimpormathereon, andwhodeessuch workhimeelfmthrough his
nemployces,provided thatsuch improvcmms not intendedoFrustrate. LL
eere nmffcmd
OCC. GROUP
RFS. UNITS
however, the buildingor improvement is sold withimme yeuofcomplelion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
sale.),
❑ ],as ownerofthe property, am exclusively contracting with licamedeontrvemrno
QTY. PLUMBING PERMIT
HEFLOOD'LOrvE
APN
construct the Project (Sec. 7014, Business and Professions Code) The Contra msec,
License Law docs not apply wan owner of propery who buildsm im proves lhermn, and
PERMIT ISSUANCE
who contracts fmsoch projects with acnmmmor(s) liceaseelpursuanumhe Committees
License Law.
AL'fLR-DRAIN&VENT-WATER (EA)
FEE. SUMMARY
❑ 1 um exempt under Sec. . B & PC for this mason
BACK FLOW PROTECT, DEVICE
OUTSIDEF ES
SANITARY YN
RECEIPT#
Owner Dae
WORKMAN COMPENSATION DECLARATION
DRAINS - MOOR, ROOF,AREA, COND. .
SCHOOLTAX Y N
❑
Or ificam of only thrmf(Snsure,or. Lab C.)iwteof
Workert Compensation Insurance oraccrtified copy there,f(Sec.3g00, Lab C.) which
WorkersCompensation
FIXTURES - PER TRAP
RECIdn#
PARK FEE YN
covers all employee's under this permit. -
Policy #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT#
BUILDING DIVISION FEES
Company
❑ Certifiedcopyishercbyfomished.
OAS - EA. SYSTEM -OVER 4 (FA)
M.ANCHECK 19tH
GRADING HE
❑ Certified copy is filed with the city inspection division GREASE/INDUS TRI. WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not be completed ifthepennit is mom hundred dollars ($100) SEWER - SANITARY - STORM FA. 2000.
or less.)
I certify that in the performance ofthe work for which this Permit is issued, I shall WATER HEATER W/VENTIELECfR
nm employ any person in any mumar so as m become object to the Workers'
PAID
Cnmpenotion Lawsof Califon ia. Data
WATERSYSI M/IREATING
Dart Reed" p
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PIMB. SQ. FT.
TOTAL:
become subject an the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be doomed revoked.
BUILDING HE
S aQ
SEISMIC FEE
s
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the performance of
the work for which thisPni t is issuedee
(S. 309], Civ. C.)
TOTAL:
ELECTRIC FEE
Leader'.Name
Ieadeh Address
QTY. MECHANICAL PERMIT
FEE
PLUMBING HE
1 ramify that I have mad this application and state that the above information is
reel. I agree comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MP.CHANICAI.ITE
building construction, and hereby emboriu representatives of this city to enter upon the
x� ve-menlioaed property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
\ (Wc) agate m ave, indadn'" oil keep henmlae the City of Cupertino against
liabililies,judgments, cos d sex which may I. my way acerae against sail City
AIR HANDLING UNIT (TO 10,000 CFM)
-
eothe a ixpermit. ���
AIR HANDLING UNIT (OVER I0,000 CFM)
PAID
at.m.dA EContractm Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ('M 100,0(1(1 BTU)
Dote Reccipl#
TOTAL:
Will the applicant or future building occupant store or handle haaardous musmind
as darned by the Cupemino Municipal Code, Chapter 9. 12. and the Iieurb and Safety
HEATING UNI "f (OVER 100,000 BTU)
Cods, Second v)?
Cl Vic, 13 No
Yes
VENTILATION PAN (SINGLE. RESID)
ISSUANCE DATE
P A
BOILER - COMP CUP OR Iq1, W BTU)
uwh Statist
Will npplicamorfumre building bythe Bay equipment Quality
haridell air comaminnns as defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Disttin1
❑Yes 0 N
1 have real the hummers materials mu,m ems under Chapter 6.95 of the
NEWRESIDENTIALMECIL SQ. FT.
AUG n/ Q
- 0 ���a�
Cnlifomiullealth&Safay Cole,Sectinw25505,25533and25534, Iunderstendtha
ifthe building does no currently have v mason, that it is my responsibility to notify the
cupont of the me uimments which must be met prim to issuance of a Cemificam of
VIII L/r CUiCf1�11VV
Occupancy.
ISSUEDBY:
Owneroramhorimdegcm Data TOTAL:
Urrlct