25880APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING A
PERMITNO.
�i C O O
APPLICATION/PERMIT
PLUMBING - MECHANICAL
O
BUILDING DIVISION
I
BUILDING PROJECTIDP.N'11FICATION
L J o 0
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATE
67
SsJUNIT#
Q Q- 2
LOT#
OW 12RS NAME.
CONTRACTOR'S
NAME: LIC NO:
❑
NT'ROLN
'Vix 0.PHONE:
2N/C
A HITE;LT/ENGINEER: ICNJJ.ADDRESS:
74
CONTACT:' PHONE:
l�ptd 72711Y?QTY.
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
Iii 0 El El
LST
PERMIT ISSUANCE
LICENSED COrARACTOR'S DCC ATION
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
1 hereby ofDivisio I amftheBdinss and rofesio Chapter 9(commencing with
Section of Division J of the Business ProfessioreCode, and my license is in
PANELS
uanJ
a and
full force and if
Liccnu us Wc.a /�G_---J�•
UP T0200AMPS
l��(W•i'y
"
-Date COn
-IOW AMPS
Fri. FLOOR AREA
E/SQ. FT.
ARCHITECTS PSDECLARATION OVER I(#10 AMPSSQ.
— OVER
lunderstmdmy plans shall be used us public rccunls.
L E ®
SIGNS ELECTRICAL roomA
I N
Licensed Professional
HUILDERmDECLARATION SPF,CIAI. CIRCUIT/MISC.
OWNER -BUILDER
I on
1 hereby effnn that 1 am exempt from the Contractors License Lew for the
following raavon.(Section 7031.5, Business and Profession Code: Anyedy or county
TEMP. METER OR POLE INST. I
/I
which requites o permit m consumer. alter, improve, demolish, cur my sometimeCl/F
11),4164-
prior o its issuance, also esquires the applicant forsuch permit to rile a signed sentiment
POWER DEVICES
that he is licensed pursuant o the Provisions of the Contractor's License Law (Chapter
VAL ATION
9(commencing with Section 7") of Division 3 ofthe Businessand Professions Cade) SWIMMING POOL ELECTRIC
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section"/031.56ymy applicant fora permit subjectsthe applicant to a civil penalty of
OUTLETS - SWITCHES - FIXTURES
nm more than five hundred dollars (1500).
❑I,asownerofthepmperty,ormyempinyeeswith wegexustheirsolecompenatinn,
'
NEW RIiSIOfiNIIAL ELGCfR _SQ. Ff.
DTORICS
TYPECONS"fRUCI'ION
will do the work, and the structure is not intended or offered for sale (Sec. RNV, Business
and Professions Cade: The Commebors Licenu Law does not apply to an owner of
property who builds or improves thereon, and whodaessuchwork himselforthrough his
OCC. GROUP
RIS. UNITS
own employees, provided that such improvementsmanot intaededorofferedfmule. If,
however, the building or improvement is sold within one yearafcomptetion, the owner-
TOTAL:
builder will have the burden of proving that he did not build ar improve far purpose, of
aisle')' IQTY,
PLUMBING PERMIT
FEE
FLOOD ZONE
APN
Los �ss onfessio withro:)
constru❑ the pr ject (S e.70 1, Business and The Contraostu
the project apply'oano Business and Professions Cade:) The Comrunadd
License Lawdcesnm apply mon ownerofpropeny whohuiWs orimprovesthercnn,and
License
PERMIT ISSUANCE
whoconbactsfor such projects with acontrmtotfs) licenxd pursuant mine Conummaa
FEE SUMMARY
ALTER - GRAIN & VENT -
License Law. WATER IRA)
❑ I am exempt under Sm. , B & P C fm this reason
BACK FLOW PROTECT. DEVICE
D
SANITARY Y N
RECEIPTIf
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR. ROOF, AREA. COND.
SCHOOLTAX YN
❑ thereby effrm that lhavcocertifimte of consenuo xlf-insure, oracmificnm of
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
Workers'Campenution Insurance or acertifed copy thercof(Sm. 3800, Lab C.) which
versallempl ssenu it '. —
GAS-EA.SYSTEM-IINC.4OUTLETS
RECEIPT
BUILDING DIVISION FEES
Policy# `n
Company p �E
GAS - PA. SYSTEM-OVER4 EA)
PLANCHECK FEF.
❑ Cmi c y i hereby umished.
GRADING ME I
❑ Certified ropy is fled with Ne ciry inpcmion Jivivinn. GREASEANDUSTRI. WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(Thissection need not becompleted Him permit is for one hundred dollars ($I00) SEWER - SANITARY - STORM EA, 20111T.
or less.)
I cmifydat inthe performunceofthe work far which this permit is issued, l sholl WATER I[EATER W/VENT/HLECI'R
not employ any person in any manner so ax to become subject to the Workers
PAID
Compensation Lewsol Celifomia. Dole
WATER SYSTEM/TREATING
Date Receipt#
Applicant
NOTICE TO APPLICANT; IL after making this Cenificole of Exemption, you should
NEW RESIDENTIAL PLMB. S FT.
Q
TOTAL:
became subject to the Worker's Compensation provisions of the Labor Cole, you must
r^1
forthwith romply with such provisions or this permiishall be deemed revoked.
BUILDING FEE
SEISMIC ME sS
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued(Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lender's Name
Lender's Address
Q'IY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
I comfy that I have rend this application and ante that the above information is
MECHANICAL FEE
carted. Iagreemcomplywithallcityaodcoumymdinmmetadsmehwerelatingto
PERMIT ISSUANCE
building consuunioo,and herebyatuhoriu represemadvesofthis city to enter upon the
CONSTRUCTION TAX
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
(We) agree to save, indemnify and keep harmless the City of Cupenino against
Iiubiliti s,judgments. costs mdexprmeylb Imayin any way xecrue ngainstnniJ City
AIRHANDLING UNIT(T010,0(MCFM)
' ��Q� fthe gr�mjf�)it(goftd nit.
^'Jinn
'� e
AIRHANDLINGUNIT (OVER 10,(00 CFM)
Sigvtu of ApplicmUConlmcmr Du
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,03) BTU)
Dole Receipt#
2
Will the applicant or future building occupant store or handle hamomm; material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL: v
Cade, Section 25532ND
❑ Yes ❑ No
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
Will the ocontamtorfuturc building usee awhich
Air
BOILER - COMP (3HP OR 100,003 BTU)
9
Quality Management
air contaminants n defined by the Day Arcn Air Queliry Mmagcmem
by the mu
BOILER •COMP (OVER 100,000 BTU)
P A
District?
y Distrin?
❑Yes 0 N
NEWRFSIDENTIALMECH. SQ. FT.
1 have read the Rhear ous materials requirements Chapter 6.95 the
FEB ����
under of
California Health & Safety Cale, Sections 25505, 25533 and 25534. 1 understand that
r
iflhehuildingdcs.amucurrently Items tenant, that it is my responsibility touchily the
C�IY Ur- (r'Ul'C(1111VV
occupant of the requirements which must be met prior to issuance of a Cer ifcam of
Occupancy.
`'
4W I
ISSUED BY: 4•'v QC
Owner or authorized agent Date TOTAL:
OFFICE