27096APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OFCUPERTINOL Is"Ill r-ol, CIRI Al.
APPLICATION/PERMIT ILPLUMBING. MECHANICAL
BUILDING DIVISION BUDINI, PRD]EC'I'IDENTIFICA9'IOIN
PERMIT NO.
n O p C
J v
BUILDING ADDRESS::
SANITARY NO.
APPLICATION SUBSUITAL DATE
1 0 V e UNITN LOT#
/ .� % Lj
J
OWNIiRS NAME PHONE:
L 0
CONTRACfORIS NAME: LIC NO:
H')
N/C
El-O.WOx
CONTROL p
ARCI II' ECI'/f:NGINEER: LIC NO:
DRE
2 %t -
CONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
TTI
1J�b g(2-? Q�D
PERMITJSSUANCF:
LICENSED CONTRACI'OR'SDECLARATION
1huebyaffms dtm lam Iicens undespmvlsionsof Chapter9(commencingwith
Section 7000) of Division 3 critic Business and Professions Code, and my license is in
full force and effe I.
license Clan` i Lic.# q, 0_ a
Dam Canlrucmr_ y�-�
APPLIANCES - RESIDENTIAL
PANELS
UP T021q AMPS
LOB DISGR ON
Qf Pl.AC� LX IS cty (1'ryw 4rk,lle
"fee
2UI-IUIq AMPS
ARCHITECT'S D ARAT N$/SQ
I understand my plans xhull o used as public records.
RKX AMPS
SQ. PI'. PLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm tion 1 am exempt from the Contractor's License Law for the
'I'IiMP. METER OR POLE INST.
followwhich requirng reason, Professional city or county
Businessimprove,
to
co3Ld.
which require a permit to
Permit demolish,
alter, improve, demolish, retail any
h, or re repair
clrucmrc
i.mc,
thevisioscd,hecant fi statement
hscsused
POWER DEVICES
thatheonto
prompt to th ClourmtiuoLicese La
that he is licensed punuanno the provisions of the he Bta ire s License Law (Chapter
9 (commencing with Section7") ofoothe Division Sof sheinn Ede)
SWIMMING Po0I. ELECTRIC
VALUATION
ed ancssund.An, of
basPermitorthects thedexemptt to civil
Sectiobeisexempt thercfmmnt for
Section 90115 by any applicant fora permit subjects she applicant to a civil penally of
OUTLETS - SWITCfIES- FIXTURES
n more than rise bunJmd dollars (ESIp),
n❑ Lasowrk,arbepmpeny.ormyempindedorohwegesasthei(See compensation,
IES TYPE CONSTRUCTION
NEW RESIDENTIAL ELECrII S FT.
Q'
will do andisnotLa a Business
Porot
Lesions e: hestrCon do appec.XW4.
Codldsor The Connector's License Law dos not apply to an owner of
and Proproperty
who
enywyees, Asor ed rowthat as who
OCC. GROUP
RES. UNITS
own suchemprove marmctende orefertil fuoughhla
ownemployees,provided lhmsuchimpmvcmenlaarenolimendedurofferedfarside. If,
A
however, Ne built ingor improvement is sold within one year ofcompletion, Ihemener.
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
.
QItY'` ,PLUMBING PERMIT" _ FEE
sale.).
❑ I, asownerofthe propeny. amexclusively contracting with licensed contractors to
ROOD ZONE
APN
construct she project (Sec. 7044, Business and Professions Code:) The Contractor's
License Lawdoes not apply loan ownerofpropeny who builds or improves lhereon,anJ
PERMIT ISSUANCE x /�
whuconeads fnrauchprojectswithaconwemKs)licenced pursuunuothe Contractor's
License Law.
ALTER (EA)
FEE SUMMARY
E M
❑ I ions exempt under Sec. , B & PC for this reason
BACK ROW PROTECT. DL'VICE
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECEIPT #
WORKMAN COMPENSATION DECLARATION
❑ Ihcteby affirm lM1m lhuveacedifeme ofconsenna ulGinsurc..racertificae of
Wmkers'C.animaloon lnsumn,v ora omifed copy lhereof(See. 3800, Lab CJ which
SCHOOLTA% YN
RECEIPTp
FIXTURES - PEE TRAP
PARK FEE Y N
GAS -RA. SYSTIiM-11NC.40UTLE'fS
vers all amployyec'Sundenh' VVBwn
Policy# WLj Iq �y)
RECEIPTp
_FEES
BUILDING DIVISION
Company / sD✓•
GAS - CA, SYSTIiM.OVF.R 4 (EA)
PLANCIIECK FEE
Cl Certified copy is hereby famished.
® Cmifed mpy is fled with the city inspection division.
GRFAS114NDUSTRI. WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRPASF.TRAP
SOILS FEE
SEWER - SANITARY - STORM G. 200FT.
RN RRGY PEE
(This section mad not beeompleted ifthe permit is foronehundred dollars(EIBI)
or leas.)
WATER HEAT ER W/VENTIELECTR
I cerhythm in the performance ofthe walk for which this permit is issued,Ishml
not employ any person in any arturater sec a to become subject to the Woderd
Compensation Lawsof Cnlilbmha, Date
Applicant
WATER SYSTEM/rREAT1NG
PAID
Dam Reccipl#
NOTICE T'O APPLICANT: If, after making this Cenifwe of Exemption, on should
,,,varne edjecth.,he Worker's Compensa0on Provisions of the Labor Code, you most
NEW RESIDENTIAL. PLM B. SQ, FT.
TOTAL:
forthwith comply with such Provisinrs or this permit shall la, deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC ME
I hereby affirm that there is a consimetion lending agency for the performance of
OT
ELECTRIC FEE
the work for which this permit is issued(Site3047, Civ, CJ
Lender's Name
lender's Address
QTY. MECHANICAL PE RMIT' FEE',
PLUMBING ERE
1 certify that I have read this application and some that the move information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL RE
building construction, and hereby aathodze repmsentatives of this city it upon the
above-mentioned progeny for inspection purposes.
ALTER OR ADD TO MF.ChI.
CONSTRUCTION TAX
(We) agree m save, indemnify and keep bmmless the City of Cupertino against
liabilities,judgmans.cartsandexpenses which mayin any wayaccrueageinn said City
AIR HANDLING ON] r(TO I0,000 CFM)
in conscluence of theg of onpcsmiC
AIR HANDLING UNIT(OVER 10,000 CPM)
,, /;/
1,,
S mare of ppliwnt/Connector to
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT (TO 100,010 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
Will the applicant or future building occupant note or handle hazardous anterial
ns defined by she Cupertino Municipal Coda Chapter 9.12, and the l health and Safely
HEATING UNIT (OVER 100.000 BTU)
TOTAL:
32(9
Code, Section Yn)
❑. 11 No
VENTILATION FAN(SINGLE RESID)
Will then Lison ur futurebuildin
pp gtccupum use cquipmemordcviceswhich emh
HOILER- COMP LHIP OR 100,000 BTU)
OC ISSUANCE DATE
T
huzatdous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Ya ❑ No
BOILER - COMP(OVF.R Ifq,(gDBTU)
"3 X99
V r u"`l'(lGNU
NEW RESIDENTIAL MECH. SQ. PT.
of the
I have real the hazardous actions 5505,5 33 under Chapter understand
CaliforniacbulingIficSafety Code, Sections a 25505, 2553] and 25534.1 undemmnd That
s
does have to notify the
ifthebuildingdoesnotments yhaveatenant, Lenoir my nuance
occupant of the requirements which must o tan prior m issuance of a Certificate of
of
Occupanry.
ISSUED BY:
Owner or authorizad agent Date
'TOTAL:
OFFIGt