27152APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO '61N'�' RI• •RICAL
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDEYTIF'ICATION
PERMIT NO.
/�
G L
BUILDING ADDRESS: M-711�
SNYU I LOT#
SANITARY NO.
APPLICATION SUBMITTAL DATE
O NIiR AME: PI10NE:
CONTRACTOR'S NAME: LICNO:
ENIC
ti/
CONTROL#
RCIiIT1CTp?NGINF, ;R: LI
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
��LDD�� ELECT PLUMB MECH
'�a(, � ❑
tt��Il
PERMIT ISSUANCE
LICENSED CONI BACTOR'S DECLARATION
Z Iheref affirm Nat l sm licensed underpmvi.aionsof Chapter9(commencing with
Satins 70o))of Division 3 ofthe Business and Pfufexonsis CWr,and my license is in
full force and effect.
y Li license Class Lic.p
Date Contractor
APPLIANCES-RESIDEN AL
JOB DESCRIPTION
PANELS
UP TO AMT'S
201 IOW AM
Z ARCI IITECTS DECLARATION
u d plans shall be used as public recmds.
-
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER I MPS
SIGNS ,[CT
Licrnse olisstonal
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License law for the
SP' IAL CIR /MISC.
'MP. OR T.
VI '
following cmm.(Scetion 7031.5. Bmiras,tad professions CWc: Any vu,mvoumy
which acquires a permit m consmct, alter, improve. demohsh, or repair any s-On-
priortoits issuance. also requires the applicant for such Permit to file a signedsmmmem
that lack licensed pursuant the provisions of the Contractor License Law (Chapter,
i 9(commencing with Section 7")of Division 3 of the Business and Professions Code)
lic and the permit sujearisthe exemption. civiny l lathy of
n Smithat e v 7031.5 by any rciapplicant
by applicant fora permit subjects the applicant a civil penalty of
Section than
G
cnot more Nan Evc hundred dollars ($S(p).
❑ 1,a,uwnerofNepmpeny.mmyemployeeswithwage, theirsolecompensmion,
will Jo the work,.ad the structure is not intendedmoffead for sale (Sec. 7064, Business
CIRIC
VALUATION
Llop
7 L w
0 ETS-SWI CUES-FIXTUR
NEW R ENTIAL EL[CIR SQ. PT.
STORIES
—TYPE CONSTRUCI'[ON
and Professions Code: The Comacmr's License Law does not apply ,o an owner of
progeny who builds or improves thereon, and who does such work himsel for through his
own employees, provided that such impmvemermare not in,eadedoroffered forsale. If,OCC.GROUP
however, the building orimpmvemem is sold within one year of completion, the owner-
Guilder will hove the burden of proving that he did not build or improve forur
ppose of
sale.).
RFS.UNITS
TY)TAL:
QTYPLUMBING PERMIT FEE
❑ Las owner al [lie pmpeny, am exclusively contracting with licensed contractors to
construct the project (Sec. 7144, Business and Pmmasiuns Coi The Connectors
PLOODZONE
APN
License Law Aacs not apply to an owserofproper,y wbobuildsorimpmves thereon,and
t PERMIT ISSUANCE
who comment far such projects with a comaclods) licensed pursuanuo the Con escamis
—110
License Law.
ElI am exempt under Scc. , B & P C fm this reason
ALI flk - DRAIN & VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE.
OUTSIDE PEES
SANITARY Yry
Owner
Dare
WORKMANCOMPIiNSAT1em UGCLARAI'ION
of
on ❑ Its'Co peradi nInsuut I vea cora ccamof copytheromman self-of(Sesure,or Lab C.) hich
ificd copy thereof (Sec. 3800. Lab C.) which
coverer%Cmployee ionler this permit.
covers all employees under permit.
Policy N
DRAINS Fl.00R, ROOF, AREA. COND.
RECEIPT p
SCHOOL TAX Y_N
RECF,IPI'#
FIXTURES -PER TRAP
PARK FEE Y N
RECEIPT p
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
Col
Company
GAS - EA. SYSTEM -OVER 4(E4)
BUILDING DIVISION FEES
❑ CmifieJ copy is hereby fontished,
PLANCHECK FEE
❑ Denoted copy is filed with the city inspection division.
GREASEJINDUSTRL WASTE INTERCEPTOR
GRADING W.F.
CERTIFICATE OF EXEMPT' ION FROM WORKERS'
COMPEsISATION INSURANCE
GREASETRAP
SOILS FEE
(This section need sun he completed ifthe peoninx furore hundred dollar, ($111)
or less.)
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FFP
Imiifyllimintheperformove the rkforwhichthispe ssn, Ishan
not employ o ter as to beer, jc
Cnmpensan n sof t a,
Applicant
WATER HEATER WNENT/El.
PAID
Date Rartptp
WATER SYSTEM/TREATING
NOT! C. PPLIC a r, enifi roof Excmption,youshould
bee art jml m the Worker's Cor nsation provism of the Labor Code, you must
forthwith comply wi,hmch pewis anon his perm' all be deemed revoked.
NEW RESIDENTIAL PLMIL SQ, P -L
TOTAL:
BUILDING IEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is u construction lending agency for the performance of
Ne work for which Nis permit is issued (Sm. 3097, Civ. C.)
Lenders Name
SEISMIC IEE
ELECTRIC IEE
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 triffy That 1 have read this applicmir,n and s,am Ilia, the above informmion is
correct. l agree to comply with all city and county ordinances and stare laws relating to
buildingamsnunion, and hereby atolum. representative, of this city 0 cmer upon the
abavc-mentioned property for impemion pmpvm,.
(We) agree ,o save, indemnify and ep hannle a the City of Cupertino against
liabilities' mems,cos¢and, at s at mayin anywamc �agaia1 dCiy
in co segues ofthe,•�in �g his our
2
PERMRISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
10,000AIR HANDLING UNIT 10,OCFM)
AIR HANDLING UNIT (OVER I0.00) CFM)
I/ (/�11.
S or ofppplican 'nor t Date
EXHAUST HOOD(WNUCD
HAZARD D 'MATERIAL ISCLOSURE
Will the applicant or future has - rot store or handle limardous material
us defined 1, the Cupertino Municipol Code, Chapter 9.12, and he Heahh and Sammy
Cade, Section 25532(¢)'!
PAID
Dec Reeeip, a
HEATING UNIT (TO 1001000 BTU)
1117ATING UNIT (OVER IOO,fKK) BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
11 Yes IJ No
Will theapplicanmrfummbuildingmcupan, usecquipmemordevim, whlchemit
hamlikow air conn a mints as defined by the Bay Area Air Quality Management
District?
BOILER- COMP(3HP OR 10(1,0(10 BTU)
BOILER - COMP(OVER IOQIIf,8TU)
ISSUANCE DATE
❑Yes 0 N
(^.
"
NEW RESIDENTIAL MECH. SQ. Fi',
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building Jews no, cm emly have a moans, the, it is any responsibility to notify the
cupaupnt of the requirements which must Is, mm prior to i,nuance of a Certificate of
Omancy.
OCT 12 n .. ,
u;U
BY:
Owner or ouNonredegenl Dam
TOTAL.: ISSUED
(1FFIf`C