25737APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO ..- EEF'CI'RICA7.
APPLICATION /PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION ] 4UILDINGPR(1JRCTll )lS.N9IFICATION
PERMITNO.
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BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE'
1
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LIC
N/C
❑
CONTROL. N
ARCHITEC/ENGINEE
LIC NO:
V.
PHONE: GM
lF-f OF.IJ�
QTY,.,E6CCIRIC
PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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PERMIT ISSUANCE
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LIC SED CONTRACTOR'S DECLARATION
Ihembyoffinat at l um licensed underprovisionso f Chapter9(commencing with
Secllon7m00)ef Di sion 3ofthe Busines wI &sio e d icusse is in
full forte and effe(I.
License Classy% LIeN
Date Contmam
APPLIANCES - RESIDENTIAL
( GcI-fl nrVl
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ilA�Ii�Il.�xiG it �e
ACC 11w++uw e1
PANELS
UP T0200 AMPS
201. 1000 AMPS
ARCHITECTS DEC RATION
1 understand my plans shall M used as pu li ecoms.
OVER 1000 AMPS
SQ. PT. FLOOR AREA
WSO I.I.
SIGNS ELECTRICAL
Professional
ewe.Licensed
DaF
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Sp�
rl_m
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OWNER - BUILDER DECLARATION
1 hereby affirm that I um exempt from the Conuvmors License l.aw for the
following moson.(Saction 7031.5, Business and Professions Code: Any city or county
which requires a permit to cannot start, improve, demolish, or repair any structure
pnm ,its isomme,aiso ruryirc, thevpplieant forsuchpermhmlllat signadsmtement
that he is licensed pursuant to the provisions ofthe Contracmes License Law (Chapter
9(commencing with Section 9000) of Division 3 ofthe Business and Professions Cade)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031..5 hyonyoppiiamt fora permit subjects dusit,licant too civil wnify.f
not more than five hundred dollars ($500).
❑ Leamanerofthepropeny ,orntyamployees with wages astheirsolecomp rear ion,
SPECIAL CIRCLIMMESC.
r�� p�
I� n I� L
M Y 000
TEMP. METE OR PoLC W$T.
POWER DEVICES
SWIMMING POOL ELECTRIC
1; VALUATION
15
OUTLETS - SWITCHES - FIXTURES
NEW RFSIDENTIALELECTR _SQ.F ..
STORIES
TYPECONSTRUCf10N
y
will do the work,tu the almemre isms intended mofferal rorsnle(Sec.J014, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
h
propertywhobuildsorimproves themon,andwhodoce such warkhimselfonhroughhis
owneniployess, provided that such impmvememsom nee intended oroffered fmsale. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the boldingorimprnvement is sold within one yemofcomplelion, theowncr-
builder will have the human of proving that he did not build or improve for purpose of
QTY.
}`j ', PLUMBING PERMIT
FP.G
sale.).
❑ 1, asownerofihepmpeny, amexclusivelycon "ciingwithlicensMcmn utomio
FLOOD ZONE
APN
omit ... the project (Sec. 9014, Business and Professions Code) The Convector's
License Law does not apply to an owner ofpropeny who builds or improves thereon, and
PERMIT ISSUANCE
who commas for such projects witha eonvaclums) licensed pursuant mthe Contractors
License Lew.
ALTER - DRAIN & VENT - WA'fLR (fiA)
PEE SUMMARY
❑ 1 am exempt under Sec. , B & P C far This memo
BACK FLOW PROTECT. DEVICP.
O D
SANITARY Y N_
Owner Date
DRAINS - FLOOR, ROOF, AREA, COND.
RECEIM U
SCHOOL. TAX Y N
RECEIPf0
WORKMAN COMPENmofcon DF.CLARAI'ION
Ihertby affirm .I. !h., veaccni0caw of consent to f(S..3pX. sb C.).¢of
Workers Co a set ion ln)) a 'fi p; th mf(Sec.3g00, Lnh CJ which
FlXTURfS - PEiR TRAP
PARK PEI: V N
en ells un Er�ri fern
Policy 0
GAS - EA. SYSIE•M -I INC.4 OUTLETS
RECEIPI'N
BUILDING DIVISION FEES
Company
GAS - BA. SYS1 F.M -OVER 4 (EA)
PLANCI lf:CK FEB
❑ Ccnir, y he rams ed.
GM,tSFJINDUSTRL WASTE INTERCEFI'OR
GRADING FEE
R; Cernifi copyi Bled with the city inspection division.
' IPTCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FUP
SEWER - SANITARY - STORM EA. 2(YN7.
ENERGY FEE
(This section need not ba completed ifthe permit is for one hundred dollars ($ IW)
or less.)
WA'ITR BEATER W/VENT/ELECIR
I rectify [be, in the pafornuea of the work for which this permit is hoped.I shell
not employ any person in any manner so as to became subject to the Workers
PAID
z
Comperandan Lawsof Culifomia. Date
Applicant
NOTICE TO APPLICANT, If. afwr mskinglhis CeniRcaleof Bsemption, you should
WAIHR SYSTEMiTMATING
NEW RESIDENTIAL PLMR. SQ. FT.
Data Receipt#
TOTAL:
ti
become subject to the Worker's Compensation provisions of the Labor Cale, you must
forthwith comply with such provisions or this pcmul doill be decmed revoked.
BUILDING FEE
SEISMIC FEE
Q
CONSTRUCTION LENDING AGENCY
z
O
Ihereby affirm that them is a concoction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Cis. C.)
Lenders Name
TOTAL:
ELECTRIC IEE
Lender's Address
Q'TY.
-; ,,,MECHANICAL PERMIT;
sFEE
PLUMBING FEET
U
acontact,
z
1 certify that I have reed this application and state that the above information is
I agree to comply with all city and county ominances and stew laws relating to
building noes` rom,v by uumorempreseawtives ofthis city to enter upon the
above- noredp nyf inspection Porpoises.
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MUCH.
CONS9RUCTIONTAX
( e) agrt o save, i amnify and l, p harmlea the City of Cupertino against
'abiliti s,jud c ts. cn .untie penis eh may in any way mcrueagainst said City
AIR HANDLING UNIT(TO Ill." CFM)
run. qu c o h mi his pe
2
AIR HANDLING UNIT (OVER 10.X40 CFM)
Sign of p Co oad r Data
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
Date Receipt N
HAZARDOUS MATERIALS DISCLOSURE
Will the appiicom or l'murt buildiogoccupamsmrtor handle hormones material
.1 Bnad by the Cupertino Municipal Code. Chapter 9. 12, and the Health and Safety
HFA'IING UNIT (OVER IaI,Bal li'1'U)
1
VENTILATION PAN (SINGLE RESID)
Cale, Section 25532(a)9
❑ Ycs 11 No
Will theapplicaat orfutumbuildingoecupanturse equipmentordevices whichemit
BOILER - COMP(3HP OR 100,000 BTU)
ISSUANCE DATE
BOILER - COMP (OVER 100,000 BTU)
hazardous air cnmamini ms as defined by the Bay Area Air Quality Management
Dlatrle'?
❑ Yes ❑ No
., P /W A 1
NEW RESIDENTIAL MECH. SQ. FI.
tend hot ud 0te hazardous materials requirements under Chapter 6.95 of the
California building do &Safety Code, Sections 25505, 25533 and 25574. I understand Net
if the building tires not currently have a wna, That n is myssuanc responsibility to the
®�� e
occupant the reyuiremens which must be and poor m issuance of a Cenifiwte of
fiat
Occupancy.
y.
,
C. r (tor uvv
ISSUED BY:
Owner or mahmnood agent Date
TOTAL:
OFFICE