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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO
APPLICATION/PERMIT
BUILDING .LLL '] RICA],
PLUM BUNG. MECHAN]CA L
PERMIT No.
n /I C �i
4
BUILDING DIVISION
BUILDING PRf1JECT IDF.NI IFICA'OON
G o G
BUILDING ADDDADDRESS.
DS7.
-
SANITARY NO.
APPLICATION SUBMITTAL DATE
l
NERS PfIONE :
C ACTOR'SNAME: LIC NO:
NAC
CONTROL p
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CHI' /nal LIC NO: ADDRESS: a
iGNTACT:
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PHONE*%8 a`i
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'YBLF;CT'RIC PERMIT
NEE
BUD DIIING PERMIT INFO
LD r [CECT PLUMB EC 1
'Y// ,/J'T',7�Aa•
/
PERMIT ISSUANCE
1:1 El
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
sed Business and isionssio Code, (c mmencincisin
Section V00O)of Division am licensed
Ihcrehy fflum thatof 3 ofthnsedinss =1 Profestutns apterCode and mmecense wish
�
IulIfnrcc w Ic if d4 // �J .(Q
LicenseC vs J ss i�-.7 �✓ /
PANELS _
UPT02W AMPS
�.7l
Use Contractor
201 - 1000 AMPS
A CHITECTS DECLARATION
OVER I" AMPS
-
yyy(((yyy��� FL(OR AREA
$/SQ, Irl'.
1 tadc,o rd my plans shell be used as public u,,mdP.
SIGN' ELGCIRICAI.
Licensed Prtuleasional
OWNER-BUILDER
SI'IiC1A1. CIRCUIT/MISC.
l
I hereby affirm that 1 am exempt frvm the Conremor's License Law for the
empt for the
ing rcama Bmincvs and o Codc: Any airy
TEMP. METER OR POLE (NSI'.
DATE
permit to consumer.demolish,stcounty
es a permit n, constmet, seer. improve, decor
which e
which improve.li or repair any structure
—
it, k i, t anmmnn
thevisios
icenscal noes
POWER DEVICES
of the Cormosch
thatheirs
Licentgned
that he is licensed pursuant to the provisions of he Cnmaems, License Law (Chapter
pusu ante
9(connnendo, ist,.mnJlh Section 7000) of Division theelod ex,splim.
SWIMOUTL iES-FI
yA,lUs�sarw-
Afecm.Calat
the
SectioheiseaempanyapromnnJmebamfomheasegeJexempltto civilpinalty of
Section 7031.5 by any dam for permit subjects the applicant In a civil penalty of
S- SWITY)OLCHES
OUTLETS-SWITCIIFS.ITXTl1RE5
T
�R
Vv—
V
a In..hundred
not m[.mownlivehupmKay,ors
n $
yemp.
❑ Lmowrk,anheproperty,e swithwagesavheirstulecompevation,
NEW RESIDENTIAL ELFCTR _SQ. FT.
STORIES
'IYPIi CONS'fRUCIION
will Jothe wons andthe s isnot remb Business
s s
ice smotwrdJ
and Professions a Contisnot
LicenseLaw does not apply to an owner of
The Contractors not apply to an
J& od Stores,
pmpowdenywyear.pdsorimpnrvsuchermn,aerrium orm,int work hlmselGmhrough Nr
a ees.p that such improv n do tarsale. If,
ear
OCC, GROUP
RES. UNITS
how er. th building or i to within
ngmlmprvvemem isautohe within of
e of completion, the owner.
pletioA
howeor
TOTAL.
will avec
M1uto.). will have the harden of that he aid not build or ire for
build
prvvin& Prove purpose of
ole.).
❑ ],as ownerof mepropeny,amesclusivelycomrading wimlicensed ctunnnemrsto
QI'Y. PLUMBING PERMIT
NEE.
FLOOD ZONE
qPN
consbua the project (Sec. 7044, Business and Professions Code:) The ConlracmrsPERMIT'
License Law does not apply loanownernfpcn
ropy whobuilds orimprovesthercon,md
ISSUANCC
r
whocontmcts forsuch pmjens with aconlractor(s) licensed Important to the Contractor's
Liwnsc Law.
ALTER -DRAIN&VENT - WA' ( )
F SUMMARY
E
❑ I um ea<mpI under See. B & P C for this reason
OUT 4iES
BACK FLOW PROiF.Cf, OEVI CM'-JNI
YNOwns,
Date
WORKMAN COMPENSATION DECLARATION
DRAINS-ELUG"GOE. AREA. NRECEIPT#
X YN7
I hmnY offimt mat 1 have a cenificem ofconsem m self-inwre.oracmiroaeof
nwRECEIPTporkers'CompensationlnsumnceoraceniOedeWythemof($caJg0.LabC.)which FIX9'URO-PER TRAP
Nrsollemployec's
Q&TY
anderthis permit.
Policy p
GAS L'A.SYSTEM-I INC. TLIi'1'RFCEIP
p
BUILDING DIVIVION P' S
PLANCI IECK FEE
Company
❑ Cmificdcopyishercbyfomished.
GAS - EA. SYSTEM -OVER 4 (EA)
GRADING FEE
❑ Certified copy is fled with the city inspection division. GR V SF/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OP EXEMPTION FROM WORKERS'
GREASETRAP
SOILS PEE
COMPENSATION INSURANCE
ENERGY FEE
(Ilia section need not be completed ifthe permit is fortune hundred dollars($ 100) SEWER - SANITARY - STORM EA. 200FT.
s.)
Icmify mal tolep for issued, lkers WATER IIIiATER WNLNT/ELECTR
not etnploy any in my manfhewmk
hcromciubjecttn
in any manner are us m become subject In the Workers
PAID
Laws
Compensation Laws of Cnlifomia. Dae
WATER SYS'IEM/I'RFATING
pat Receiplp
A,lill
NOTICE
OT( E TO you
after this Certificate of
Ncome
NEW RESIDENTIALPLMB. SQ. PI'.
TOTAL:
mull
subject to Compensation
Compensation previsions the Labor Code, you mull
become subjen the Workers Labor Code,
famwith comply with such provisions nr this permit shell he deemed revoked.
y Ju t l
BUILDING ltil: crd
SEISMIC PEE
CONSTRUCTION LENDING AGENCY
1 horhy aRrn that to. is a construction lending agency for the performance of
the work for which his permit is issued(Sen. YN7, Civ. C.)
Name
L:
ELECTRIC FEF. is—
Leader's
Lcr
Lenders Address
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
1 cenify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county oninances and state laws relating to
PERMIT ISSUANCE
l
MECHANICAL FEE �-
building conswnion, and hereby authorize rcprcsemtives ofthis city toen¢rupon the
CONSTRUCTION TA
above -mon Toned properly for inspection purposes.
ALTER OR ADD I O MIiCH.
(Wo) agree to save, indemnify and keep harmless the City of Cupertino against
Habilitiecjudgmems,costs and expenses which may in my way accmeagainsl said City
AIR HANDLING UNIT(TO BLOW CFM)
crit of the grunting ml this pomma,
�]]]
_Jp��9;�,
AIR HANDLING UNIT (OVER 10,070 CPM)
Signature of Applicm Commnnr Uve IXHAUSTIIOOD(W/DUM)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (10100,000111 U)
Dam Receipt#
Will the applicant or future building mcupanl store or handle hazardous material
Us defined by he Cupenino Municipal Code, Chapter 9.12, and he Health and Safety
IIiAI'ING 11NIT (OVER OO,fgfO BI U)
'TOTAL:
Calc, Senior 23532(a)i
❑ Yes 1:1 No
VEST ILATION FAN (SINGLE. RESID)
ISSUANCE DATE
Will theapP pun licamorl'uwrchuilJin&oc [u Iuxcequipment ordrvireswhich emit
BOILER - GGMP(JHP OR IM." BTU)
at mons as defined by he Bay Aron Air Quality Management
BOILER - COMP (OVER 10.0(1(1 BTU)
strica
"
Vr
❑ Yes ❑ No
NEW RESIDENTIAL MECH.—SQ. PI'.
1 have real the hazardous materials respur mems under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25574. l understand Ina
ifhe buildingdnes nulcaremly have annnm,Iha it ismy responsibility mnmify the
P`k
occupant of the reyum men¢ which must be met prier to issuance of n Comfica c of
Occupancy.((sa1�
AIV - 41993
Ownanrruuthnrlwd agnm Date T
ISSUED BYJ
OFFICE f11 DtlJ