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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING— FITETRM.A
APPLICATION/PERMIT PLUMBING-ECHANICAL
BUILDING DIVISION 1 UILDING PROMC'I' IDEN'1'IRICA'1'ION
PBRMITNO.
25052_
BALDING ADDRES�S�:
OV T�G-/(/S �I'� ��-1 LOT«�
SANITARY NO.
APPLICATION SSUUBBBM`UTAL DAT I:
)hH
O SNAME4 O L
CCOONTq@f�{A/q(]J[ORgN Li!!? :
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CONTACT:: PHONE:
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QTY. ELE ICP IT FEE
-
BUILDING PERMIT INFO
I- ']LOG :CECT PLUMB IGC
JA
�sTyaj
PERMD'ISSUANCE e'^
I.ICENSI!DCONTBACTOR'SDECLARATION
1 hereby affirm that I um IicenxJ underprovisinnsof Chaprer9(commmcingwith
Sretion]IKKI)of DlvlsionJ of the Buslnese and Professions CWe,andmyliecoxeisin
APPLIANC - DEN'TIAI.
PANE(.
��ss��ss If pISCRIPI❑ION
1.11 force and of t.
j Llwns Lic. N
UPT9 MI'S
-
Dmc ;j
I It AMPS
IECTCommD
ARhall b'BGTSDECLARATIDN
1 understand my plana shall be maladies public records.
I(1W I
SQ. I9'. FLOOR AREA
,.,
S/SQ. FI'.
S ELF.
I
Q
Licensed
OWNER -BUILDER DECIAR
'PECIAI. CIR /A11
I hereby n. inn than I am exempt from the Cosions Cs License Law
to harba the
TEMP. METER 1.13 MST.
following revoa. Business and Profession Code: Any city county
co
permit to]031.5.
ave. Jemnllsh, m repair any structure
..
which requires a permit us construct, alto, int
plat tos b gned statement
lhumlpr
fili,tLicense
rsu
POWER DEVICE
licensed pursuant provisions Caspermiao
nt to th
Nm heislicensedmSelli n7theprovisionsof the Contractors License Law (CCode)
9that heI&ixemit pt therefrom and the Division teltheed exemption, Ari,st.li Code)
Sethoheises by
refromnt f the basPermit subjects
Section 7031.5 by any is the exemption, Aivil anon of
fora permit subjects the epplicanno a civil penalty of
SWIMMING POOL ELECTRIC
VALUATION
3TLETS-SWITCHES-FI%TURES
dmd dam
not nmrc than live hundred Anllun ($500).
ElI, asnwnerophepmpcny.ormyemployres withwegesnthcinole compensa.ion,
NEW RESIDENTIAL ELI!CTR _SQ. FT.
MORRIS
'TYPE CONS'1'RUC'1'ION
will do the work, and the structure trial intended or offered for sale (Sec. ](194, Business
and Professions Code: The Contractor's License Low does not apply in an owner of
property whobuildsor improves thcommand whodoes such workhimmlforthmugh his
nemployees, provided that such improvements are not iatendedamffered forsale. If,
OCCGROUP
RES."N' ITS
T.O. �,
however, the building orimprovement issold within one yearofcomplefon, the owner-
builder wil I have the burden of proving that he did not build or improve for purpose of
QTY' PLUMBING PERMIT PGE.
❑ I, asnwnernf the pmpenY•an exdmively commcting with licrnsed can.muors to
FhUOU LONG
AIN
..,[met the project (Sec. 7094, Haziness and Professions Cade:) The Commclnrs
License Law does not apply to an unsocial pmperty wllo builds or improver (hereon, and
PERMIT ISSUANCE
whoemroctaforsuch projects with a contrnta(s) licensed pursuanuothe Conountoes
License Law.
ALTER IiA)
(
FEE SUMMARY
❑ I um nxempl under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
T S PI. S
SANITARY YN
RHCEIPI'M
Owner Date
DRAINS - FLOOR, ROOF,ARFA,COND.
WORKMAN COMPENSATION
SCHOOLTAX Y N_
FIXTURES -PF.RTRA('
ofco nt in seRATION
Ibi Compifirm that lhave re'o.wmoallpyntaal'Scsure,o, Lm C.)wtenf
Warkers'Cnmpenmion lnxurunee nruaniEul copy thereof(Bec.7gW,larb C)whieh
RI:CL•119M
PARK F88 YN
arsrdlempl Wde /
Policy N (O
GAS - HA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT
BUILDING DIVISION FEES
Company y C
GAS - EA. SYS'T'EM-OVER4(EA)
PLANCHECK FEE
I
❑ Certified cap is hereby famished.
eniBeJ copy is EleA with the city inspection division.
GREASPpNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEF.
SGWEN - SANITARY - STORM HA. 2k)FT.
ENERGY PER
Gl issection need not be completed ifihe permit is home hundred doll. ($10b
or less.)
WATER DEALER W/VENT/ELECTR
I no Py that in the performance of the work for which this peon:. is issued, lshell
not employ any person in any manner so as to become subject to the Workers
PAID
WATER SYSTF.MOREATING
Compenaa.ion Luwsof Culifomia. Date
Applicant
pate Receipt#
NOTICE TO APPLICANT: If. fmr makingthis Certificate of Eaemplioa•youshauld
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Libor Cash, you must
forthwith comply with such provisions rn this permit shall be deemed revoked.
BUILDING FEE
SEISMIC PER
CONSTRUCTION LENDING AGENCY
I herchyaffirm dial iso ememuelion lendingagency fortbe pada,, ,e of
work far which this permit is issued (See 3097, Civ. C.)
Lender', Name
TOTAL:
ELECTRIC FRI.the
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING PEE
I certify that 1 have read this application and stale that the above information is
meet. legree to comply wi.h all city enA coumy nNinancea and sate lnwe relating to
PERMIT ISSUANCE
MECHANICAL FF,fi
building omerractlan. and hereby.mati ire represcnanivesaf.hiscity toemarmon the
shove-memione l pameny far inspection purposes.
ALTER OR ADD TO MECH.
CON5IRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
'dgments coxaa 'chmayinany ecrueagainst said City
eF.tie
AIR HANDLING UNIT CIO 10,1100 CFM)
in vonseyuenc imgm ng pica,
/
AIR HANDLING UNIT (OVER 10,000 CFM)
natureof Apph, itycmr Date
EXHAUST HOOD(WB)UCT)
PAID
HEATING UNIT (TO IM." BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt N
Will the applicant or future building occupant share or handle mommux material
as defined by the Cupertino Munppp:pal Cale, Chapter 9.12, and the Health road Safety
HEATING UNIT' (OVER 100,0110 BTU)
'
TOTAL:
VENTILATION FAN (SINGLE RESID)
Code, Seetina 25532D).
❑ Yes
Will the uppBeanor (more building occupant use equipmem ordevices which ami.
BOILER - COMP UHP OR 100,000 BTU)
ISSUANCE DATE
BOILER -COMP (OVER 100,000 BTU)
barardois air contaminants ss dp
IJ Yes Imed by the Bey A. AG Quality Management
Diamee �.N/
Q
PAID
NEW RCSIDENTIAI. MACH. SQ, FT.
I have rend .he hazardous materials mgnire nsw s under Chapter 695 of the
C ahh dt Safely Code , Sections 2550 25533 end 25534. I undersand that
ave t ha it is my rtsponsibiliry to notify the
0
'al/�I
edulbeapahilAing
eupan of halt -I nus. to ' a m issuance of a CimFcate of
W
CIr
?IyVOwnerof
ISSUED BY:
mmizedwenDam