26192It
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING - ELECTRICAL
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION - - BUILDING PROJECT IDENTIFICATION „� . ,
PERMITNO.
/� C (�
L o L
BUILDING ADDRESS., //��, ���� *LVa.
2 -✓330 5' ^ UNIT# �I LOT
SANITARY NO.
APPLICATION,SU`BMfITALDATE
OWNERS NA MP' � ^^ ^���n PHONE:
co N ,4e
CONTRACTOR'S NAME LIC NO:
5111C°N V4tJ6y CfJVJ7A,114 01 57-108
N/C
�
CONTROL#
ARCHITECT/ENGINEER: LIC NO:
♦conITncr:
ADDRESS:
TSA 8,4a,* Avg, s„/, cA, t2z.7
PHONE:
QTY:. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO '
B7 DG PLUMB MECH EhF.
rLaP"
n �bj q
Z&
O �(NQOS KC/ y `�^"+�0�0
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that l am licensed underprovisions orchapler9 (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section ]000) of Di�v�is�ion �3 of�the Business and Professions Code, and my liceosa Is In
full forceandeffee•
License Clans Lie.# 296
PANELS
UP T0200 AMPS
1000 AMPS
Date Contractor
-
V ARCHITECTS DFCLA TIO
1 undersand my'plans shall be used as public records.
OVER 1000 AMPS
OVER
SQ. FT. FLOOR AREA
/ co
(_yL IV_
$/SQ. PT.
-
SIGNS ELECTRICAL
LicenseU Professionul
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby that I am exempt from the GessionmC6 License Law for the
TEMP. METER OR POLE INST.
n. (Se
reasoa(Semi Professions Code: Any city orcrmnty
andimprove,
whichfollowing
to madmen,
which requires a construct, aheq improve, demolish, fi repair any stmcture
d, alsore
the for file a statement
Pimmsaemmedpursrnt
POWER DEVICES
prvisiosocant
to the the Copermino
License La
9 (c he is licensed pursuant to thn provisions of the Ce Rusin ss Lieerwo Law (Chapter
9(wmmencing with Section 700h) of Division 3rFtha Business and Professions Cede)
or shut he is exnnpt therefrom and the basis for the alleged exemption Anyvii alionof
Section 9031.5 by any nppllcwt for a permit subjeca the eppllcam m a dv11 penalty of
SWIMMING POOL ELECTRIC
VALUATIO
�y
"l f
5IF
f OUTLETS -SWITCHES -FIXTURES
not more than five hundred dollars ($500).
❑
wok,and eproperty,ormyempindedorofwagesusidei(Sec. ess
NEW RESIDENTIALELECTR SQ.FL
STORIES
TYPE CONSTRUCT ION
7W, Business
do Business
will do thework, andthe structure isnotintendede offeredforints(Sea
and Professions Cade: The Oommeto/s License Law to a
apply to an owner of
uch or
property who s, provi i d thavwthereon, vement donsuch work himffered hroagh his
own employees, provided that such improvementserenot intendedoroffercd [nasals. If,
OCC. GROUP
RES. UNITS
O A
however, the buildingor improvement is sold within one yearofcrmpletion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY., _.`PLUMBING PERMIT; FEE,'
r
sale.).
❑ I, as owneroftheproperty, amexclusively contracting with licensed contractors to
construct the project (Sec. 9M4, Business and Professions Code) The Coundedn"s
License Law doimmIlyto ownerofpmpeny who builds aimprrvt thereon,end
n an
FLOOD ZONE
APN
9_ 0/ _02V
PERMIT ISSUANCE
who contracts forsuch projects withaeonracar(s) licensed pursuant to the Contractor's
License Law.
ALTER - DRAIN&VENT WATER (EA)
< -. FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE
OI SIDE FEES
SANITARY Y N
RECEIPT#
Owner Dan
DRAINS-FLOOR,k00 E
FIXTURES -PER TRAP
_,
WORKMAN COMPENSATION DECLARATION
�❑ IhaeM1y affirm tha lhaveucenificam nfcrnsem to self -insure, orueertifcan of
Norkere'Compensntion lnvumncerracertified copy therm[(3ea3A00, Lab CJ which
M,0 XI YN
RECEIPT#
YN
GAS -EA. SYSTEM.11 OTE
covers all employee's under this permit.
Policy#
RF.CEIP1'#
BUIL DING DIVISION FEES
Company
❑ Cenifiedcopyisherebyfumished.
GAS - EA. SYSTE -OVER4 EA)
Tr
NCHECK �E
GREASEANDUST111 WASTr1
DING FF
Cenified copy is filed with thecity inspection division.
CERTIFICATE OF EXEMPTION PROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20st
ENERGY FEE
(Thissection need not be completed iftheperrnitisforonehundreddollars($100)
rants.)
WATER HEATER WNENT/ELECTR
I certify that io the perfmmurre.fthe work for which this permit is issued, Ishan
nut employ any person in any manner so as to become subject to the Workers'
-
PAID
Compaxistionfawsof Califomia. Date
WATER SYSTEM/I'RFATING
Dam Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such Provisions or this permit shall be deemed revoked.
BUILDING FEF
— 1—C —
CONSTRUCTION LENDING AGENCY
SEISMIC FEE 0) Lip
i ,
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sea 3099, Civ. C.)
i
T A .:
-
ELFCTRIC FEE
Isnders Name
Lenders Address
r c -
QTY. MECHANICAL PERMIT HHH' ;
r
-
PLUMBING FEE
\
I certify that I have read this application and state that the above information is
correct, l agree to comply with all city and county ordinances and sate laws relating to
'
PERMITISSUANCE
MECHANICAL. FEE
handing mamirmaion, and heroM1y authnrim representative of thiscily m ennroper the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments.msts and expenses which may In any way acerae against said City
AIR HANDLING UNIT (TO 10,000 CM)
in wnsequenoe of the greming of[hie permit.
AIR HANDLING UNIT (OVER I0,000 CFM)
e/
Signature of Applicaht<rmtrvctp,Date
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle hazardous materiel
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
Code, Section 25532(e)P
13 Yes No
�
Ll
VENTILATION FAN (SINGLE RESID)
Will the applicanmr future building occupant tree equipment or devices which emit
BOILER - COMP (BIP OR 100,000 BTU)
ISSUANCE DATE
BOILER - COMP(OVER 100,000BTU)Pill
11 Mous air contaminants as defined by the Bay Area Air Quality Management
biav
❑Yes ,� No
PAID
P N
NEW RESIDENTIAL MECH. SQ, FT.
I have read the haeardous materials requirements under Chapter 6.95 of the
California Health &Safety Code, Sections 25505,25533 and 25534. 1 understand that
^ Q �I�{A�
�N�IAR Z ZIP"(
MAR
if the building docs net cunemly have a tenant, that it is my responsibility m notify the
occupant of the requirements which mus[ be mu prior to issuance of a CenlRrato of
Occupancy.
-
1 I f CHh
GilI�
ISSUED BY:
Owner or aahmiced agent Date
'TOTAL:
OFFICE