26821APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIBI:11AT.'1'1.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERM] P NO.
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BUILDING ADDRESS: �{(y/{���I�(/,�� �!�TI(/ / �
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SANITARY NO,
APPLICATION SUBMITTAL DATE
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CONTnCT: e PHolve
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TY..B ECTRIC PERMIT, _ FEE
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BUILDING PERMIT INFO
PLEB.rECy�
/YI�_ly�
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihembyaffimn ailamlicemedunderprovisimsofC pter9(commencingwiN
APPLIANCES - RESIDENTIAL
JOB DISCRIPTION
Sect on ]Ono) of Divis'.n 3 of the Business send ^Professions Code, end my license is in
full f,c CI aeffat. 51�
Licenx Cl s Lic.# s `+ 1
PANELS
UP TO 200 AMPS
Y
Dam Go T'S D
IIT, over DECIARATION
I undemtand my plana shell b. axd un public records.
- I AMPS
OVER I
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. Er.
I�
`C
SIGNS ELECTRICAL
Use ed Professional
OWI
SPECIAL CIRCUIT/MISC.
from the CoATION
an exempt License law for the
I hereby affirm.(Se that 1 sm exempt from the C.sions
TEMP. METER OR PULE INST.
Co
regmason. (Section constru Business and Professions Code: Any city orcounre
which requiresa permit to construct, ve,
which improve, demolish, ore. sig my structure
pfic (Cement
thevisios fmmch pemdrs filLicense
POWER DEVICES
that h.slicensed positiorein
to th Laned
(Cheater
Thalheis licensedparsuann.the)of Division
the Contractors add Professions
9(rnmmencing with Sudan]000).(Division3of Ne Business and Profession Code)
SWIMMING POOL ELECTRIC
VALUATION
or Nut be is e.mpt,herefinmamd the basis fee thea leged caemption. Any,tZo.1on of
Section 7031.5 by any applicant for a permit subjects the applicant w a civil penally of
�
CTLETS- SWITCHES - FIXTURES �-
not mare than five hundred dollam($500).
❑ I,:nnwnenaftheproperty, nrmyemployeee withwegesastheiraolecnmpenserinn,
Y
NEW RESIDENTIAL ELECTR _SQ. PT.
SIORIES1
'I'YPECONSTRUCI'ION
will do the work, and the slr em.isnm intended nroffcred faseloo(See. 70,14, Buslness
and Professions Coda The Connector's License Lew does not apply m an owner of
pmpertywholooldsorimproves thereon, and whodoes such workhouselfdrthrough his
employees, providedinar such halmormentare not intended oroffered forsole. If.
OCC. GRO P
RES. UNITShowever.
Ne huilding mimpmvemem is sold within one yearofcomphokso, the owner
builder will have the burden of proving that be did not build or improve for purpose of
-
QTY. PLUMBINGPERMIT - FEE
a1c.).
❑hnuwner.flhe propcny,aro exdusivelymntracting withicenedcommctomm
FLOOD ZONE
APN
construct he project (Sec. 70,14, Business and Professions Cade:) The Canacmrs
tr
License Lawdeasimapply loan ownerafpmo Aywhobuildsorimprovesthemon,and
PERMIT ISSUANCE
whncomracts forsuch projects with a cotdramods) licensed pursuant to rhe Contractors
License Law.
ALTER (L )
FEESUMMARY
❑ 1 am exempt underSo. , B & PC for This reason
BACK FLOW I 'I' 1
TSIO: FF. Eq
SANITARY YN
RECHIPl' #
Owner Dale>"
DRAINS- FLOOR`ROOF, AREA �QONDR
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have acciifiene ofconunt to self-moure.ma cemific,de of_
Workers' Compensation Insurance ora certified copy thereof(Sce. 3800, Lab C.) which
SCHOOL TAX Y N_
RI!CEI
r
FIXTURES -P P L J
PARK FEE Y N
GAS - .SYSTH OUTLEf
rsall employee's undermB permit.
Policy
RECEI T#
BUILDING DIVA ION FEES
Company
GAS- OVER 4(liA)
P CHECK FEE
❑ Certified copy is hereby fumished.
GREASEANDUSTRL WASTE.INTERCEPTOR
GRADING FEE
Certified copy is filed wish the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILSFEE
SEWER - SANITARY - STORM F.A. 20nFT.
RNERGY ,Ii
(This scctiorneed not b.e.mpleled Elie permit is feature hundred doll(s(SIO(q
or less.)
WATER HEATER W/ViNT/ELECfR
I certify Nal in she performance of the work for whichmispeman Ts issued, Ishall
s.
not employ any pc. any m es to become subject to the Workers'
WATER SYSTEMIMPATTNG
Compensmionlswsnf Califomie. Date
Dam Receipt#
Applicant
NO'T'ICE TO APPLICANT:If, after making this Certificate of Exemption, you should
became subject,. the Workers Compean6on provision of the Lahr Code, you must
NEW RESIDENTIAL PI.1,1B. SQ, FT.
TOTAL:
foMwith comply with such provisions or this permit shell be domed assured.
BUILDING FEE/
CONSTRUCTION LENDING AGENCY
SEISMIC FE
I hereby uffirm NC Nem is a construction lending agency for the performance of
the work for which this pcomit Is Issued (Sce. 3097, Cls. C.)
Lender's Name
TOTAL:
-
ELEGIRIG .E
.mnlc's Address
r
Q „ Fa L -PLUMBING
E
rectify then I have need this application and state that the above infmmntion is
meet I agree m comply with oil city and county ordinances and slam laws mleling m
-
PERMITISSUANCI?
MECHANICAL CCN.
building construction, and hereby authorise representatives ofthis city to enter upon the
above-mentionedm
ppeny for inspection purposes.
ALTER OR ADD TO MECH,
CONSTRUCTIO A%
e rx to s e, indemnify add kap harmless the City of Cupenirn against
ilities,ju gonads ores and expo hich mayin my wayaccrue against mid City
AIR HANDLING UNIT(TO 10.000CFM)
o uqu ft granungel' noir.
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCn
PAID
\�s
r of pl' a rear Date
HEATING UNIT (TO 100,000 BTU)
IWARDOUS MATERIALS DISCLOSURE
Dam Rc 'r
Will the ml,licam or future building occupant store or handle leati d.us rtuomial
an defined by the Cupertino Municipal Code, Chapter 9.12, andshe Health end Safety
L:
HEATING UNIT OVER 100,000 BTU)
Coda S[Ctl.n 2 x)?
C-) Yeses El No
VENTILATION PAN (SINGLE RESID)
Will thea licmtorfumrebuildinocuantuse
pp g p e. Airtr Quality Manage ant
hazardous air canmminanm as Defined by Ne Bay Arse Air Quality Management
District?
BOILER - COMP (31111 OR 100,11010 BTU)
ISSUANCE DATE
a
BOILER - COMP(OVER IW,(gO BTU)
I ❑Yes ❑ No
NEW RESIDENTIAL MECH.-SQ. FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
UG` -21994
AUG
Culilbmia 11c.IN & Safety Codq Sections 25505, 25533 and 25534. I i nderstwd NC
if the holding does nor currently have a mmatt That it is my responsibility to notify tha
c allam ill the reqummor is which must Iw met pdnr 1. Issannm .f u Ce(IRuwm ear
Occupancy.
CI I L �r �/Urrw n
,
ISSUED BY:
Owner or authorized agent Dam
OF I