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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO. " BUMUINO-MECHA ICACAL
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION !YNV,e,7g($7�:BUILDING PROJRITJDENTIFICATION){{p;,<;:ybpyzy:
PERMIT NG. O
BUILDING ADDRESS: T. �1 -- �Or•
ZOZoa STEUEwS E' Ek- uafTaP2 IMC test �i4bT14
SANITARY NO.
APPLICA/TIONSUBMfITALDN11
�\
OWNftS NAME: s PHONE —
CONTRACTOR'S NAME: ,u LIC NO:
S E:
N/C
❑
CONTROL p
CHUFF 71
ADDRESS: ��
CONTACT:. _ PHONE:
�(�.�
6<_0Vk � IC I-�� v (
,. -.' y ,F
ELECTRIC PERMIT FEE..
...^:.BUILDING PERMIT INFO
`'
BLDG ELECT PLUMB ME❑CH
J1I0i1pBl('DFSCRIPf10N
PERMIT ISSUANCE.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm than I am licensed underpnomrnr maxtur,9 (commencing with
Section 70W)of Division l of the Business and Pmfmions Code. and my license is in
Lin CIO Z
Cl as effete Lic. ,q
Dae Con actor
I c ON
HlTi�fcdmpubl Ci ,antritis
and my plans rs
APPLIANCES - RESIDENTIAL
.I 00 A $/SQ. Ff.
T
ERLmenmd
PANELS
UP T0200 AMPS r la As
201 - IOW AMPS
OVER HAM AMPS
SIGNS ELECfRICAI. I
Pmmssional
OWNER -BU LDERDECLARATION
1 hereby .room that 1 oro exempt from the Ctmern.e. License Law for the
following mason. (Section 703l L Business and Proanoa Code: My city or county
which nouim a permit to construct, altar, improve. demolish, or report any swcra m
print to im issuance, Alan "notes she applicant for such pemtitto file a signed suumcnt
tMt he is licerucd pursuant b the pmviume of the Comaanols Lice. I.A. (C)epur
9 (commencing with Section 7000) of Division 5 ofdm Business arta professions Code?
.,shat he is exemp0herefrom and the basis for the alleged nemprion. My smIg.nof
Section 7031.5 by any.Mlicam for o permit objectsthe applicant to; civil penairy of
n., more Nan five hundred dollar (5500).
❑ I,uowncrnfdrc Properry.ormYemPloYmwithwagcaa Jr'vsolernmpesuedan,
will dolhe .,it. andtheawctum isnatita ndedmaRerN formle(Sec. 7046, Business
and Professions Cade: The Conb.,&A License Law dm An, apply to an owner of
pmpeor, he bmiciscrimprovu therean,andwhodm,such work himxlfordsonh his
own emplayces,provided Nets.chimprovema.ths
emtaencnealeroHered fmwe. If,
however, the building or improvement is sold within one yearofcompletion, the names.
a ma -
builder
builder will have the burden of proving W, he did And build err improve for puryme of
O.)l,aowne,ofthe Property,am excluaivel onsxdn ith licersedconwctonto
Yc Bw
.aruct the project (Sec. 704,1,
Ono Business and Profmio.a Codes The Conoocsor's
beano Wwdoes nosapply Min. nohaossupmparryuchoW whobtildsmimpmvba,Cmt .and
Lt. Leets fmsuch plgecs withamnurmr(s)IimisNpurtuaubrMConoocbfv
License Law.
❑ I And aempn under Sec. .B Se PC fm this rwon
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLET'S - SWITCHES - FU(TORES
NEW RESIDENTIAL ELECfR _SQ. FT.
STORIES
TYPECONSTRUCTTON
OCC, GROUP
RES. NITS
4-3
wa.csv xwvtrsw.+ar;rs.
"PI%OMBING Pµ 1J -
ff�£�kraauw+nz'.e�wW.tavbR.
FLOOD NE
APN
PERMIT ISSUANCE 10
ALS, DRAW A VENT-WATER(EA)
SU61A1ARY
–----
- �OUTSIDE
.--N
BACK FLOW PROTECT. DEVICE
rM
we Dau
DRAWS -FLOOR ROOF, AREA. GOND.
SANITARY Y
RECETPT,
WORKMAN COMPENSATION DECLARATION
❑ Ihmby offirm tha,l heveecenifieau o(cortsatbulf-iaae,macertifiweof
Workerf Compensation lnsurems, or a cersifiN
penes copy Otvmf(Sec. ]800, Lab CJ which
covin ell employee's undo this permit.
Policy g -
SCHOOL TAX Y N
RECEIPT,
FIXTURES - PFA TRAP
PARK FEE Y N
RECEIPT' g
GAS - EA. SYSTEM -I INC. OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE -
❑ Cenified copy is hereby furnished.
❑ CcniBW copy is Rued with the cityinspection divWm
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is forone hundMdollan(SIM)
Ar lay.)
Ientity than, in the perforral of Ne wink for which this permit is issued, Ishail
no, employ any person in any manger so as As become subject to the Wokm'
Compmarnionlawsof California. Dau
. Applicant
I N0110E TO APPLICANT: If, .fur making this Certificate of Esemption, you should
jbecmne subject b the Weak,, A Compenntion pnovigams of the lab. Code, you mum
foMwith comply with such provisions or thin pcmdt "I be Amounted hooked.
t CONSTRUCTION LENDING AGENCY
Ihereby.ffirodu,thaei,a coarrucdom lenth.,a,ermy for due pafmmaue of
Ube work for which this permit is issued (Ser. 7097, Civ. C.)
Lenme.Name
Lender', Adsi m
GREAS ANDUSIRL WASTE INTERCEPTOR
GRADING FEE
GREASE TRAP
SOILS FEE
SEWER -SANITARY -STORM EA. 2U017.
ENERGY FEE
WATER HEATER WNENTIELELRR
WATER SYSTEMfIBEATNG
NEW RESIDENTIAL FILMS. SQ. Fr'.
'
PAID
Dau pccciPtg
TOTAL:
BUILDING FRE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
TW Awl -,r7e;mca(eu - ` V,
QTY. MECHANI PERMIT
""'ss `� "' W s<.zpram�+sr: ✓.in1 seu:Y 1v : ii.
PLUMB WG FEB .
I rcrtify than, I have rad this .'Im dan and awe than the above infomudm is
orates. l agree b comply withal) city and cauntyordinarun and.uu laws salad.,..
building construction, and hereby Authorize representatives of this city to enw upon the
gra.-themio wd property for naked. purpom.
(We) Agrees to save, indemnify and keep hemdm the City of Cumnino agma,
liabiliti.,judgments, costs and expenses which may in any way ensure against said City
in mnsaluence of she granting of Ws purl
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT ITO 10,000 CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,000 CFM)
Sigwbrcuf ApplicanVContraaof Dau
HAZARDOUS MATERIALS DISCLOSURE
Will0m Applicata.,for.. buildin,recupantsbre mhamdle heaardoa nuuriai
a deflned by the Cupertino Municipal , Chapter 9.12. And the Health and Safety
Code. Section 25372(e)]
1:1 Yu
WilHhee licanwrfmumbuildin Accu
Pp 8 Pantuxequipmem mdevimwhichemit
1azWoa An cormminans As cadmad b y Areas Air Quality Management
Diaries❑
Diaries! 12 o
re
I have ad the h.r olous m.sdals re9uirenu as under Chapter 6.95 .f the
California licalthAtSafety Cole, Sections 25505, 25513 And 255]4. l understand that
if the building docs not currently have a mount,that it is my respon.ibiliry m notify the
ucupam ni 1h yuiremcros which must 4 inn prim m iwuuna m a Ccnificae .I
Occupancy CVa„AD
(Dae
EXHAUST HOOD(WIDUC)
PAID
Dau Recti 0
HEATING UNIT(TO 100.000 BTU)
HEATING UNIT (OVER 100,000 BEV)
VENTILATION PAN (SINGLE RESIDI
BOILER - COMP DHP OR 100.00d BTU)
ISSUANCE DATE
p I /D
4
#' A v
R 7 �//�,
4a j-
�r ('0
ISSUED BY:
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. Pr'.
Owner nr am agent
TOTAL:.
OFFICE
1 11
OZZ
O IC_I--�
zUL
FZ4
fav
ye'
rA
.J
�Ca
06L-
3�v
a0a
,aC
CyC
dOty
taxi=v
FZa
c
A.
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO. " BUMUINO-MECHA ICACAL
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION !YNV,e,7g($7�:BUILDING PROJRITJDENTIFICATION){{p;,<;:ybpyzy:
PERMIT NG. O
BUILDING ADDRESS: T. �1 -- �Or•
ZOZoa STEUEwS E' Ek- uafTaP2 IMC test �i4bT14
SANITARY NO.
APPLICA/TIONSUBMfITALDN11
�\
OWNftS NAME: s PHONE —
CONTRACTOR'S NAME: ,u LIC NO:
S E:
N/C
❑
CONTROL p
CHUFF 71
ADDRESS: ��
CONTACT:. _ PHONE:
�(�.�
6<_0Vk � IC I-�� v (
,. -.' y ,F
ELECTRIC PERMIT FEE..
...^:.BUILDING PERMIT INFO
`'
BLDG ELECT PLUMB ME❑CH
J1I0i1pBl('DFSCRIPf10N
PERMIT ISSUANCE.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm than I am licensed underpnomrnr maxtur,9 (commencing with
Section 70W)of Division l of the Business and Pmfmions Code. and my license is in
Lin CIO Z
Cl as effete Lic. ,q
Dae Con actor
I c ON
HlTi�fcdmpubl Ci ,antritis
and my plans rs
APPLIANCES - RESIDENTIAL
.I 00 A $/SQ. Ff.
T
ERLmenmd
PANELS
UP T0200 AMPS r la As
201 - IOW AMPS
OVER HAM AMPS
SIGNS ELECfRICAI. I
Pmmssional
OWNER -BU LDERDECLARATION
1 hereby .room that 1 oro exempt from the Ctmern.e. License Law for the
following mason. (Section 703l L Business and Proanoa Code: My city or county
which nouim a permit to construct, altar, improve. demolish, or report any swcra m
print to im issuance, Alan "notes she applicant for such pemtitto file a signed suumcnt
tMt he is licerucd pursuant b the pmviume of the Comaanols Lice. I.A. (C)epur
9 (commencing with Section 7000) of Division 5 ofdm Business arta professions Code?
.,shat he is exemp0herefrom and the basis for the alleged nemprion. My smIg.nof
Section 7031.5 by any.Mlicam for o permit objectsthe applicant to; civil penairy of
n., more Nan five hundred dollar (5500).
❑ I,uowncrnfdrc Properry.ormYemPloYmwithwagcaa Jr'vsolernmpesuedan,
will dolhe .,it. andtheawctum isnatita ndedmaRerN formle(Sec. 7046, Business
and Professions Cade: The Conb.,&A License Law dm An, apply to an owner of
pmpeor, he bmiciscrimprovu therean,andwhodm,such work himxlfordsonh his
own emplayces,provided Nets.chimprovema.ths
emtaencnealeroHered fmwe. If,
however, the building or improvement is sold within one yearofcompletion, the names.
a ma -
builder
builder will have the burden of proving W, he did And build err improve for puryme of
O.)l,aowne,ofthe Property,am excluaivel onsxdn ith licersedconwctonto
Yc Bw
.aruct the project (Sec. 704,1,
Ono Business and Profmio.a Codes The Conoocsor's
beano Wwdoes nosapply Min. nohaossupmparryuchoW whobtildsmimpmvba,Cmt .and
Lt. Leets fmsuch plgecs withamnurmr(s)IimisNpurtuaubrMConoocbfv
License Law.
❑ I And aempn under Sec. .B Se PC fm this rwon
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLET'S - SWITCHES - FU(TORES
NEW RESIDENTIAL ELECfR _SQ. FT.
STORIES
TYPECONSTRUCTTON
OCC, GROUP
RES. NITS
4-3
wa.csv xwvtrsw.+ar;rs.
"PI%OMBING Pµ 1J -
ff�£�kraauw+nz'.e�wW.tavbR.
FLOOD NE
APN
PERMIT ISSUANCE 10
ALS, DRAW A VENT-WATER(EA)
SU61A1ARY
–----
- �OUTSIDE
.--N
BACK FLOW PROTECT. DEVICE
rM
we Dau
DRAWS -FLOOR ROOF, AREA. GOND.
SANITARY Y
RECETPT,
WORKMAN COMPENSATION DECLARATION
❑ Ihmby offirm tha,l heveecenifieau o(cortsatbulf-iaae,macertifiweof
Workerf Compensation lnsurems, or a cersifiN
penes copy Otvmf(Sec. ]800, Lab CJ which
covin ell employee's undo this permit.
Policy g -
SCHOOL TAX Y N
RECEIPT,
FIXTURES - PFA TRAP
PARK FEE Y N
RECEIPT' g
GAS - EA. SYSTEM -I INC. OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE -
❑ Cenified copy is hereby furnished.
❑ CcniBW copy is Rued with the cityinspection divWm
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is forone hundMdollan(SIM)
Ar lay.)
Ientity than, in the perforral of Ne wink for which this permit is issued, Ishail
no, employ any person in any manger so as As become subject to the Wokm'
Compmarnionlawsof California. Dau
. Applicant
I N0110E TO APPLICANT: If, .fur making this Certificate of Esemption, you should
jbecmne subject b the Weak,, A Compenntion pnovigams of the lab. Code, you mum
foMwith comply with such provisions or thin pcmdt "I be Amounted hooked.
t CONSTRUCTION LENDING AGENCY
Ihereby.ffirodu,thaei,a coarrucdom lenth.,a,ermy for due pafmmaue of
Ube work for which this permit is issued (Ser. 7097, Civ. C.)
Lenme.Name
Lender', Adsi m
GREAS ANDUSIRL WASTE INTERCEPTOR
GRADING FEE
GREASE TRAP
SOILS FEE
SEWER -SANITARY -STORM EA. 2U017.
ENERGY FEE
WATER HEATER WNENTIELELRR
WATER SYSTEMfIBEATNG
NEW RESIDENTIAL FILMS. SQ. Fr'.
'
PAID
Dau pccciPtg
TOTAL:
BUILDING FRE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
TW Awl -,r7e;mca(eu - ` V,
QTY. MECHANI PERMIT
""'ss `� "' W s<.zpram�+sr: ✓.in1 seu:Y 1v : ii.
PLUMB WG FEB .
I rcrtify than, I have rad this .'Im dan and awe than the above infomudm is
orates. l agree b comply withal) city and cauntyordinarun and.uu laws salad.,..
building construction, and hereby Authorize representatives of this city to enw upon the
gra.-themio wd property for naked. purpom.
(We) Agrees to save, indemnify and keep hemdm the City of Cumnino agma,
liabiliti.,judgments, costs and expenses which may in any way ensure against said City
in mnsaluence of she granting of Ws purl
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT ITO 10,000 CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,000 CFM)
Sigwbrcuf ApplicanVContraaof Dau
HAZARDOUS MATERIALS DISCLOSURE
Will0m Applicata.,for.. buildin,recupantsbre mhamdle heaardoa nuuriai
a deflned by the Cupertino Municipal , Chapter 9.12. And the Health and Safety
Code. Section 25372(e)]
1:1 Yu
WilHhee licanwrfmumbuildin Accu
Pp 8 Pantuxequipmem mdevimwhichemit
1azWoa An cormminans As cadmad b y Areas Air Quality Management
Diaries❑
Diaries! 12 o
re
I have ad the h.r olous m.sdals re9uirenu as under Chapter 6.95 .f the
California licalthAtSafety Cole, Sections 25505, 25513 And 255]4. l understand that
if the building docs not currently have a mount,that it is my respon.ibiliry m notify the
ucupam ni 1h yuiremcros which must 4 inn prim m iwuuna m a Ccnificae .I
Occupancy CVa„AD
(Dae
EXHAUST HOOD(WIDUC)
PAID
Dau Recti 0
HEATING UNIT(TO 100.000 BTU)
HEATING UNIT (OVER 100,000 BEV)
VENTILATION PAN (SINGLE RESIDI
BOILER - COMP DHP OR 100.00d BTU)
ISSUANCE DATE
p I /D
4
#' A v
R 7 �//�,
4a j-
�r ('0
ISSUED BY:
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. Pr'.
Owner nr am agent
TOTAL:.
OFFICE