25025APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO U -
APPLICATION/PERMIT DINGPRNG-MFICHANICAL
BUILDING DIVISION BUILDING PRf3JBf:'1'IOEN'1'll'ICAq'IfIN
FICA
PERMIT NO. ^ 0 ^
[ L
BUILDING AD^D/RP.S�S:
2�2 st—G.�]�j� ► UNIT# LOF#
SANITARY NO.
APPLICA'DON SUBMITTAL DATE
OWNERS NAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CONTROL#
Nfl)jQ(/E�GuJn' I �. i OLAN^:
rl I(
ADDRISS:
:ONTACF: PHONE:
QTY. ELECTRIC PERMIT ITE
BUILDING PERMITINFO
G ELECT PLUMB MECH
PERMIT ISSUANCE
•
4100
FC W I—I..
LIC13NSED CONTRACTT OR'S DECLARATION
I herebyamm rthat l xm licensed underprovisions of Chapter9etm
(mencingwith
Section 7000) of Division 3 of the Business and Professions Cute, and my license is in
tall force and effect.
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
Fzfid
m sxti
FO NZa
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u.0,following
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License Class Lic.p
Date Contmetor
UP TO 200 AMPS
201- IOW AMPS
ARC[ IITECTS DECLARATION
l understand my Plans shall be used., public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Liacnsal Professional
OWNER -BUILDER DECLARATION
I hereby affnd that 1 am exempt from the Conuaaors Unclose Law for the
reasoa.(Section 7031.5, Business and Professions Code Any city or county
which requires a permit to consumer, alter, improve, demolish, or repair any structure
priorto its issuance, also requiresda.,licmn for such permiun fileasi8nel statement
Thu, he is l ecre,ea pursuzal to the provisions of But, Contracmrs License Law (Chapter
9(commencing with Section 7000)of Division 3 ofthe Business and PnfeasionsCale)
SPECIAL CIRCLT ISG.'
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALID
al—m
�ZQ
ASO
Fm
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 71131.5 by any upplicum for a permit sahjects the applicant 0 a civil penalty of
n namenfican five hundred dollars ($500).
will dnthuwons and the
❑dothewrk,andthe operty,ormyempladedorawegeorsale Sec. 044,Bsiness
mkpply 7044, Business
OUTLETS - SWITCHES - FIXTURES S
NEWRESIDENTIALEL=R _SQ.FT.
STORIES
'TYPE CONSTRUCTION
heCotratotimenJede Law dolor
and Pmfexsions Cale: The Contractor's License Lew does nm apply to an owner of
r as as a1
own emplhe,pmvirimpatsucM1improvemenzistatint workhimsfeared hroubc.I.
employees,providedlhmauchimprovements arenotimendedorof(ertJforsale. If.
I =
� � /�
OCC. GROUP
RES. UNITS
1 IS• / 1� �I
however, the building or improvement is sold within oneyear of completion, theowner-
builderwillhavetheburdenofprovingthathedidnotbuildorimplove forpuryose of
sale.).
❑ Las owneronhepropeny, am exclusivelycommcting with licensedconlraclors to
QTY. PLUMB NGP MI N E
FLOOD ZONE -
APN
construct the proj14
ect (Sec. 74, Business and Professions CndeJ The Contrmmr'e
hicertsc Lew Jces not apply to an owner of property who bei Id s ar i m proves ,hereon. tint
PF.Ru7il�
who contracts for such projects with acomrnnor(s) Iicensedpurauanttmhe Conmemr's
License [.aw.
ALTER-DRAIN&VENT- •A)
slid
FEE SUMMARY
❑ 1 ate exempt under Sec. , ]I & PC for this reason
BACK PLOW PRO'fF:CT. II :VICE
'1'. IDE Flab
SANITARY Y N
Owner Data
DRAINS- FLOOR, ROOF, AREA, GOND.
R17CEIKN
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y_N
❑ I hereby affirm that l have a cutiftcale ofcousent to self -insure, or a certificate of
Workers Compensation Immmecuacenified copythermfgas. 3800, Lab C.)whieh
RECEIFI'9
FIXTURES - PER TRAP
PARK LLE Y N
ecivers.11 employees underthis permit
Policy IF
GAS - [A. SYSTIiM-1 INCA OUTLETS
RI:C p
BUILDING SION PERS
Company
GAS - P.A. SYSTEM -OVER 4 (EA)
PLANCRECK FEE
❑Cradlled copy is hereby famished.
GREASFANDUSTR[. WASTE INTT;RCEPFOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM BA. 200FT.
ENERGY
("issection recd net be compleel ifthepennh is for are hundred dollars(SIM)
or less.)
WATER HEATER WNEMT1l! CTR
I certifythat in Be perfortmmce of the workfar which this peord, is issued, I0a11
not employ any person in any rammer ao as to became subject be the Workcn'
PAI
z
Compensatinnl.uwsaf Califumb. Data
Applicant
WAIERSYSTEMaREATING
nm Receipt#
Q
p]
NOTICETO APPLICANT: IL after making this Certificate of Exemption, you should
hccomesubjea m the Worker's Compensation previsions of the Labra Ode, you must
NEW RESIDENTIAL PLMB. SQ. IT.
TOTAL:
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDI GFEEAt
SEISMIC FEE
Q
CONSTRUCTION LENDING AGENCY,
1 z
1 O
I hereby affirm that them is a construction lending agency for the performance of
the work far which this pe man is issued( Sec. 3097, Civ. C.)
Lender'. Name
TOTAL:
ELECTRIC FTE
tender's Address
QTY, MECHANICAL- PERMIT FEE,
PLUMBING 5
U
' W
'
7
1 craify, Ihst 1 have read this application and state that the above irformmion is
correct legs.,comply with ell city and county ordinances end start laws relating to
building construction, add hereby amhorre representatives ofthis city to enter upon the
nMvomeationed property for inspection purposes.
PERMIT ISSUANCE
-
MECIIANICA 19iE
ALTER OR ADD TO MECI I.
CONSTRUCT NTA#
G7
(We) agree to save, primaify and keep harmless the City of Cupertino against
list, I Iias, ji gmenta,costs and expenses w is may in any way oecrueagainsI 'd City
AIR I IANDLINO UNIT TO 10,000 CFM)
in co in eofthck antingofthispc il.
AIR HANDLING UNIT (OVER Ig000 CFM)
gmarmofA IicanlContr¢mr ate -
EXHAUST HOOD(W/DUC11
PAID
HEATING UNIT CFO 100,0Ig1 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Da • Receipt P
Will the applicant or fumm building avocation store or handle hazardous materiel
as defined by the Cupertino Municipal Cade, Chapter 9. 12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
O
GMe,Sateen x)7
Yen
❑ Yes 11 No
VENTILATION PAN (SINGLE RESID)
W[IHhe applicant orfumrcbuildingm<upam usceyuipmemordevi<awhichemit9
District? air cmnaminanrs as Defined by the Buy Area Air Quality Management
District?
BOILER -COMP (JHP OR 100,000 1{TU)
ISSUANCE DATE
�' O
k
BOILER - CHMP(OVER 1111/000 BT U) -
❑ Yes ❑ No
I have rend die h o,mulous materials reyairemcma under Chapter 6.95 of ,he
California Health & Safety Code, Sections 25505.25533 and 25534. I understand the,
{� 9
APR $ 9 199
NEW RESIDENTIAL MECII. SQ. FT.
if the building dares not currently have a Friend., that it is my responsibility to notify the
cencern of the requirements which must be met prior m issuance of a Certificate of
Occupancy,
/s nI(IYl1/
C1 Y ur 1iUf
ISSUER NY
Owner or totaul zed agent Date
TOTAL:
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