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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO- aIMMMAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
NUILDING PROJECT' IDENTIFICATION
PERMrr NO. ^ ^ O
L L
BUILDINGADDRHSS:
SANITARY NO.
SUBMITTAL DATE
� I � UNITN LOT N
/APPLICATION
OWN RS A
E:
PHONE:
C R'S NAME: LIC NO:
NIC
CONTROL#
i u
A C ' 1'/ENGINEER: LIC O:ADDRESS:
�6 — /�}
i 2 62T IA1�'� O
CONTACT: PHONE:
., s,,
QTY. '..ELECTRIC P PEE
BUILDING PERMIT INFO
L ELE UMB MI
ISSUANC
LICENSED CONTRACTOR'S DECLARATION
I hereby uffireathat l om licensed under provisions idChapter9 (commencing with
Sttrion](k11D of Diviiyy'Sof tM1e Business anJ 'q'(%e mCede, myliuveisin
Jct-xLic.p
CES RES L
JOB DESCRI ION
IOU
IJvrnu Ca°n�Td�ef—fJav
MPS
�.
Date Conuanm
AMPS
/ ARCIIITECPS DECLARATION
al
my plans ehall beaxed ns public records.ILicensed
00 Mpg1
WSW(MMING16OL
SQ. FT. FLOOR AREA
$/SQ. Fr.
Profe si
Prb(essionelOWNER-BUILDIfr
DECLARATION
C /MISC.
License Lew farte
1 hereby n.(Se Net 1 ata eumpt from the Cosions
OR PO BgST.
followwhichrectms a. Business and io o
Code: Any cm or county
pont to constru ve. de li
which requites a permit re cons the nlmq improve, demolish, or repair any swcturtprinrmssissuanro,rsotaryitth thevisiosof such
so file a
Licese Law(CvnentEVICEchat he is licensed pursuant m the poMvisi of Ne Contractors Littnu hew (Chapter
Coneract&st
9(wmmencing with Sation]0o()of Diviaion3 of Nc Business end Professionv Code)
orthat he is exemptnherefwo and the basis for the alleged exemption. Any violation of
Section 7031.5 by y applicant for a Permit subjects the applicant to a civil penalty of
an
NG OL ELECTRIC
/ VALUATION/
�N /_�/,„'
IIILLL t
LL OUTLETS -SWITCHES -FIXTURES
nm more than five hundred dollars ($500).
❑ I,asownerofthepmop,ormyemployeeswithwagesutheirsolecompemadon.
i� LLL[[[JJJ
NEW RESIDENTIALELECTit_SQ, FT.
STORIES
TYPE CONSTRUCTION
will do the work, and dissipations is not intended croffertd for sale (Sec. 7M4, Business
and Professions Code: The Contractors License law docs not apply in an owner of
pmpcnywhobuildsmimprovestherebn,andwhodoessuchwo&hitmelfoTimughhis
wnemployecs, pmvidedthat suchimpmvementsarenot itnendmoroffemd forsMe. If,
OCC:GROUP
RES. UNITS
T
however, the building or improvement is sold within one yew ofcompletion, Neowner-
builder. vivid have the burden of prey ing that he did not build or improve for purpose of
QTY, { . PLUMBING PERMIT FEE
s Ic.)
❑ l,uawnetnOhe property,emeaclusivelycbnvaning withlicensm contncmrsm
FLOOD ZONE
APN
consumer the project (Sec. Tltd, Bmmeas and Professions CNet) The Contmcmex
License Law does not apply to an owner of property who builds or improves nhercmr, and
PERMIT ISSUANCE
who contracts for such projects with a contractors) licensed purmanuothe Convectors
Lice se L.w.
nl
gLTP.R- DRAIN&VENT -WATER (FA)
FEE SUMMARY
❑ em exempt under Sm. , B & P C for this reaun
BACK Fl.C)N PROTF E CF
DRAINS -ELI O P ,C
D F
ANIT 0.Y V N
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
CHOOLTAX YN
❑ I hereby affirm that l have a caNficate ofconsem no uhf-insute, or a certificate of I
Workers Compensationlnsumnecorecenifiedcopythemof(Sec. 3800, Loh C.) which
coven all empbsyep;T fish¢ t.
Policy CC77VV JJ
TL RECEIPT#
FIXTURES -PF. Pivi
PARK FEE Y N
RE LIPTN
GAS - EA. SYSTEM -1 INC. 4 OUTLETS ro
BUILDI# VISION FEES
pantGpS-EA.
STEM-
CHECK FEF O
CerifedcoPyiahereby umishm.
GRFAMbIN STRL WASTE INTERCEPTOR
GRADINGF
Cenifm copy is film with the city impectioa division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP
SOI
COMPENSATION INSURANCE.
SEWER - SANITARY - STORM EA. 2001T.
ERG E
(This section nem oat be completed if Ne permit is forone hundred dollarsHIM)
or less.)
WATER HEATER WNENT/F.LECIR
I cmify that in me if... of the work for which this Permit is issued, ?shall
u
am employ any person in any m u to become subject m the Workers'
PAID
Compensation Laysof California. Date
WATER SYSTEM/BEATING
Date ciptp
Applicant
NOTICF. TO APPLICANT.If, at= making this Cmifian of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL;
hecame subject to the Workers Compenution pmeniom of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE �+
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby.ffimm the,them isaconsuucrion lending,may for the perfan .of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE itas 412
lamer s Name
QTY. MECHANICAL PERMIT FEE
PLUMBING IEE �--�
Lenders Address
I certify dun 1 have read this applicadob mad dare that the above infnnnntion is
sect. l agree to comply with all city and county ordinances and state laws relating to
` PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby whit ori a representatives of this city to enter upon the
above-mentioned pmpeny for inspections urfwses.
TER OR ADD TO MSCI 1.
CONSTRUCI'IONTAX
(We agree to save, i rani( keep h the City of Cupertino against
Ruth cx,ju mos,co end us whit many way income against said City
AIR HANDLING UNTr(i'O Io,okki
rs pe
ire u of7 4q
AIR HANDLING UNIT (OVER 10,000 CFM)
:' nawre of pliwMCommcror/ ate
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO 100.000 BTU)
IL MATERIA CLOSURE
Date Receipt#
HEATING UNIT (OVER 100.000 BTU)
O
Will the applicant or fiaLWInidifir, uam,con storenr handle huordous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the l health and Safety
Code, Section 25532(x)1
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
trio
ISSUANCE DATE
Willthe aWlicantorfatum buildingorcupent uuequipmenmrdevices whichemit
BOILER- COMP(3HP OR 100,00) BTU) s
P A B
BOILER - COMP (OVER 100,01) BTU)
zeom air cormorants m defined by the Bay Area Air Quality Management
haNtaminan
District?
NEW RESIDENTIAL MECH.—SQ. FT.
❑ Yes ❑ No
q1 �p Q
UL 9
I have read the haxutdous nationals enals requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not curuntly have a mnam, that it is my responsibility to badly the
i l� ail- Qurcti I IIVL/
occupant of the requhements which must be met prior to issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or omhonmd agent Data
OFFICE