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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINOratoot.111,1. - n1n, rRICAL
BUILDING DFVISION APPLICATION/PERMIT PLUMBING - MECHANICAL,
11 1 NG 1'ROJF.IT IDN IF'ICATION
PERMITNO.
n C /I 2 xi
G v L� 1
BUILD�I ADDRESS: ^
M?iz
SANITARY NO.
D
APPLICATION SUBM'IT'TAL DATE
SNAG
!/ ✓V 0 I—s" / - ✓ UNITE( LOT
OWNERS NAMEPHONE:
r tY
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CONfROLN
ARCF f( TEC' /BNGI GE : y.. _ C O
TI�If�
ADDRESS:
CG.�NsyTIM1yA`alllc�fl/'
#HON .
QTY,: },'' fiL EQI'RIC PERMIT FEE
BUILDING PERMIT INFO
BLDG PLUMB IiC
�j.
,
PERMIT ISSUANCE '
1 Ea rI yP� 1/ — - a ✓
LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(cotmnencing with
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
PANELS
Section ]000) of Division 3 of the Business and Professions Code, and my license is in
full farce and effect.
License Clive Lic.N
UPTO200AMPS
- \
'
Dile Contractor.
ARCIIITECTS DECLARATION
201 - 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
OVER 1000 AMPS
1 understand my plans shall be used o public reeds.
SIGNS ELECTRICAL
Licensed Promssimul
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that I am exempt from the Connector's License Law for the
following reason. (Section 7031.5, Business and Formations Code: Any city or county
TEMP. METIER OR POLE INST.
which requires a permit to construct, alter, improve, demolish, or repair any structure
,no, no its issuance. also requites Neapplicann for such permit to fileasignW statement
POWERDEVIM
,hat Inc is licensed P.1arafta'he ,mvi,ima of the Contracmra License Law(Chapter
9(commencing with Section 000()of Division 3 of the Business and Pmfosiow Code)
SWIMMING POOL ELECTRIC
VALUATPi�
or Nat he is exempt thcmfrmn wdthe basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant fora perem, subjects the applicant n, e civil penally of
OUTLLTfS - SWITCHES- FOCTURES
NEW RESIDENTIAL F.LECIR 5 . Ff.
Q
but more than five hundred dollars ($500).
❑ Lazownemfnhepropmy,ormyemployeeswifh wegesotheireolecompensation,
will do Ne work,and the strumurcis not mendWaroffered forsale(Sec. 2044, Business
and Professions Cade: The Contractors License law does eat apply to an owner of
® �Tt
TYPECONSTRUCTION
it
`
u 1 P 5
property whobuildxorimprovesdereon,and whodcas such work himselfor through his
ownemplayees,provided that such improvements see not intendedoroffemd hassle. If,
ffrt UP
RES. UNITS
TOTAL:
however, the buildingor improvement is sold wimenone yearofcampletica, the owner-
builder will have the burden ofpmvieg that he did not build or improve far purpose of
salc )
❑ I.asownerofthepmpay.ameaelusivelycontractingwithliceusedcon0 torsm
QTY. PLUMBINCP MIT DATE
LONE
APN
construct the project (Sec. 704.4, Business and Professions Cmb,) T1v, Contractor's
Liceve Wwdoes not apply mnnownerofpropery, whobuilds or improves therem„and
PERMIT ISSUANCE
whocomrectsforsuch pmjecu with acontractor(s) licensed pursued India Conwctm4
License law.
pLTF.0.-DRAIN&VT-WATER
ENGIA) )
FEE SUMMARY
❑ 1 am exempt under Sec. , B & PC for this masan
BACK FLOW PROTECT. DEVICE
OUTSIDE
SANITARY YN
RECEIPTN
Owner Date
DRAINS - FLOORROOry AREA, COND.
,
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ (hereby affirm that l have a certificate ofcomentto self-insum, or a certificate of
Wmkeri Compensation lnsuraacema cenified copy themof(Sec. 3800, Lab C.) which
covers all employee's under this permit.
Policy#
RECEIPT#
flXTURPS-PER TRAP
PARK FEE Y N
RECEII'l' #
GAS - EA. SYSMM-I INC. 4 OUTLETS
BUILDING DI TSION FEES
Company
GAS - P. SYSTEM -OVER 4 (EA)
PLANC14ECK HIS
❑ Certified copy is hereby fumishW.
GREASEANDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspersion division.
CER2'IFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER- SANITARY. ST ORM PA. 200FP.
ENERGY FEE It
Oldssectien need ambecomplined if Ne permit is fwoae hundred dallm($100)
w less.)
WATER HEATER W/VENT/ELECIR
Icenify Na in the performance of the work far which this permit is issued. I shall
not employ any Amon m any norma, an as, In become subject in the Workers'
PAID
Compereatimi Lawsof Califnnu. Date
WATER SYSTEM/IRE.ATING
a Receipt
Applicant
NOTICE TO APPLICANT: If, after making.his Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become abject m the Workers Compensation pmvisiutu of the Labor Code, you mus,
forthwith comply with such provisions or this permit shall be, deemed revoked.
BUILDING PER
SEISMIC HE
CONSTRUCTION LENDING AGENCY
I herehy affirm that is a construction lending agency for the performance of
the wo&for which this Permit is iamed(Sec. 3097, Cis. C.)
TOTAL:
QTY, MECHANICAL PERMIT FEE
Name
Lenders Address
1 certify than T have mad this applicationandsum thin Ne shave informationiscomet. l agree tocomply with all city and county ordinances and state lws relating to
PERMIT ISSUANCEbuilding
W�-ELender'.
construction, and hereby mulamiee reresentatives of this city to ems upon the
aMsve-mentioned property, for inspection purposes.
ALTERORADDTOMECI.
(We) igrm to save, indemnify and kap tombless the City of Cu,cnino agdnst
linbilitias,judgmenu,cusu andexpensu which may in any way accrue agsiastsaid City
AIR HANDLING UNIT TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,0(# CFM)
in cons,came of the granting of this permit.
EXHAUST HOOD(W/DUCT)
PAID
Signature of A,pli,mr/Comucmr Data
HEATING UNIT(TO IM.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Recei p
Will the applicant or future building occupant store or handle haerdous material
as defusby the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
ed
T A '
HEATING UNIT (OVER IIXI,IKKI BTU)
VENTILATION PAN (SINGLE RESIDE
Code. Section 25532(a)'1
❑ Yes ❑ No
BOILER -COMP (JEEP OR 100,00011TU)
Will nhenpplicannarfmare huildingmcupannueeequipmemortleviceswhich emit
BOILER - COMP(OVER [OB” BTU)
hmaMous air contaminants as defined by the Bay Area Air Quality Management
y 6
District?
lii}`/ U 994
NEWRESIDENTIAL MECH. SQ. FT.
❑ Yes ❑ No
I have mad the haoadous materials tequimments under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
CITY OF,uCUPERTTIIINO
@1)LpIj�G
it the tires nm cumemly have a to notify the
that it is myssuance
la,n,
ofla
sa;cu,em of the reyuimttmnus which must M met poor to issuance of a Cmificate of
ant o t must
Occupancy.
ISSUED BY:
Owneroracthonzcd a gem Data
T
OFFICE