28273APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B IL 1-hLLCI'RACAL
BUILDING DIVISION APPLICATION/PERMIT PI.UMBINf.-MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
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BUILDING A(DRC^SSSS:���
SANHARYNO.
APPLICATION SURMDTAL DATE
A
O 1'p LOT It
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OWN SNAMF:
PHONE:
CO
NAME: ♦ �I IC NO
N/C
❑
CONTROL#
ANC E(1L•NGIN
'LER: LICNO:
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CONTACT: PHONE:
QTY. ELECTRIC P17RMIT FEE
BUILDING PERMIT INFO
BLQG ELECT PLUMB M,CIi
PERMIT ISSUANCE
4ET sirr—
LICHNS[DCONTRACTOR'SDECLARATION
I M1ereby affirmthatlamlicenseJ under provisionxof Chepter9 (nrmmencingwith
APPLIANCES -RESIDENTIAL
TOB DESCRIPTION
Section 7000)of Division 3 ofthe Business and professions Code. and my license is in
PANELS -
full fame and effect
Class Lo,4
UP TO 2IXI AMPS
C0111040License
Dam Contractor
201 - Icgq AMPS
ARCHITECTS DECLARATION
I undersmad my plans shall be used as public records.
SQ. FT. FLOOR AREA
M. FT.
OVER IIXXIAMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUITIMISC.
1 hereby affirm that I am exempt from the Contr ssmes License Law for the
TEMP. METER OR POLE INST.
following maxon.(Section 9031.5,13mums unit Professions Calc: Any city or county
which requires a permit In construct, alter, improve, demolish, or repair any amumure
Priam its issuance, also requires the applicant for such Permit o file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contrman's License law (Chapter
9(commencing with Section 7000)ad Division 3ofthe Busmeasond Praftwimi Code)
or that he is exempt Nerefram and the basis for the allegial exemption. Any violationof
Section 2031.5 by any applicant far o pernit,mbperathe ripplicam m a civil pes
SWIMMING POOL ELECTRIC
VALUATION
J�'''00O
a��
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars (S500).
❑ I,osowneroftheprupeny,ormyemployeeswithwn
.
NEW RESIDENTIAL ELECIR S PI'.gesustheirsolecompensution, Q
STORIES
TYPE CONSTRUCTION
will Jo the work, end the structure is not intendedor offered for sale (Sec. 7044, Business
and Professions Code: The Commutes License Law don not apply to an owner of
propertywholmilds., any me, thensm.and whodossmch w.& himselfmthrough his
own employees, providedthatsueh improvements are nal incendedoroffered fmsole. If,
OCC. GROUP
RIS. UNITS
TOTAL:
however, the building orimpravement is sold within one yearofcampledon, the owner-
builder will have the burden of proving that he did nm build or improve for par arse of
sale.).
ElI, ns nwnurofthe pmpeny. um exelusivelynmtroning with licensed enn0amars to
QTY. PLUMBING PERMIT' FEE
FLOOD ZONE
APN
aminal the project (See. 7W. Business and professions Code:) The Conwant's
License Law Jens nm.pplytn annwnerofpmpeny who builds or improves thereon.and
PERMIT ISSUANCE
who contracts forsuch projects with o conttactons) licensed pursuant to the Contractor's
License Low.
ALTIiR -DRAIN&VENT - WATER (EA)
FEE SUMMARY
❑ I oro eaempl under Sec. , B & P C far this rc..
BACK POW PROTECT. DEVICE
UT IDI FE
SANITARY Y N
RPCEIPI'N
Owner Dam
DRAINS- FLOORROOFAREACOND.
, , , .
WONKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ IM1ercby affirm thatlhaveecenifiwm of conxennnself-insure. oro cenifcute of
Workers CumpensarionlnsumrmmncertifiM copy thereof (Ser. 38(p. Lab C.)which
r.vec, all employee's under this panni.
Policy #
RECEIPT'#
FIXTURES - PER TRAP
P ME Y
RECEIPT
GAS -EA. SYSTEM -I INC. 4 OUTLETS �
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
LANCH
❑ Certified copy ishemby furnished.
GRP.ASEIINDUSTRL WASTE INTERCEPTOR
G It f FEE
❑ Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAPS
Ols
ILS kll
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA. 200fT. a
' ERGY TEE
(This section need not la, completed lithe permit is intone hundreddollars(SIM)
or less.)
WATER HEAT HR W/VENTIFLEMR
I centry that in the performance of the work for which Nis permit isissuW. i shall
not employ any person in any manner so as to become subject to the Workers'
PAID
WATER SYS MM/TREATING
Compeasaion Laws of Califomia. Dam
Dam Receipt#
Applicant
NOTICE T'O APPLICANT: If, afte, nedinglhis Certificate of Eminini ...... should
NEW RESIDENTIAL PLMB. SQ. PP.
TOTAL:
become subject o the WorkeTa Compensation provisions of the tabor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC PE?
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a commotion lending agency for the performance of
the work far which this permit is issued( Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
I.endet's Name
ME HANICAL PERMIT PEE
PLUM RING FEE
Leader'. AddressQTY.
I cenify that I have read this application and ssm that the above information is
feet. l agree to comply with all city and county ordinances and state laws blaring to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby auNndn rcpfesentmivesof this city to enterupon the
above-mentioned properly for inspection purposes.
ALTER OR ADD TO MECI I.
CONSTRUCTION TAX
(We) agree m save, indemnify and keep horMev the City of Cupertino against
liabili's.judgme Icosy modem#cnseswhichmayinanywaysimmeagainat a„id Cil
AIR HANDLING UNIT(TO ULMICPM)
in con eyu ce of th mit lhispe L le/II
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST f100D(W/DI1Cq
PAID
Signature of AppliCam/Conrocor rhac
HEATING UNIT (TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
HEATING UNIT (OVER I00,00B BTU)
T TAE:
Will the applicant or future building occupant store in handle hassrdous material
us defined by the Cupertino Municipal Cale, Chapter 9.12, and the L lealth and Safety
VENTILATION FAN (SINGLE RHSID)
Coda Sectio 25532(.)?
❑ Yea ❑ No
�.
ISSUANCE DATE
Will theapplic.mor future buddingoccupant usecyuipment ordevices bi.chemit
BOILER- COMP(3HPOR I041,000BTU)
P
BOILER -COMP (OVER IM.0M BTU)
hazardous air conWmimanm as defined by the Bay Area Air Quality Management
Distinct?
❑ Yea ❑ No
AR o
NLW RESIDENTIAL MECH. SQ. FT./)�
dous materials rcmes under Chapter 6.95 of the
I have read the howquircm
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understood that
if the building does not currently have a tenant, that it is my responsibility m notify the
v o 19ge
C/r
�rEHr/h
mccupern of the requirements which must he mel prior to issuance of a CeniLeare of
Occupancy.
ISSUED BY:
Owner or inflate ed.gem Dae
TOTAL:
OFFICE