24664APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - RLRCTDtewa.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUIL% ' PROJECT IDENTIFICATION
- PERMIT NO4 b b LT. p ^^ e1
BUILDING ADDRESS:
U DNITN PL sill
LOTH
SANITARY NO.
APPLICATIONSUBMITTALDATE
« Z
OWNTM NAME: PHONE:
TRAJO
CONTpnrTOQ'SN LIC NO:
C,x L
N/C
C^ONTROLIt
❑
r
D
RCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:1-j
QTY. ELECTRIC PERMIT
PERMIT INFO
BLDF PLUMB
PERMIT ISSUANCE
LICENSE CONTRACTOR'S DECLARATION
Ihereby affirm flim1 con licensed underprovisionsof Chapter9 (commencingwith
APPLIANCES - RESIDENTIALB
DESCRIPTION
SCer1on 7000) of Division 3 of the Business nd Pr'femi ode, and my licenm is in
Lull force unit feel.
PANELS �!
License las. Lich `
HE TO 200 AMPS`1
Date Contractor
201 - IOW AMPS
ARCHITECT'S DECLARATION
trade st d m plans shell be usedaspublicrecords.
OVER 1000 AMPS IRAREq1
ELECTRICALLicensed
kEBU1.LIING
/'V'�IV�SIGNS
ProfssionalOWNER-BUILDERm
ATION
SPECIAL CIRCUIT/MISC.
the Co
1 hereby affirm thm 1 am exempt tram the Genions
License Law for thefollowing
TEMP. METER OR POLE INST.
retro.. ( Cs
Business nnJ Professions Code: Any city or county
.it to constr,
which requires a permit to construct. alter, improve, demolish,
repair any suuctcrepatheisscensed
permit fi
sthevisios
POWER DEVICESNat
prsr,nttot oftheCo s Licese La (Chapter
he is licensed pursuant m the provisions ofthe Ce Busin ss License Law (Chapter9t
Profusions Code)
ixemithSthereforraandtheDivision 3ofrheed
SWIMMING POOL ELECTRICVAWATION
hat heis
onto b7031.5 by nyap romaad the basPermfonhea0egedexemplion. Any violation of
exemptio
Section by any applicant for v permit subjects the epplicam b n civil penahy of
VVV
OUTLETS -SWITCHES -FIXTURES •��
than
t mora than five hundred dollars yemp.
❑ Lae fl campensiness
NEW RESIDENTIAL ELECIR _SQ. FT.
STORIE
TYPE CONSTRUCTION
work, andthe arofwaguas0eivale
will dr,thework, ands awcmre7enot intendede offered forsale(Sea 7004, Business
and Professions Code: The License Law not apply lf an owner of
ve,Contractor
propertywho buildsvi improvesthereon,andwho tlmssuchende himself.,dfor through his
nch
vemwithinne iatendedmoffered tarsale. If,
employees,providrimprmcment
OCC GROUP
RES. UNITS
is withinonebuild or
howaer,
emithat
will avec theof he
comm¢ for will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑ Las propurry,annexSce.70i,Busiessandely ing eensed
FLaoD zorvE
APN
the Poflhe
)Himommunfseo
ions Cdth
Professions
License the project (Sec. ]040. Business and Refusions Code:) The minces, ad's
License Law ticesnm apply manr,wnerofproperty who minces,addPERMIT
ISSUANCE
sed paorimprovee
whocontractsLaw. for such prr,Jems wbh nconrractogs)liomeed pursuanuo the Conmaclor's
License Law. -
ALTER EA
< )
PEE SUMMARY
❑ I am exempt under Sec. B & P C far This reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FENS
SANITARY Y N
RECEIPT#
Owner Date -DRAINS-
FLOORROOFAREA, COND.
,
WORKMAN,
COMPENSATION DECLARATION
❑ Hoorebers'Coyaffirnlhmlhave a rance or acmmofcoaseahe siffiScsure,or Lab C.)
ate which
fled copy thereof (Sec.3800, LabCJwhich
Workers Cmployee
SCHOOL TAX Y N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y N
ars all employee's under this permit.
ander this Permit.
Policy M
RECEIPT #
GAS - EA. SYSTEM-] INC. 4 OUTLETS
BUILDING DIVISION FEES
Ca any
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
�.
Certified copy is hereby famished.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200Pf.
ENERGY FEE
(This section need not he completed ifthe permit is harane hundred dollars(SIM)
an less.)
WATER HGTER W/VENTXLECTR
I certify that in the Performance of the work for which this permit is issued, )shall
not employ any person in any manner so as to become subject to the Workers
Compensation Laws of California. Date
PAID
Dam' Receipt
WATER SYSTEMJMEATING
Applicant
`
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ, FL
TOTAL:
become subject a the Worker'a Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
-
SEISMIC PEE l
1 h Toby efBrm thuuhern is a combustion lending agency far the perf..cc of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders
TOTAL:
ELECTRIC FEE
Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that 1 have read this application end into residue above inforamim is
correct. l agree to comply with all city and county ordinances and state laws relating 0
PERMIT ISSUANCE '
MECHANICAL FEE
building construction, and hereby authorize representatives oRhis city reenter upon the
above-mentioned property for inspection purposes.
ALTERORADDTOMECIL �•
CONSTRUCf10N TAX
(We) agree to save, indemnify and keep harmless the lye Cu ulna against
lialudifies,judgments,coala unit expenses whichmay in any way ague aintisaitl City
AIR HANDLING UNIT (TO 10,000CFM)
onaequen sof thegmntingof 'x pe
AIR HANDLING UNIT (OVER 10,000 CFM)
Si aturen t nn acor
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dere Receiptk
Will the applicant or future building «Gain[ score or handle hazardous material
As defined by the Cuticular, Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 10.BOM BTU)
25532(e)?
Code, Swri 0 Yes I] No
❑
VENTILATION FAN (SINGLE RESID)
P' ISSUANCE DATE
Will the acontplica contaminants
ihnznrJous air contaminants as defined by the Bay Area Air Quality Management
s definedby the Bay Area it ualityc Management
'District?
BOILER- COMP QHP OR 100.000 BTU)
'
4/0
If %
Q/ A4�
BOILER-COMP(OVER 700,0(X1 BTU)
❑ Yes ❑ No
1 have read the hazardous materials requiremunder Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
fine building does not amorally have a tenant, that it is an, responsibility to natifyda,
occupant of the requirements which must b, met prior to issuance of v Certificate or
NEW RESIDENTIAL MECH. SQ. FT.
�Ij '
/qQnents
�! r �r 1ax73
L C/Y�IT 'wr.i
J ryati
-
Occupancy.
ISSUED BY:
Owner ormilimized agent - Date
TU
OFFICE