28076APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-F.LF.C'I'RICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG - MECHANICAL
BUILDING PRHdECT unity iFICA'I'ION
PERM] TN . L^ a�CSJ!1/0.a
{V�
BUILDING A DDRREZSS:
SANITARY NO.
APPLICA'DONSUBMITTALDATE
/� /
/ { p � /Lltl All UNIT# LOT
4 •-2ilr4;S
OWNER NAME: PHONE:
CO RACTORSN 1'' LIC NO:
NIC
El2e
CONIROI,p
✓� Ls F
I)xe 2Lf 9
L
ARC] II'IECI'A?NGINIi9R: LIC NO:
ADpRF ':
CONTACT: PHONE:
QTY, ELECTRIC PERMIT' PEE
BUILDING PIiRM1T INFO
BLDG ELECT PI. M9 MECH
❑ ❑ ❑
//l�[ �CC
'�V'N JO
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I Imrehy al'Gmt that ].at Ilecnsed momodavi, mr s of Chapter9 mumarm cooing with
Scotian 70W)ofD'vision J of due Balmeasmnd Pmlbssiona Code, andmy license is in
APPLIANCES - RESIDENTIAL,
PANELS
DOB DESCRII'1'ION
full f,caand cffcm.
p
License Cress Lim. #_
UP TO 2W AMPS
Dam Contractor
201 - I" AMPS
ARCHITECTS DECLARATION
I understand my plans $hull bec
e used as public rords.
OVER I" AMPS
SQ. FT. FLUOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Profcasinnal
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 am exempt from the Contractors License Law for the
TEMP. METER OR POLE INST.
following reactor. (Section]0715,Business artdave,de ioli Cade:Any city
a
repair any swcmre
ammo
which requires u permit ne tures the alma improve, demolish, file
itsissuance.f,$uchlsrniuo
POWER DEVICES
that heor
pursuant to Prvisiofflosocam
that he is nci ng w pursuant to she provisions ofthe Commnar s License Law (Chapter
LicenseLaw
9 Code)
exempt Division Sof theed
SWIMMING POOL ELECTRIC
VALUATION
that he is t erefro and the bazmfor the tio, Any vena
exemption, of
Sethiohcis 1.5 by a therefrommnt for
Section $permit subjects the applicant ecivil penalty of
cts thedexemant to civil
OUTLETS - SWITCHES FIXTURES
than hundred
n five dollars
not marc than five hundred dollars ($SW).
contpe
❑ I,asnw,k.mhcpropmairrim.,
NEW RESIDENTIAL ELECT _SQ.
STORIES
TYPE CONSTRUCTION
walldo andrho irmayeeswithwad fimsthei(sole
intended, ofw isiors,
Bonino
and Proles is int Cmaisnot
Pml.ss x does not apply to
The Convenor's License Law docs not apply m un owner of
words or
facrown erry mployees, providedthaprnvestheuagsndwasarow inardech hrofficorshroughhis
himpmvemwithin otiewofdmpletired forsole. If,
ownemplthyebuiping
OCC. GROUP
RES. UNITS
TOTAL:
or improvement
hmwcwill avete buren (shat he id noneycw of improve for the owner.
builder will have the harden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
.1.).
sale.).
❑ L.scomm.fille pmpeny,amexdusively, contracting with licenmdcommnors to
FLOOD ZONE
APN
construct the project (Sec. 7044, Business and Professions Code:) no Contractor's
License law does Natapply to tiownerofptopcny who buildsorimpmveathemon,and
PERMIT ISSUANCE
who contracts forsuch projects with a cormomar(s) licensed pursuanttothe Contractors se Law.
Licen
ALTER- DRAIN@VENT - WATER (PA)
FEE SUMMARY
❑ 1 am aempr under S.. , B & P C f, thin mmmn
PACK FLOW PROTECT. DEVICE
OUTSIDE EES
SANITARY Y _N
RECEIPTp
Owner Date
DRAINS- FLOOR. ROOF, ARG, COND.
WORK MAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ lbcmbyaffimtthatlhaveaceoificmeofconunnowif-insum,oraunificateof
Workers'CompcnsationlnsunnceoracMir)edcopyrherwf(Sec.J8W,I.nb CJwhich
RIiCEInN
FIXTURES - PER TRAP `
I J
PARKFEE Y N
covers all employee's under this permit
Policy N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT p
BUILDING DIVISION FEES
Company.
GAS - G. SYSTEM -OVER 4 (EA)
PLANCHECK AEE
❑ Cmhlied copy is hrmby fww,hwL
GRGSE/INDUSTRL WASTE INTF.RCEFTOI{
GRADING EEE
❑ CertilieJ copy ie filed with rhe city inspection division.
CURT 'H (CATH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM FA. 200FT,
ENERGY FEE
(T his wrist need not be Completed tithe permit is for one hundred dollars(SIW)
or less.)
WATER HEATER W/VENT/ELECIR
I certify that I. the performance of the work for whichthis permit is issued, Ishull
not employ any person in any manner so as to become subject to the Workers'
PAID
Cmnpwsnd.nlawsaf CNlifww.. Dam
Applicant
WATER SYSTEM/IREATING
Date NariptN
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDEN71AL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the labor Code. you mon
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I herchyaffirm rhanhere iso catnwdion lendingegency forma performance of
the work for which this permit is issuul (Sec. JW], Civ. C.)
Lcadcis Name
^
SEISMIC FEE
IOTA
ELECTIC FEE
Leadera Addre.
QTY. MECHANICAL PERMIT FEE
PLUMBING IEE
1 certify don 1 have read this eprifr.d. and wom that the above nth o rmion is
l agree to comply with all city and County ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEEeel.
burild'mg coruvunron, and herchy uwhorize represemmives of this city to enter upon the
al,ove-mnnronnl property for inspection purposes.
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
(We) ugme to save, andlfy d keep harmless the City of Cupertino against
lishili ties,judg r.costsunde s which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
neons a dihegrandn f spe it.
C ,V—/q
AIR HANDLING UNIT (OVER 10,000 CFM)
ignammof ApplicunU mr Data
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO I001100 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant m future building occupant slam or handle hazardom metadal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IW,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
Cade, Section 235J2Iep
0Yu CI No
WiIDM1ca licanmrfmurebuildin occu anmse
PP B P equipmem,devica which emit
BOILER - COMP (IHP OR IW.fpO BTU)
SD N TE
bamrdous it Cowumiwdaa us defined by the Bay Arco Air Quality Management
DlsuictP
❑ Ycv ❑ No
J 28
�� 1995
BOILER - COMP (OVER 100,0M BTU)
NEW RESIDENT IAL MECH. S0. FT.
1 Lave mud the hazardous mamrims requirements under Chapter 6.95 of the
CI I Y Vr
Culllimtlu Iwllb@Potl'uy Code, Senlons 25505, 25533 and 25594. 1undnslamithat
I ul–ch I ll� U
tlnrceqsuanrctrrant, which noensto, ta, "1., mto yisrcsusaponesare Carnnipoteimfyethe
o,lcalphnnuoldieof
Oner
IS �/l.•
Owwner,
or uuthnrizeJ otlem Dom
TOTAL:
OFFICE