25065APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO m'BIRr'-"'
BUILDING mvISIGN APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILIIING PRf xcr IDENTIFICATION
PERMITNO. O
'
BUILDING ADDRESS:
SANITARY NO.
A/P/P T�IION SUBMITTAL DATE
/` -�/F
We ` I `-' 1 UNIT# LOT#
\V`
J
.-NMME: AME: PHO ?:
4 Z
CONTRACTOR'S NAME: LION1299
IC
❑
CONTROL#
'ARCHI'I ;C /ENGI TiR: LIC NO:
A DRESS:
v ' u , 0)" a
CONTACT: PHONE:
/ee,,,o,
QTY. SA f) EL�0RI� PBwgm �.T� F;
BUILDING PF. INFO
PLUM
BLDG ELECT PLUMB MECH
❑ ❑ ❑
Ito T—nat, L —cy1I
PERMIT ISSUANCE
LICENSEDCONTRACTORS
unerpmviiomofCATTON
(co mmencing with
1 herebyaffirmthat Iora licensedundcrural
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PramooCCorde,
full fume andnfecivision3 ofine Business nnJ Professions Cade, and myBane ie in
full farce and effect.
ppryp5
J License Class Lic.p
UPT0200AMP5
Dom Contractor
201 - I" AMPS
ARC] IITF.CFS DECLARATION
I understand my plans shell be used as public records.
OVEN 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT
SIGNS ELECTRICAL
Licensed Prdessional
/ henOWNER-BUILDER an DECLARATION
I hereby that 1 an exempt from the Gonioma' License Law for Ne
SPECIAL CIRCUITR.fISC.
TEMP. METER OR POLE INST,
following reason. (Semon 7031.5, Business and Profession
n.(Se Any city
which requires n h, or
alma improve, demolish, fi repair my structure
tamnum
issuance.also re chew the
thea permits flem.Lad statement
offorsuchthe
POWER DEVICES
Chit heir licensed falsamqulres
isitas Co
j thanheislicensedpursumnnthe provisionsof the he Business
9(commeis ixemith Senioanandthe Division Softhe Business and.My profession, Cars)
andproLew (C Cars)
therefmmre for a basis for bjectsalleged
m�tionlial lit 03 LS by to Mystatementof
subjects the epplicannoocivil Penalty of
applicant
• Section 7In.
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
riy hundred ($501rmit
not ml,mownfveheprt) Jollan yempi
❑ LnownernHhepstructuerm
(/
NEWRFSIDENTTALELECTR _SQ.FI'.
S'1'ONIGS
PE CONS'T'RUCTION
will do[lieCi o: mintenyecswithwegomafic(S (Sm. 70an Business
urines,
isnot inLicense
and Pmfeacrty.hnns Cale: The Cont
The Com License Lnw does vat apply s ma owner
Law do s not apply
iof
chma. s
ownemywyces, pdsorimpsvw themagmdwhadoessuchwmk himulfonhmugh his
improvememsartne earolfdmaffered(orown.R,
wnemr,
OCC. GROUP
RES. UNITS
TOTAL:
the bs,pmvldMoprve
hnwevegthebuildingorden ofcmcntishathwithin oneyes or improe forthrpose of
builder will have the burden o(pmving Deo he did nm build car improve for purpose of
QTY. PLUMBING PERMIT PER
❑ Lasu exduais
0 nectonto
pe,
FLOOD ZONE
APN
the (See, 70,14.
a project Business and Code) The
ad Prtrad kers C rl,:) he Contractor's
Licensr.astrue
easnoi in an o ywhobhnu
on,and
Licensetrawdoesnm apply mewith
wMsed
PERMIT ISSUANCE
acofpspmy
for projatswlohaconnacsr(e)Iicensed pursuamslhe Conwcsr's
puminforms Contractor's
who icense Law.
License law.
ALTER. DRAIN A, VENT -WATER A
( )
FEE SUMMARY
❑ I am exempt under Sec, , B & P C for this reason
BACK FLOW PROTECT, DEVICE
Tur-
Owner Dam
DRAINS- FLOOR, ROOP, AREA,
SANITARY Y N
RF.CEIFI'If
WORKMAN COMPENSATION DECLARATION
❑.IhembyafrrtmillallhaveaCeMifcaLeofconsenttoself-insum,oracertificseof
Worker%Compemation Insurance macerified copy ihermf(Sec, 3800.Lub CJ which
OOL" Y N
RI?CPIPT#
KPE Y N
FIXTURES - PER TRAP •�
- - r
U.
GAS- EA. SYSTEM. I INC. 4 OU' Ef
covers a 11 employee's under this permit.
Pal icy #
RECEIPT#
ILDING DIVISION FEES
Company
GAS - RA. SYSTEM -OVER (EA)
a_
PL IIECK
'
❑ Certified wpy ie hereby famished.
❑ CcrtiliW copy is fled with the city inspection division.
GRPASIJINDUSTRL WAS TIN'I'ER ? M . ........
G :E
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS IIF,
SEWER - SANITARY - STORM P.A. 210FT.
ENERGY FEE
('This section need not he completed ifthe permit is forme hundred dollars ($100)
or less.)
WATER HEATER W/VENT/F.LEC
I certify that in the pcdotmrce of the work for which this .it is issued. Ie hall
not employ any person in any maaner m as m became subject to the Workers'
Cumpenationluwsof Califamia. Date
Applicant
WATER SYSTEMRENTING
PAID
Date R<ceipo#
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provision of the labor Code, you must
NEWRFSIDENTIALPLMIL SQ. FT.
TOTAL:
forthwith comply with such provisions or this pemdt shall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FER O
1 hereby off that them is a construction lending agency for the performance of
TOTAL:
ELECTRIC FEE
the weak far which this permit is issued (Sec. 3097. Civ. C.)
lender's Name
Lenders Address
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
1 certify that 1 have read this application and sum that the above information ie
correct. I agree to comply with all city and county mormnces and sum taws relating to
PERMIT ISSUANCE.
MECHANICAL FEE
building comttuction, and hereby author ee repreuntafives of this city ooenterupon the
above-mentioned property far inspection purposes.
AMER OR ADD TO MECH.-
CONSTRUCTION TAX
(We) agree in save, indemnify and keep harmless the Cil, of Cupertino against
Iiabitides,judgmenta,cmb andeapenus which may many way accmeagainso said City
AIR HANDLING UNIT (TO I0,h9d CFM)
in onuquence of the gmndng man. permit.
AIR HANDLING UNIT (OVER 10."CFM)
C
reofA s Vmrecnrt pet
EXHAUST HOOD(W/DUIig
PAID
Ifl?ATING UNIT (TO 100,00) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
Will the applicant or (sure building occupem sere or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health road Safety
tl
HEATING UNTF OVER 100,1101 BTU)
Gale, Seniors 25532(0)7
EI Yes ❑ No
VENTILATION PAN (SINGLE. RESID)
Will the applicantmfusre buildiagcecupant mempapmemordeviceawhichemh
BOILER -COMP (3fIP OR 100,000 BTU)
ISSUANCE DATE
hazallous air contaminants 0s defined by the Bay Area AG Quality Management
)met?
BOILER COMP (OVER I00,000 BTU)
❑ yet ❑ No
NEW RESIDENTIAL. MECH.—SQ. FT.
1 hove read the huatdous mtle,uls requirements uMe, Chapter 6.95 of the
pA (y 5
California Health & Safety Code, Sections 2.5505, 25533 and 25534. 1 umdcoquad Nut
IT A 1
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the acquirements which must Ise met prior to issuance of a Certificate of
#
Occupancy.
v
ISSUED BY:
Owner or amhndzM ages pas
TOTAL:
L)hh�(:t (VIII VI vv..