26484APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B I. In, -LLL RI AL
APPLICATION/PERMIT PLUMBING -MECHANICAL. BUILDING
BUILDING DIVISION BUILDING PROJEC'FIDEN'I
PERMUTING.
O A
4 o 4'IFICA99UN
BUILDING ADDRE$�� LOT x
SANITARY NO.
AI'1'LICATION SUBMITTAL DATELL//
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L--,MklL IaVa Y
CO RACfOR'S NAM . LIC N0:
YNe
N/C
❑
CONTROL p
ARCHI'I IiCT/HNGINP.E LIC NO:
RI?SS;�r - rJ a�
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB
ISSUANCE?
xPERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Nat l a mliansedunderprovisionsofChepter9(commencing with
APPLIANCES - RESIDENTIAL.
JOB DESCRIPTION
Section 700)of Dima.p4cf1he Business and Pacification Cade, ad cripluarbanut
PANELS -
ffu11 fmce and at
icenseCnaa Lic.N
UP1'02W AMPS
DareCdntmch
ARCHITECTS D. IARATION
1 understand my plans shelf be used i n public recants.
911 - 1000 AMPS
SQ. IT. FLOOR AREA
$/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
that I um pt fmthe Contractor', License Law for the
1 hereby affirm Nuemm
fallowing reason (Section 9031.5. Business and Professions Code: Any city or county
TI?MP. METER OR POLE ST.
��
which requires. permit to consumer, alter, improve, demolish, or repair any swaurt
poor o its issuance, also acquires Ne applicant for such Permit to file a signed statement
,
POWER DEVICES 1l p
that he is Lanced innocent to the Provisions of the Commodes License law (Chapter
9(commencing with Section 700d) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is cxempttherefrom and the basis for the al leged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Family of
OUTLETS -SWITC ES -FIX
not moreNen five hundred dollars ($500).
❑ I,asmwnerofNe Mro ay.ormyemployaswiNwagesastheinalecampenaation.
NEW RESIDENITAI. ELECTR _SQ. FT.
STORIES
TYPECONSTRUCTION
will do work, and the Business
lle he Contractor'sicenserofw dolor of apply to an
and Professions Cade: The Cnnwcmr'e License Law does not apply m an owner of
property whnhuildsorimproveatbareon, and whodoes such work himselforthrough his
own employees, provided that such improvements me not intended or offered for said. If,
OCC.GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving Out he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEEFl.000
sale.).
❑ I, mawnerofthepropeny, can exclusively contracting with licensed contractors to
ZONE
pl'N
construct the project (Sec 701 Business anti fhoPosslons Code:) The Contractor'a
License Law duesnnt apply to an ownerofpropeey whobuilds or improves thereon, and
PERMIT ISSUANCE
somemtmms for such projects with smartmnot(s) licensed parmam to the Contmmoea
License law.
DRAIN
-@VENTWATER PA
FLYER ( )
FEESUMN
❑ 1 am exempt under Sec. , B & P C for Nis remm
BACK FLOW PROTECT. DEVICE.
. '
SANITARY Y N
RECEIPTp
Owner Dare
DRAINS- FLOOR, ROOF. AREA, GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ IhemM1y affirm thmlhavc occrtificate of conumro ulf-insum,meanificem of
Workers Compensation lnaurmceofa ceniftenl copy themo'S., 3810, Lab C.) which
coven all employee's under this permit.
Policy x
RECEIPTx
FIXTURES - PER TRAP
PARK FEF. Y N
RECF.IPI' p
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
❑ Cenifl d copy is hefeby famished.
GAS - EA. SYSTEM -OVER 4 (ELI)
PLANCHECK FEE
GRHASFANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenificd copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA, 200IT.
ENERGY THE
(Th'us<ctionnced not be completed ifthe permit is Forane hundred dollars ($1(a))
ori s)
WATER HEATER W/VF.NT/FlECTN
I nceofth for which Nispemti W,lshall
that in the Fin
awork
employf. he
employ any person in any manner sn u to brume subject to the Workers
my
PAID
Co
Applicant nn laws of Califomia. Data
WATER SYSTEM/1'RfsATTNG
Data Receipt
NOTICE this Certificate should
Exemptiode
Ncome
NEW RLSID13N1'IALPLMB. SQ. I'f.
TOTAL:
h
subjAPPLICANT':IL Compensation of the IaMrt Code, you muss
become subject m the Worker's Compensation p you
nnisims
Forthwith comply with such provisions or this permit stall h dttmW revoked.
BUILDING PER
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a construction lending agency for the performance of
the work for muchodis perm' t is issued (Sec 3107, Civ. C.)
TOTAL:
ELECTRIC FM
Lender's Nome
QTY. MECIIANICALP13RMIT FEE.
PLUMBING FEE
Leaches Address
I certify that I have mW this application and we that the above infomtation isMECHANICAL
correct l agree in comply with all city and county ordinances and state laws relining to
PERMIT ISSUANCE
PEE
building construction, and hereby authorize representatives of this city to enter upon the
above-meminned propeny for inspection purposes.
AM 17R OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep handless the City of Cupertino against
liabiliti .gracomemd" a which may in my way eecmeagainst said City
AIR HANDLING UNIT (TO 10,000 CFM)
c ace he fda mtit.
AIR HANDLING UNIT (OVER IBfg)t CFM)
Si(mmof ApplicarmsCmttracto t Date I
I IAUSTHOOO(W/DUCT)
PAID
HEATING UNIT IT, 100,0000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
HEATING UNIT (OVER 100.0011 B'I'IB
OTA
Willdir.ppliemt or future building nempanmrs. or handle heurdon, materiel
as defined by the Cupertino Municipal Code, Chapter 9. 12. and the Haalth and Safety
VENTILATION FAN (SINGLE RRSID)
Code, Section 25532(e)4
❑ Yes ❑ No
BOILP.R- COMP (313POR Hat BTU)
ISSq 5E DATE
,S
d �I1y��
•U — 6 (�
19919
C/,
Will the applicant armat re buildingoccupant use equipment ordevices which emit
hoaardous air contaminmts as defined by the Bay Area Air Quality Management
Dishla4
❑ Yes 13 No
ROR,RR. COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ. IT.
1 have mud the hamnlous materials requirements under Chapter 6.95 of the
Califomia Ilealth & Safety Code, Sections 25505, M533 and 25534. I understand that
`r
L01-
h�/rye
if the building does not currently have a tenant that it is my responsibility in notify the
occupant of the requirements which must be met Prior to issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner nr yuthonizNJ agent Date
OFFICE