25103'Jt
❑CZ
PSI O_O.
UV
,Zw
ZOrn
OZ1--O
L YE)W,
XOd
m30y
C
CCC
xoN
uuFZ<
ad
d3=
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD;N i.-HLEVDITCA -
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IUEN'TIF'ICA'I'ION
PERMITNO. ^ 5 1 O
L V{
BUIL/A�IyNr�G]aAV/D�I)lR%13�5:
SANITARY NO.
AIRLICAIION/SUBMIT] 'Ah DA 31:
—ryJ�kry�_J `1 I,'
In•'✓ 500 --i{/�/(�/Y/ '�Fe WG / UNIT# LOT#
OWNERSNAMH PHONE:
CON IRACI'OR'SNAME: �` EICNO:
NIC
CONTROL#
w ❑
A
-7 7 q' 0
eA!lC 11' A'. GI EER' , CNO�
ADDRESS: a ���� STs ��(
CONTACT: PHONE:
' �1 I
Stu.-
1/ .- I 1S� �� I Z+
QTY. ELECTRIC PERMIT FEE
BUILDING PEER/MIT INFO
BLDG .LE PLUMB MECH
❑ ❑
PERMIT ISSUANCE
hICENSEDCONilu.dm R' DECLARATION
I hereby elfirmthmam llicensed undermnspvisioof Chepta9(commen<ing with
APPLIANCES -RESIDENTIAL
OB DESCRIPTION
Section 7OW)of Division 3ofthe Business and Promssiam Code. and my license is in
PANELS
full force and effect.
Lice • Class I.ic. #
UPT 2W AMPS I}
1 l e
c RCHI=S DECLARATION
1 understand my plans shall be used an public records.
01 P
V I PS
s G LEMICAL 9
SQ. Ff. FLOOR AREA
v
i^.\ II E
—\\ LL44��
^ B p
$/SQ. F7'.
Licensed Professional
OWNER -BUILDER
V
SPECIAL CI CU /MI
rimaLDERDECLARATION
1 hereby affirm that I am exempt from the Cenunctor's License Lew for Ne
following reason. (Section 7031.5, Business end Professions Code: Any city or counry
TEMP. R R ' 1
which requires u permit as construct, alter, inrymve, demolish, or repair nay structure
poormiu ismaneaalao rcyairca me appEeant roraaan penahn. Bleaaigned gaga
POWER es
that he is licensed pursuant to the provisions of the Contractors License law (
9( arm me is exempt therefrom a9(X10the Division 3o(the Business and Profusions Cod e)
.r that h7031.5 by anya and the basis for the alleged exemption. Any violation of
Section subjects the applicant loucivil penaltyof
ynnydleddollars
-
SwIMM G LELECIRIC
M
VALUATION d G/
O O d k
OUTLETS-SWITCHES-FI%TURES
S500)permit
not mom than five hundred Jolters (SSW).
ddinfi
❑ basoweer.(thepropery,ermycmployecswithwagcsssdseirwle<.mpcwti
NEW RESIDENTIAL ELECTR _SQ. FT.on,
S'ORIPS
TYPE CONSTRUCTION
will Jo the work,and the xpuctum is not intendedorof(coned forsile(Ses.]1144, Business
.ad Professions Cale: The Crnrva x's License Law does not apply no an owner of
pvgxny who builAs orimpnrva thereon end whodres tach workhimselfort rro,inhis
wnemployecs.pmvidodthatsuchimproverenme notintendc moffe forWe.IL
OCC GROUP
RESUNITS
.
TOTAL:
however. the building or improvement is sold within conte yearafecmpletion, me owner-
builder will have the burden of proving that he did act build or improve for purpose of
QTY. PLUMBING PERMIT' FEF:
sa1e.).
ocm
CI Lits evorrof the properly, amendusively contracting with licensed coaursm
FLOOD%ONE
APN
construct the project (Sec. 7814, Business and Professions Code I The Co..tar's
License Lawdoes nmply m apan owner of property who bol Ida or im proves thereon, and
PERMIT ISSUANCE
who contracts for such projects with acontractor(s) licensed pursuant to the Contractor's
Liccn.nc Law.
ALTER - DRAIN &VF,N'f-WATER (PA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
❑ 1 am exempt under Sec. , B in P C for this reason
SANITARY Y N
RECEPTp
Owner Date
DRAINS - FLOORROOF. COND.
, .,
WORKMAN COMPENSATION DECLARATION
❑ Thereby uf0rm thatl havcxcertiheme of consenu. sdf-insure. ora cenifcam of
'NMkns'Compcnsation Insurance or a ccnifed copy thereof (Sm. 38W, Lab C.) which
coven all employee's under this permit.
Policy #
SCHOOL TA% Y N
RECEIPT#
FIXTURES-PERTRAP
PARK FEE Y N
NIiCE1PT #
GAS - E.A. SYSTEM -I INC.4 OUTI.M-
BUILDING DIVISION FEES
Company
GAS - EA.SYSTEM OVER 4(EA)
PLANCHECK FEE x 7�
❑ Certified copy ishemby furnished.
GREASIVINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM F.A. 20(FT.
ENERGY FEF:
(Tlds section necd not becompleted ifthe permit is for one hundred dollars ($100)
or less.)
WATER HEAT'FR W/VIiNT/ELEM
�L L
I certify that in the Killmmmentsf the work for which this per mit is issued, ishan
nut employ any person in any manner so as to become subject to the Workers'
Compensation lawn.(Cxlifnmia. Dale
PAID /
Dane Rmcia#
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT, If, after making this Cenificam of Exemption. you should
NEWRESIDENTIALPLMB. SQ.FT.
IA 37,,75—
a S^hcome
licentiatesubject o the Workers Compensation Provisions of Ne Labor Cade, you must
forthwith comply with such provisions or this permit shall b<deemed revoked.
BUILDING PEE O d
SEISMIC FEB
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a construction lending agency for he perfamnnce of
the work for which this permit is issued (Sec. 3007, Civ. C.)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
QTY -
PLUMBING FEE
Landers Name
Lcnders Address
I mnify that I have read this application arM stem that the above information is
comet. I agree to comply with all city and county ordinances and sum laws reining m
PERMIT ISSUANCE
MECHANICAL. 3E
building construction, and hereby amhome representatives of this city to enter up nn the
aMwe-mentioned property for inspection purpoxes.
ALTER OR ADD TO MSCI L
CONS NTA%
AIR HANDLING UNIT (TO IRKKI CFM)
(We) agree to save, indemnify and keep harmless the Ciry, of Cupndno against
liabilities,judg andexpenses whichmayinanyway <rveagdmtsaid City
eon
AIR HANDLING UNIT (OVER IU.IXX) CPM)
in urmeque o nth ung ofthisa
EXHAUST HOOD (W/DUCT)
PAID
S' ata ApplaanVContrac r Da
HEATING UNIT (TO HMM BTU)
SCLOSURF,
Dam Receipt #
HEATING UNIT (OVER IW,DW 13'1 U)
T
ill iheu,heant or future building om.pamnme or handle huvardoux material
as Je , M by the Cupertino Municipal Cede, Chapter 9.12, and the Health and Safety
Code. Sermon 25532(x)?
❑ Yea ❑ No
VENTILATION FAN (SINGLE RFSID)
V
ISSUANCE DAl'G
Will the applicamorfuture buildingoccupant useeyuipmeat ordevices which emit
BOILER- COMP(3HP OR I00,01(s) B' N)
ha>axim, air contaminants an defined by the Bay Area Air Quality Management
�DisaicB
BOILER - COMP(OVER HM" BTU)
G� A
NEW RESIDENTIAL MECf1. SQ. 14.
❑ Yes ❑ No
W
1 JD
I have read the hamrdous materials requirements under Chapter 6.95 of the
i J
California Health &Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a mason, that it is my responsibility to notify the
(>. 8 •lax
Rig,
/• % �1
Occupam of the rewiremens which must he met prim m issuance of a Certificate of
ceupaaey.
`f.
GU
ISSUED BY:
Owner m mthorizcd 'em Dae
TOTAL: