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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING - E.I.ECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
IIUILUINf: PROJECT IDEN'i'IF'ICATION
P17RMITNO. a� w
1 {JJ
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
J%
UNIT# LOTH
O NER NAME: PHONE
•I 11;Q
CONTRACfOR'SNAME: LICNO:
U
NX
❑
CONTROL M
CHII'EM/EHGINEIIR: LIC NO:
ADDRES':
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑
'53^ 533
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby offirn that I am licensed under provisions of LTapter 9 (commencing with
Section nodal fDivision 3ofthe Eusmax,radProfissions Code, and my license is in
APPLIANCES - RESIDENTIAL
LOB DGSCRI ON
PANELS
toll rend-ff p.
rase Claes Lic.p T
UP T02(p AMPS
\
201- IOW AMPS
me Camrector
FT. A A SISQ, FT.
ARCHITECT'S DECLARATIONSQ.
I undemand my plans shall 4 usN az public records.
OVER IWDAMPS
SIGNS ELECTRICAL
-... #
SPECIAHr-• -
Littrwl Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from Ne Convector's License law for thefiollwa
CNrmiAny ay ofenumY
inquiresa SeetPermit
TEMP A:_
toT031.&B,alte,imprPe, deranns
im
which mash any saudurc
which requires a pemm re construct, alter, improve, demolish, file
pnnrm its issuance, also requires Ne applicant for such pemduo fileasigned statement
POWER DEVICES
Ban he is licensed pursuant no the provisions of the Contractors License Law (Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)
or then he is exempt therefrom and the basis for theallegN exemption, A 1 io �fnry
Section 7031.5 by any applicant for a promos subjects Ne traditin to ae lt4'"V
SWIMMING IMMING POOL ELECTRIC
VALUATIjIkV�
OCIO
UTCIi - ES
not mom than five hundred dollars (S500).
❑ I,asownerofNepropmy,mmyemploymswiNwagesus Nrirsolec io
S A E _SQ. FT.
STORIES
'TYPE CONSTRUCTION
will dmhewon, and Ne 41 u�
Law does not apply 1
uactnra License Law alma not apply no an owner of
is Craeisnor'. License
and Cale: The
my whions
ee;
propcnywyces,pdsorimprovu Nem,somdwhomenin i uende M1imselfonM1own
finblu
ne
employecs,prmgorithat such impmvld
OCCGROUP
UNITS
within yearol meNcered
however, ill have the bur len of patent is hat he di in of build of completion. the ower-
buihlrr will have the burden of proving What he did not build or improve for purpose of
TO
QTY. PLUMBING PERMIT FEE
a.).
❑ hos nwnernl Nepmpery,umendusivelycmlracting wiNlicersN conuacmrsm
FLOOD ZONE
APN
construct the pmject (Su. 7044, Business and Professions CNet) The Contractor's111.
License Law alas nm apply to en owner of property who builds or improves thereon, and
PERMIT ISSUANCE
who contracts forsuch projects with aeonuacmr(s) licensed pursuant to the Commetor's se Law.
License
pLTF.R- DRAIN&VENT - WATER (EA)
ITE SUMMARY
C]I am exempt undtt Sm. . B & P C fm this masonBACK
MOW PROTECT, DEVICE
SDE
SANITARY Y N
RECEIPT#
Owner Date
DRAINS- FLOOR. ROOK AREA, CONO.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y
❑ Ihereby affirm thatlhaveecenificum of consem merit -insure, oraarnificate of
Wnrkern Cnmprnsationlneurance nrattnified copy Nercof (Sec.38W,Lob C.)which
covers all employce,s under this permit.
Policy It
Fl%'NRLS-PER TRAP
RECEIn0
PARKFEE YN
RECEIPT #
GAS - HA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
pant
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
Certified copy is hereby famished.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
Ceni6ed copy is filed vol the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPINSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This action need not he completed lithe permit is forone humboddollars(SIM)
m less.)
WATER THEATER WNEN'DELECTR
I minify Nat in the performance of In, work for which this permit is issued, Ishall
not employ any person in any manner so ss to become subject to the Workers
Compemanionlawsof Caliromia. Date
PAID '
Date Receipt#
WATER SYSTEMITREATING
Applicant
NEW RESIDENTIAL PLNEL SQ. PT.
0TAL
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
comply it Workers Cations or tom proenshalaf NefaedeNlted. must
fnnhwish comply with mcM1 provisions or this permit shall be deemed mvokN.
forthwith
BUILDING FEE
SEISMIC FEE `
CONSTRUCTION LENDING AGENCY
I hereby off that them iso mrsuumiom leadingagency for Ne peirmummoo of
the work for which this permit is issued(Sec. 3097, Civ. C.)
I'OT �
F.LF.CfRI
Lender's Name
QTY. MECHANICAL PERMIT' FEE
BNO FM
Lenders Address
1 certify Nos 1 have read this application it turn, that the above information is
correct I agree m comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECH CAL FEF.
buildingconswction, and hereby.uthonm represent ecsof Nis city harmer upon the
obove-enrammed property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
AIR HANDLING UN IT (TO 10,000 CFM)
(We) agree no save, indemnify a d kap harm era the City of Cupertino against
liabilities judgments costsand which may inany way amerce against said City
n
tpe
AIR HANDLING UNIT (OVER 10,000 CFM)
income na of egran' of t.
EXHAUST HOOD(W/DUCI)
PAID
gibroc.iM,pplielisoCciritimem, D.
HEAI'WG UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Datj Receipt#
HEATING UNIT (OVER 100,00`0 B -M
I..
Will the applicant or future building occupant storm or handle hasardous material
as defined by the Cupertino Municipal ",Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE. RESID)
Cade. Section 25532(.)7
13 Yes 21 No
ILI
NCE DATE
Will Neupplicantorfutumbuildingoocupantuseequipmennmdevittswhicheran
laminate, it contaminants as defined by the Bay Area Air Quality Mwagemeet
BOILER- COMP CHP OR IW." BTU)
pp y „
P A I
BOILER - COMP(OVER IM,000 RTU)
District?
Y
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yes ❑ No
/I�•
1 have read the launders materials reyuircmems undtt Chapter 6.95 of the
g^(
• 1 199
Culifomia I lealth & SufetyCNe. Sations 25505.25533 teal 25534. I understand Nut^
if the building Jas not curtently have a tenant that it is my responsibility to notify the
occupant of the re Wournens which must Is, met prim to issuance of a Cerificam of
V' r , 1
yr LUI-[y I HIV`/
Occupancy.
^}a
ISSUED BY l /
Owner or auNonzW agate Dore
TOTAL:
OFFICE