24854APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBN PLUMB N ; MECHANICAL
APPLICATION/PERMIT ING11ROJEC1[DENFFICA
BUILDING DIVISION fIW LAING 1'RI3JRG'L' IUBN'I'IF'ICA'1'ION
PERMIT NO . 8 5 4
�-
BUILDINGADDRE�SS �+
2
SANITARY NO.
APPLICATION SUBMITTAL DAI H.
pS`2.511A UNIT# LOT0
�
OWN[ PHONE:
CONTRAC R'S NAME: LIC NO:
NYC
CONTROLaf
ARCHITECT/FilsGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
yLD[]BCf PLUMP M1
J�Gk{A
O�
PERMIT ISSUANCE /
LICENSED CONTRACfOR:S DECLARATION
1 hercby affirm Nat I an licensed under provisionsofCTapter 9 (commencing with
Section 9000) of Division 3 of the Business and Professions Code. and my he. is in
APPLIANCES - RESIDENTIAL.
PANELS
JOB DESCRIPTIONDESCRIPTIONION
If lfom<and efface.
Licena CFav Lic. N
UP T0200 AMPS
201 - Has) AMPS
Date Contractor
ARC] 111'12M S DECLARATION
I unJerstunJ my plans shall he used as public rttoNs.
SQ. Ft FLOOR AREA
/'�
E/SQ. FT.
OVER I0f0AMPS
SIGNS ELECTRICAL
J
��
Licensed Professional
OWNER-BUILDERptfrom
SPECIAL CIRCUIT/MISE.
he ComoION
1 hereby affirm that I am exempt from the Conramrs License Law for the
a. Business anti Code: Any city or county
TEMP. ME, TER OR POLE INST.
which it., requires a permit necon.arua, ahoq Improv.. demolish, ar repair any mmcmrc
which proof construct.
theapplicant Pore ch statement
suant Licese
POWER DEVICES
Commmiuo
to the Use
Nat he is licensed pursuant to 0e provisions oldie the Barctols License Law (Chapter
that hos licensed
9(commencing with Satinn]DIX) of DivisionJof the Rosiness and Professions Code)
unhat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Imumbna tsnb eros the licunt nrucivil h 1
y any app' permi j applicant Penalty
SWIMMING POOL ELECTRIC
VALUATIONQCO
8 �iilrfll ���
V �rVJVI
UTf.ICI'S- SWITCHES - FIXTURES
•
nm mora than I! se hundred Anllurs (Scor).
outon,fain I!
❑ I,nmwncrolthcpropeny,onnycmployceswith wagcs astheir sole compensation,
NEW RIiSIDENTIAl.Ii1.13C'1'H SQ.17.
STORIES
TY1'Ii CONSTRUCTION
will do the work, and the strut ture is not intended or of fared for sale ( Stu 7044. Business
and Professions Cale: The Contractor's License Law does not apply to an owner of
property who builds ar improves thereon, and who Jens such work himself or through his
own employees, provided that such improvements we not intended proffered genial, If.
OCC GROUP
RES. UNITS
A
however. the building or Improvement is sold within one year ofcomplction. the owner.
builder will have the burden of proving that he did not build or improve for propose of
QTY. PLUMBING PERMIT FEE
:ale.).
❑ I,aeownerofthepropeny.amexclusivelycontmetingwiN licerrsed conwemrsto
FLOOD ZONE
APN
construct the project (Sec. 1614, Business and Proliexim s code:) The Contractor's
License Lawdae not apply to an owncrofpropeny whobuildsorimprovesthereon,and
PERMIT ISSUANCE
who contracts for such projects with a commemr(s) licensed pursuanuothe Contractor's
License Law.
ALTER - DRAIN & VENT- WATER HA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C f or this reassm
BACK P VI �.
OUT'. IDE FEES
ANITARY YN
RECEIP II
Owner Dare
DRAINS R. ROQF,
z
r. C'OND.•
WORKMAN COMPENSATION DECLARATION
❑ Iherehypensat ton Inswveacenl0cateof ron ,nano (Seturgm Lab C.) which
Wmken'Cnmpensmian lmwruncc OrucenilieJ copytherenf (Set. 3800, Lab C.)which
mull em c}Kuvdel I ':Uypil r
policyM L!/ YLl1 L90.
SCHOOL TAX VN
RECF.IPfp
Fl%TUR EPs A
t
PARK 1'lili YN
1
GAS -1i1. S INCA
BUILDING UIV ION PIJi.S
Company
G . SYSTEMOV :
PIANCHECK FEE
❑ Ceriftedcapy islmrsbyfumished.
Ccnif Jcnpy is filed airtime city inspection division
GREASIONDUSTRL WAS TE INTERCEPT OR
GRADING FEE
CERTIFICA'T'E OF' EXEMFI"ION FROM WORKERS
GREASE TRAP
SOILS PER
lei
COMPENSATION INSURANCE
SEWER - SANITARY -S1"OHM EA. 200FT.
ENIiRG t �sr
This section neat not becompleted iftbe permit is for one hundred dollars(SIM)
or less.)
Icertify that in the Performance of the work for which this permit is issued. l shall
not employ any person in any manner an as to become subject to the Works.
Cumpem,atinn Lnwsof Callfmnia. Date
WATER HEATER W/VEM'/ELECTR
PAID
Dote Roc ipt
WAI BR SYSTF.MiTREATING
Applicant
NOTICE: TO APPLICANT: If, after making this Certificate of Exemption. you should
NEW RPSI DENTIAL PLMB. SQ. FT.
TOTAL:
become subject o the Workers Compensation provisions of the tabor Cade, you must
forthwith comply with such provisions of Permit shall be deemed invoked.
BUILDING FEE �a
SEISMIC FEE
CONS rRUCIION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the Performance of
the work for whi�dltt his permit is issucd(See 3097, Civ. C.)
TOTAL:
ELECTRIC PEE
Q TY. MECHANICAL PERMIT FEE
PLUMHING
Leader's Name P40 DTS
Lender's Address
1 certify that 1 have read this application and stare that Ne above infomtatiun is
correct. l agree nm comply with all city and county ordinances andstate laws relating to
PERMIT ISSUANCE
MECHANICA FEE
CONS'1 RUCI ON'1'AX
building construction, and hereby authorize representatives of this city mender upon the
above-mentimned Micro, for itopecdion purpuses.
ALTER OR ADD TO MSCIL
AIR HANDLING ON IT (TO I ROOD CFM)
-
(We) agree to save, indemnify and keep harmless the City of Cupertino against
1,bili' judgment, costs andexpcnscs which may in anywayacc., agaimsd said City
AIR HANDLING UNIT (OVER 10,000 CPM)
in eo up::I ing of Nis permit. —1�
��
EXHAUSTHOOD(WIDUCr)
3 �t37 2¢
PAID
Si6namrc Or Applicant R'nmctm )ate
HEATING UNIT (TO 103,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt
HEATING UNIT (OVER 100,001 BTU)
TOTAL:
Will the applicart or future building oecu tamre or hurdle hazardous mmerid
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Ilealth and Safety
VENTILATION PAN (SINGLE RESI))
ISSUA CE TE
Code, Nation 25532(a)R
❑ Yes No
BOILER. COMP SSP OR 100,000 BTU)
Will thea lieenmrfututebuildin anmse t ordeviceswhich emit
PP cquipmir
A V D
d by the
avNwa air mntamimme ss defined by dM1e Bay Arta Air Quality Management
BOILER - COMP (OVER 100.000 BTU)
r
sa aY
C1 Yea XNo
1 have read the hazardous materials requirements under Chapter 695 mf the
1
MAR �+
H 1993
NEW RfSIDENTIAI. MF.CII. SQ. FII
California I lealth & Safety Code, Sections 25505, 255)3 and 25534. 1 understand thin
if the building does not cuready have a tenant, that it is my responsibility to notify the
CffY OF i;UFLNfINO
occupant mfNit men rich must be met prior w issuance of a Ccoificain of
Occup
ISSUEDBY:
Owner ar author n'ad n6 em Date
'It
OFFICE