24820PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'TTY OF CUPERTINO Bull.11lNG EI
/'"BUILDING DIVISION APPLICATION/PERMIT Pl.un+nmc S+ECHANICAL BUILDING PROJFCI' IDENTIFICATION
24820,ECI'RICAI. PERMH'NO
BUILDING ADDRESS:
SANITARY NO.
APPLICA"ON DAIM
,/�l
36 C �./ UNIT# LOT It
�SUBMITTAL
��✓ \�
OW FR. A
CE r PHONE:
G
COC�'RgCrO :S NAME LIC NO:
It /V—• PL.
N/C
❑
CONTNOLa
ARCHITECT/ENGINEER: IC NO:
AD _ `�
CONTACT: PHONEBUILDING
QTY. ELECTRIC PERMIT PEE
PERMIT INFO
BLDG F:LECTMECII
P.UMB
PERMITISSUANCH #
El
LICENSED'haticen CONTRACTOR
IhcrcbyaffDinisiHamlice
APPLIANCES- RFSIDPNTIAL
'f)111wwwppp PTI
Busuderpmv'mfe ionsCprer9(dmylicengwirh
the Businexs trod l'w&ssians Cale, and mylittnse ix in
PANELS
fatio.redefDivision3of
falllnse Clow effect.
License Close Lica
UPT020o AMPS
���/� ',w w
L'jl}[,r'• �., ^r/
Date Contractor
ARCIIITECTS DECLARATION
201 - 1000 AMPS
SQ. FT. FLOOR AREA S/SQ. PT.
OVER 1000 AMPS
1 undcrsmnd my plans shell be used ispublic Taofds.
SIGNS ELECTRICAL
Licevaed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm That 1 nm exempt from the Cootrnmor's License Law for he
following rcawm.(Scutum 70315, Bre incssand Profeaious Code: Any city or county
TEMP. METER OR POLE INST.
which requires a permit to stover, alter, improve, demolish. or rcpab troy svucirrc
prior to its issuance, aim recants the applicant for such Permit o file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License taw (Chapter
9(commencing with Section](MIO) of Division 3 of the Business and Professions Code)
VALUATION
SWIMMING POOL 17LEMIC
ON'LITI;S-SWITCIIIIS-PI%TURES
or rhut he is esempt thcrcfmm and the basis bo the alleged exemption. Any vmmion of
Scene. 7031.5 by any cep,licmd fora permiraubjeas he applicant to u civil penally of
not more lM1un five hundred dollars (SS00).
❑ me ownefof hundred
yaawitM1 wagesasthciranlecompemmion.
NEW RESIDENTIAL 1iLECTR_SQ. FT.
STORIES
TYPE CONSTRUCTION
will dothe work,andthe structure isnot intendedofoffeted forsale(Sec. 7044, Business
and Professions Cade: The Contractor's License law does not apply to an owner of
property who bu Ilds or improves thereon, and who does such work himself or through his
own employees,prwided that such impmvenwolsom nm intended or offered foreale. If.
OCC GROUT'
RFS. UNITS
TOTAL:
however, the buildingor improvement is sold within one year of completion, the owner-
builder will have the burden inflaming that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
HOOD ZONE
APN
fie')'
❑ Luz uwnerofrhe property,trm cxdusiv<ly convecting with liccnxd<onwctonm
construct the project (Sec. ]0,14. Business and Professions Cade:) The Crntrucmr's
Lleeme Lavedoes not apply... rot owner of pmpatly who builds or improvexNuusn, unJ
` PERMIT ISSUANCE
who commets f orsuch projects with a contricmr(s) licensed puronand 1. the Contractorx
License Law.
ALTER - DRAIN & VENT - WATER (VA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSID � I S
❑ I am exempt under Scc. . B & P C far this ¢awn
SANITARY YN
RECEIPT It
Owner Darn
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ T hereby aftlrm that l have acenificme ofconsenl lasell-insure,or a certificate of
Workerv'Compensation Insurance or a certified copy rhereof(Sce. 3800, Lab C.) which
L
X I�1Go i
SCHOOLTAX Y N
RECHIF1'p
FIXTURES - PER TRAP
PARK FEE Y N
Rers'licti�J0
GAS-EA.SYSTEM-I INC.4OUTLTS
BUILDING DIVISION
FEESPolicy
C ny • rCrtwN
GAS. EA. SYSTEM.OVER 4( EA)
PLANCHECK FEE
ertin;lJoIly ri, Ai,rZt, fmniabed.
GRIASMNDUSTRL WASTE INTERCEPTOR
GRADING FEE
Ccroied copy is fled will, the city inspection division.
CERTIFICATE OF EXEMPTION MOM WORKERS'
GREASETRAP
is
SOILS FEE
COMPENSATION INSURANCE
SEWIi .ANITARY-STORM EA. 200FT.
ENERGY FEE
(This section need not he completed iftbe pewit is for one hundrevidollan(SIM)
orlus.)
WAI'FR HEATER W/VLNT/ELECTR
PAID
Date Receipt
I comity motor the performemeofthe work lin which this permit is coed.I shall
not employ any person in any manner so as to become subject to the Worker,'
Cmepensminnlawsof California. Date
WATER SYSTHM/TRHAI'ING
Applicant
NOTICIII0 APPLICANT:If, afe,makingthis Certificamof Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEL
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a cooawctinn lending agency far rhe performance of
Be work for which this permit is issued (Set. 3097, Civ. C.)
ELIVCfRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEF. 0X�
Lenders Name
Lenders Address
L ec,tily that 1 have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances andslam laws relating to
PERMIT' ISSUANCE
MECHANICAL FEE
building conswction, end hereby authorize apms[nlalives of chis city loen¢r upon IM1e
above-mentioned property for impation purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
AIR HANDLING UNIT (TO 0.000 CFM)
(We) agree m save, indemnify end kap harmless the Ciry of Cupertino against
Iiabilitica,judgmend. costs an expenseswhich may inanywny name against said City
AIR HANDLING UNIT (OVER 100X10 CITNE
it meyucncc the gor 'gat- .mit.
EXHAUST HOOD(W/DUC1)
PAID
Sign reof Apphic `it MCI omncmr Dam
HEATING UNIT (TO 100MO BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dae RccciptN
I IHAI NO UNIT (OVER Ig1,Og1 RTU)
Will theoppliemi nr future mildingoccti,mo xIom or li,ndle haaafdoas materia1
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
VENTILATION FAN (SINGLE REST D)
�-
15
Cale, Section25532nd?
❑ Yes ❑ No
ISSUANCE DATE
Will the applicuntorfoture building occupant use equipmentordevices whichemit
BOILER- COMPOHPOR 100.000 BTU)
heom!ous air cmurrimor, as Defined by the Bay Arca Air Quality Management
BOILER - COME(OVER IM,WO BTU)
f'f Lk i
A
DimricE
V'
NEW RESIDENTIAL MF.CIT SQ. Ff.
11 Yes 0 N
I have read the hacandous mamrials requirements under Chapter 6.95 of the
B�1AADp
Njjll� 2 1993
C.1ifomia Health & Safety Cade. Sections 25505, 25533 and 25534. I understand that
if the building does not currently have a tenant, than it is my resgmsibiliry to coli fy the
occupaof the requirements which must be mel prior to commice of a te Certificaof
CITY UY�� c�!I 4
ont ccupancy.
ISSUED BY: �J L�7'1'�
Owner or molmiad agent Date
TOTAL:
OFFICE