25593APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO RUITTING- HIFCfRICX
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION BUILDING. PROJECT IDEN_'fIFICATTON,, ;.
PERMITNO.
ACC (� �]
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BUILDING ADDRESS :�f,`
SANITARY NO,
APPLICATIONSU�BBMITTALDATH
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OWNI?RSNAME: PHONE.
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CON'TRACTOR'S NAME: LIC NO:
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\RCIIITECT/ENGIN[ER: LIC NO
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ADDRESS
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CONTACT: PHONE:
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QTY. ELEGI RIGPERMIT$
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#:G 3BOIL13ING PERMIT INFO '
BL ELE PLU MF.CH
PERMIT ISSUANCE ��
On'Z
P400
LICENSED CONTRACTOR'S DECLARATION
(hereby affirm lhaJ em licensed underproviaionsofChapter9(commmcingwiN
Section TIDO) of Division 3m' the Business and Professions Code, it my license is in
fall force amdeffmt.
APPLIANCES - RESIDENTIAL
fOBDESC PTION
PANELS
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ONZa
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License Class Lic.#
Date Convector
IB'T0200 AMPS
S Y
201-Io00AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL'
��j
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm in., I am exempt from the Curncmr's License law for the
following rou-n. iSectinn 7031.5, Bmiwws mud Professions Code: Anyciry moronity
which requires a Permit in consumer, alar, improve, demolish, or repair any structure
xima, its issuance, also requires the applicant forweh perm,to fileAsigmed sutemem
_1
'ce<
0a6-
30.y
yEe
Win
p
I'L'.
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
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f,m
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C�mt
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that he is licensed pursuant the provisions of Ne Coactors License law (Chapter
9(commencing with Section 7W) of Division 3 oflhe Business and Professions Code)
and The bmisfrrthealleged exlicand n.Any ivil violation of
or that hei31.5 exempt by .1
Senim VO315by arundred cwl ($50rmit subjmuthe Applicwnrecivil penalty of
more than five hundred dollars (55 W).
❑ I,asrwmroOhe Prn n Ye p Y 8 penntion,
Pe ones, m In eeswithere esmthei Ser. mmSTORIES
will Jr NrBusiness
SWIMMING POOL ELECTRIC p
A I
ALUA O
/
OUTLETS - SWITCHES - FIXTURES
NEW RPSIDENTIAI. ELECTR—SQ,FT.
ONSTRUCHON
Code License Law Boased
and ProfessionswimiCode: The
no Comment's of apply to an,
License Law does not Apply Tr an owner of
o.therwar's
ownerrywhobuildsorimprnvwthempmAndwhodoessuch n oroffforNmughhis
iewafdoplettired IL
OCC. GROUP
RES. UNITS
however, improvement iesold edid meyearmcnmplmioar Neowner-
theforow.
hrwwer, theavet the
builder will have the burden rf paving that he did nal huild m improve far purpose of
!
QTY!'. = PLUMBING PERMIT '}`..FEE'
❑ 1,asownerofthepmpeny,wnexclusivclycrnv tingwuhlicenudcontractomm
FLOOD ZONE
APN
construct the project (Sec. 0044, Business and Professions Cale:) The Contractors
License Law does not apply to an owneroftemiamy who builds or improves thereon, and
PERMITISSUANCE
'
.
who coroners for such projects with a conormands) licensed pursuanuo the Contractors
License Law.
ALTER (E )
FEE.SUMMARY
.
❑ I con mwapt under Sec. , B & PC for this reason
BACK (LOW PROTECT. DEVICE
SANITARY YN
Owner Das
DRAINS-FLOOR,ROOP,AREA,COND.
RECEIPT#
WORKMAN COMPENSATION DECLARATION
Cl Ihereby affirm that l have a cenificale ofcontent to self -insure, ma coniGeate of
Workels'ComPentation Insurance or acidified copy lhereof(See. 3800. Lab C.) which
rs nil employee's under this Permit,
Policy #
SCHOOL TAX YN
RECHIPI'p
FIXTURES - PER TRAP
PARK FEE Y N
RECHIFT #
GAS - EA. SYSTEM-( UEC. OU TLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 TEAT
PLANCHECK FEE
El CeniOed copy is hereby famished.
❑ Certified copy is Rled with Ne ciry inspection Division.
GREASFAINDUSTRI. WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
(This section need not he completed if Ne permit is Turner, hundred dollars(SHIT)
or Leri.)
SEWER - SANITARY - STORM FA. 200M.
ENERGY FEE
WATER HEATER W/VENT/HLECTR
Icmify that in The pcdormmceofthe work far which Nis Noma is issued, Ishall
z
not employ any person in any manner sr w to become subject to the Waken
Compsmationlawsof Califonia. Date
Applicant '
WATF.RSYSTEMMEATING
PAID
Date Rec<iptp
O
NOTICE TO APPLICANT: If, 'Sir' making Nis Certificmeof Exemption, you should
become subject to the Workers Compensation provisions of The labor Code, you must
NEW RESIDENT IAL' PLMB. SQ. FT.
TOTAL:
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fonhwith comply with such provisions or this permit shall b, deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING FEE -mss
SEISMIC FEE
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O
I hereby affirm that there is a convection lending agency for the performance of
the work fm which NPermit is issued (Sm. 301, Civ. C.)
TOTAL:
ELECTRIC HE —
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Lenders Name
Lcndcrs AJJresh
Q7�'; z;'T� ,MECHANICAL PPRMIT���"PI
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PLUMBING
I comfy that I have read This application and state That Ne above imiu nation Is
correct. l agree to comply with all city and county ordinances and st laws altering to
building convection, and hereby authorise representatives ofthis city menterupomhe
above-mentioned pia dy for inspection purposes.
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
(We) mIrsave, Inial wit keep leasthe ofe
gainausidChy
IinM1ilitiw Jg u, cods mdexpen. swN a in myw ccrveegeinn said Ciry
AIR HANDLING UNIT (TO IQOW CFM)
in con trice 3 Rntin6 flF'Tlria rat
AIR HANDLING UNIT(OVER Op0)CFM)
( _ �O
i
ignaw AI'ontncm Date
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data RmciPlg
Wi 11 the applicant or future building occupant some or handle hazardous material
m defined by the Cupertino Municipal Code, Chnpar 9.12, and the I Iealth and Safety
HEATING UNIT (OVER 100,000 BTU)
Cale. Section 25532(a)1
❑Yes 11 No
VENTILATION FAN (SINGLE RESID)
Will the upPlicmt nr Ihmrebuilding neupam use equipment or devices which emit
BOILER - COMP (311P OR I W,WO BTU)
ISSUANCE DATE
>mdous air contaminants as defined by the Bay Area Air Quality Management
mie'?
P A '
D
BOILER -COMP (OVER IW,OW BTU)
C3 Via ❑ No
M {J
NEW RESIDENTIAL. MECH. SQ, FT.
1 have read the hazardous mnariels requirements under Chapter 695 of the
CAlifomw Health & Safery Code Sections 25505, 25533 and 25534.1 no mated Nat
SEP $ 1993
V the building d«s not currently have n nnant, thin it is my rea rrobday to notify the
reentrant.,.,arequiremems which mum be met prior a issuance of a Certifeaa of
O
C11 �r
memey.
Uh' GUr j 1
ISSUED BY:
Owner Or wthrdzed agent Dam
9'OTAL:
OFFICE
COON'S PENUNSU�
P®®
FM � � ARE
E [1
2M cFJFs1r464E AVE. i.' ei " 2 81993 LUJ
SAN JqM CA 86125 FAX (409) 4M S'tP
APPROVED
M ACCORDANCE WITH THE CITY Ur
QUP_ERIINO CODES AND ORDINANCES
WE
91GNED
This set of plans and specifications MUS -1
be kept on the job at all times and it is un
lawful to make any changes or alleratiow
.on same without w uten pe.m;ssion Iron.
the building Dept., City of Cupe:tmo.
.,The stamping of the pen ::nd specification:
,:.SHALL 1401' be hel 4:: pe roil or b, be an
t:epproval at um viuiation of any
any Qty v:d.aance or State Law.
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