25942APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO IUILU .- .LF. 1 AL
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION HUILDING PROJECT IUEN'nF'ICA]'ION
PERMT1'NO.
(� 5 /1 r� (�
L J VV 4 L
BUILDING ADDRESS:
SANITARY 0,
AAP�PWCAON SUHMUTAL DAT.
A)S IWLOT#
U ERS Mk I PHONE:
1lll 1/+.
C ACTOR'S NAME: LIC NO:
N/C
❑
CONTROLp
IARCl11TECUINGINEER: A LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMITINFO
R [CECT PLUMB MECH
PERMIT ISSUANCE
F-1 El
LICENSED CONTRACTOR'S DECLARATION
I hereby Others that l am hemosed underprovisions of Chapmr9(commencing with
Simian 7000) of Division 3ofthe Husincssand Professions Code,and my license is in
APPLIANCES - RESIDENTIAL
PANELS
////�� TOB DESCRIPTION
�JibxlDr7w5
full force and effect.
License Class Lic.is
UPT02MAMPS
W)
Dam Conn.,
ARCHITEM S DECLARATION
I undentandmy pla..,,hall be oed a, public records.
201 - IMRAMPS
SQ. M. FLOOR AREA
fS II
u2Vp
$/SQ. IT.
OVER IIXNIA 1'S
SIGNS IELECI'RICAI' .. ���, I
L"riord Professional
OWNER-BUILDERIaDECLARATION
7
SI'IECIAI. CIR HIT/ TSC. ( I1 j
.,
I hcrcby n (Ser that 1 am exempt from the Conlmno o License Law for the
following reason sand Professions Code: Any city orcountyTEMP.
- u
MITE OR PoLE INS'T.
permit aper, improve, demolish, m repair any mucturt
which to cons.5ct. alt
which rtyuircs n permit to tdoeS the mal
throvisins for
priore secsnsed
POWER UL•VI
pursoral to the the otramiuo License Lav,
9 (o he is ucensd pursuant to the provisions of IM1e Contractor's License law (Chapter
9(c.mmencing wilM1 Section ]fX)o)ofDivision JofBre Business and Professions Cale)
SWIMMING POOL ELECTRIC
yp,N
.,that he is cxcmplthcufrom and the basis for the alleged exemption. Any violationof
Section ]OJ 1.5 by any applicant for a pencil subjects IM1e Wheam to a civil penalty of
OUTLLTS- SWITCHES - FIXTURES
m mare than five hundred dollao($5W).
n❑ T. sownerofthepropcny,ormyemploymwithwagesastheirsolecompnuatitrn,
NEW RESIDENTIAL ELECTR SQ. FT.
STORIES
TYPE CONSTRUCTION
willdothe work, and the structure is not intendesdoroffemd forsale(Sec. 7044, Business
and Professions Code: The Contractors License law does not apply to an owner of
propertywhomiIdsm mpmer,thereon,and whodoessuchwort himself.,throughhis own
employees, provided that such improvements acenm intended oroffemd for sale. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one yearofcomplet e , the owner-
builder will hove the bond.. of proving that he did cat build or improve for purpose of
QTY. PLUMBINGPERMIT FEE
FLOOD ZONE:
APN
sale.).
❑ I.asndthe propeny,u xclusively contracting with livensedcommcmrsto
consumer thenprnjeel (Sum. 7W. Business and Prof sawas Cod J The Contractor's
Licemclawdrwsnolapply to an owner.fpropety who builds or improves lhercon.and
PERMIT ISSUANCE
AIf[ER - DRAIN & VENT- WATER (EA)
FEE SUMMARY
who contracts for such projects with acorn wands) licensed pursuant to the Contractor's
License Low.
❑ 1:vn .xcnhpt under Scc. . B & P C for this rcawm
HACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT,
Owner Date
DRAINS- FLOOR, BLOW, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ Iberchy affirm thmlhaveacenipcmc ofennsem to ulLinsttm. ora cenificam.f
Workeri Compenmtam Insurance or a.ratified copy thmoof(Sce. 3800, Lab C.) which
Covers all employee's under this perm i.
Policy If
SCHOOLTAX Y N
RECEIPT#
FIXTURES - PER TRAP
PARK FIEF. Y N
RECEIPT' p
GAS - EA. SYSTEM - I INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS. EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GR ASERNDUSTRL WASTE. INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CIERIIFCATE. OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS IEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Tis union need not be completed ifthe From, is fame, hundrdd.11—(SIM)
or los.)
WATER HEATER W/VENT/ELECTR
PAID
Dam Receipt It
I cmlfy that in the perfomtance of the work for which this permit is iomd.I shall
not employ any person in coy manner so as to become subject to the Winners'
C.mpetemion Lvwenf California. Date
WATER SYSTENLIREATING
Applicam
NOTICE TO APPLICANT: if, after making this Cenificate of Exemption, you should
NEW RFSIDFN'TIAL PLMH. SQ. FT.
TOTAL:
becomc.subjectto the Workers Compensation provisions of the Labor Cods, you must
forthwith crampy with auch proviainca or this permit shot] be deemed mvokd.
BUILDING PEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm than there is a construction lending agency for the performance of
mascots for which this permit is issued (Scc. 309?, Civ. G)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Num.
1,amkCs Address
I certify that I have ream this application and state that Ice above informnnon is
bonding lagree mcn. with allcitycounty statelaws existing to
PIERMI'I'ISSUANCE
MIECIIANICAI, FIEG
col e,,oft is
building c.nan¢Iinn, anJ hot in. th.rize repress mtivesof Nis city to amenuponthe
a
ahwcnncmi opc Ibr in. sc-
ALTER OR ADD TO MECH.
CONS'IRUCI']ON TAX
AIR HANDLING UNIT (TO Ig0o0 CFM)
abiagrc m sat emni and keep less oh ty of Cu Inst
ima
iubilitieaj gi cote, ixtxu des nus cord w aeClefe
iANDLING UNIT (OVER 10,ODOCFM)
onuyuec.f lh thisPen^ lj
EXHAUST HOOD (W/DUC 1
PAID
Si amt of Applica. ,nor Date
HFATINGUNIT(TO 100,/I0013TU)
IIAZARDOUSMATERIAI.SDISCLOSORE
Date Receipta
HEATING UNIT(OVER 100.000 BTU)
T
Will the applicant or future building occupant some m handle hazvdous material
defined by the Cupertino Municipal Code, Chapter 9.12, and the Health end Safety
FAN (SINGLE RE$ID)
Cane. Section 25532(q?VENTILATION
❑ Yes 11 No
ISSUANCE DATE
tuy
Will the ,coma Fir
BOILER -COMP QHP OR 100.0(10 BTU)
Fp pp
Area Quality Mahichemio
harardous air contaminants as dcfineJ by the Bay Area Air Quality Marugemem
moans s defined by the
BOILER - COMP (OVER 100.000 BTU)
r 4a9
District?
I
NEW RESIDENTIAL MECH.—SQ, FT.
❑ Ycs ❑ No
R'Ea� o
1 have read the haaardous materials requirements under Chapter 6.95 of the
r a f�j 3 'f(�aS�
/ Jl�
California Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that
i1tire building does not currently havc a unapt, that it is my responsibility to notify IM1e
yr �urCN
occupaal of the requirements which must be met prior to issuance of a Cenilicme of
t j
Occupancy.
ISSUED BY:
Owncr err amhmi,ed .gem Date
TOTAL:
OFFlUt