28061APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OFCUPERTINO BUILDING - EUETR .AI.
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENT'IFICAT'ION
PERMITNO. O
BUILDING ADDRESS.
SANITARY NO.
APPLICATION SUBMITTAL DATE
UNIT# LOTH
^g — IF -9S
v J
.:
5 NAAM PRONE:
CO CTOR'S N LIC NO:
N/C
❑
CONTROL It
A III'I'EC'1'/ENGINEER: LIC NO:
ADORE.
S LA
CONTACT : P`HHONE: C$,a/�
WA.r+ Olti� 735 /ai-(
QTY• ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MHCII
❑ ❑ ❑
PERMITISSUANCI3
FJ 00
z�100
p(�
LICENSED CONTRACfORSDECid Clop r9(
I hereby Nil l3 n of Ci mmecenseal, with
th
APPLIANCES - RLSIDENTIAL
JOB DESCRIPTION
ol'Di ss andvisiom
of Business
See1beca mall effect, siren J of the Business and pro(euiav Codc, enA my license is in
Cork. and
full farce and effect,
PANELS
License Clmx Lic.N
UP'T03(I(1AMPS
may
y�y'Z
0 Z— O
Dae Convector
201 - I" AMPS
ARCHITECIPSIECLARA'VION
I understand my plans shall he used as public records.
OVER 1000 AMPS
SQ. FT. F1.001k AREA
E/SQ. FI'.
SIGNS ELECTRICAL.
Lictmed Pe fissional
KLKOyV
93 Y.y
Oy
Y >�
p D OC
=yx oT
OWNER -BUILDER DECLARATION
1 herchy affirm tat hI am exempt from the Cnnnuaor's License Law fun Ne
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a pemr, to comsduct, alcor, improve, demolish, or repair any structure
prior o its inuumce, also rtqumes the applicant for such persniuo file a signed statement
that he is licensed pursuant to the provisions of the Convectors License Law (Chapter
9(commencing with Section 7000) of Division 3 ofthe Business and Professions Code)
SPECIAL CIRCUIT/MISC.
THM P. MET' ER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
W❑m
QSection
or that he is excitant herefrom and the basis for the alleged exemption. Any violation of
7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
011'fLE1'S-SWITCHES-pIXTURCS
C o
a3o0
not more than Eve hundred dollars ($500).
❑ I, asuwnerofNepropmy,ormycmployeeswiNwag<saz Neirwle compensidam,
will do the work, and the structure is not intended oroffered for eile(Sec. 7044. Business
NEW RESIDENTIAL ELGLTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
and Prnfcssiona Cade: The Contoutors License [.so does nm apply to an owner of
Employ who builds orimprover thereon,and whodoes such work himself athroughhis
ownemploycer, provided dularch improvements are normacnded reoffered forsala It,
I
OCC GROUP
NCS. UNITS
TOTAL:
however, the buildingor improvement is sold within one yearofcomplelion, the owner-
builder will have the banded of proving that he did not build or improve for pmPtu of
QTY. PLUMBINGPERMIT FEE
sale.).
❑ I. as owaeroRhe property. umeaclusively contracting with ticenudemobacmrsm
MOODZONE
APN
nnstna the project (Sec. 7044, Business oad Profc.l.as Cede:) The Cnntrannr'n
License 1.ewdocs not apply nam ownerofproperiy whobuildsor improves thereon, and
PERMD'ISSUANCE
who contracts for such projects with a convecmr(s) licensed pursuanno the Contractors
License Law.
ALTER-DRAIN&VIM- ATF.R (E?A)
FEE SUMMARY
❑ I nm exempt under Sec. , B & P C for Nis reason
BACK FLOW PROTECT. 5 -DEVICE
OUTSIDE el
SANITARY YN
Owner Date
DRAT OO F, AREA, COND.
RF.CEIPI'p
WORKMAN COMPENSATION DECLARATION
SCHOOL '1'A% Y N
❑ Ihcrcby affirm thatlhevcuceniFicete of cnnsem to self -insure. ora cenificata of
Workers'Cnmpensetionlas.ran cenracenifed ropy Hereof (Sec.3800,Isb C.)which
RECEII'1'q
TURPS -PER TRAP
PARK FEE Y N
covers all employee's under this permit.
Policy M
GAS - EA. SYSTEM -1 INC. 4 OITILES
RF.CEIPI' M
BUILDING DIVISION ICES
Company
GAS -ELI. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Cerlifiedcopyisherehyfrr isheJ.
GREASEIINDUSTRL WASTETs�TERCE R
RAUING FEL'
❑ Cenifed copy is riled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
5 SS FEE
COMPENSATION INSURANCE
SEWER-SANITARY-S'TOR EA.2 FT.
ENE GY FEE
(This section need not be completed lithe permit is foram hundred dollars(§100)
or less)
WATER HEATER W/VENT LE
I eerily that lnlhe perfannavice.fdbe work for which this permit is marred, l shall
not employ any person in any manner so a to became aubjecl to the Workers
PAID
WATER STEM/fR
NEW RESID LMR. .FT.
Z
O
Compevatienlnwsof Califnnam. Dau
Applicant
NOTICE TO APPLICANT: If, art, making this Cenlricate of Exemption, you should
Date Receipt
TOTAL:
Z)
7
become subject o the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or lhix permit shall be damad revoked.
BUILDING FEE:
I
SEISMIC FEE
UJ (�
CONSTRUCTION LENDING AGENCY
2
J O
PLenders
U
!" a
_ rA
;) 7-.
I la rthy.!find thad there is a construction lending agency for the pedo.. of
the work for which this permit is issued (See, 3097, Civ. CJ
Name
L:
ELECTRIC FEE
Leaders Address
QTY, MECHANICAL PERMIT FEE
PLUMBING FF.F.
O
MECHANICAL FEE
1 codify that I have read this application and stele that the above infonmatho is
covert. l agree to comply with all city and county ordinances andstate laws relining to
building conswaion. and hereby authonee repcammaivesofthiscity to enter upon the
above mentioned property for inapeato" purpa
PERMI SUANCC
ALTER OR TO MEC
CONSTRUCTION TAX
(We) once to save, indemnify and bond a e City of Cupertino against
,
liabilitiex,juit w.caxt uule.ism, loch may' way uccrucnguinsl saiACity
AIR HANDLING UNI '1'(TO Io,Bf10 CFM)
in cim Ce foe gr ting of 'permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
S ry f plic omract Data
EXHAUST HOOD(W/DUCT)
PAID
I MATING UNIT TO I Dr,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE?
Dina Receipt#
Will theapplicant or forum building occupant store or handle hazardous material
as defined hymn, Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
EIHA'fING UNIT (OVER 100,001r) BTU)
T0T
Code, Section 25532(a)7
❑ Y. 13 No
VENTILATION FAN (SINGLE RFSID)
Will theta licamarfmure huildin msec tai mnnlevices which emit
PP Soccupan y pine
BOILER - COMP (3NP OR Fat" BTU)
E
ISSUANCA'f[i
BOILER -COMP (OVER 100,000 BTU)
hazardous it cmnvminad¢ as defined by the 11, Are. Air Quality Managenenl
Dismal
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the
p Q
1C
NEW RESIDENTIAL MF.CEI. SQ. FT.
Cnlifoniu Health & Safety Carle, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a renum, Far it is my responsibility to notify the
Occupant of Ibe reyuiremcros which mull be con prim m issuance of a Cenificme of
AY ry
a
Occupancy.
ISSUED BY: 1 epiIINU
Owner or authorized agent Dau
'TOTAL:
OFFICE