28067APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - HILEM RICA].
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMITNO.
28067 O 6 7
o O
BUILDING ADDRESS: `�..!n
SANITARY NO.
TIOUBMHTAL DA
APPLICAN' 19
46 inse, QO UNIT# LOT#
AME:
PIIONE:A
IN
ME: LIC NO:
NIC
❑
CONTROL#
III ' UENGINEER: LIC NO:
A D ISS
-oNTACT. PHONE:
3 IJ Op+
u"-107
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
EL PLUMB fdleCH
'�710�•\V,
PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION
Coer 9 (commencing with
1 h7000) ff airsthatI 3molicensed undernd
gppl.lANCFS- RPSIDENTIAL
TOB ES RIYITON
Priortsions
Section 7000) of Division or the Rosiness and Professions Code. and my license is in
I If.rce vndc�.
PANELS
�
'
License loss
Dore Lic.M_
ConTS Ids
,
UPT02MAMPS
(Mp
201-IAMPS
"ARCHITECTS DE icyA 1 N
1 understoodmy plans shall he used ar public records,
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/gQ. FT.
SIGNS ELECTRICAL
Licevcd Professional
OWNIeR.BUII.DER DECLARATION
SPECIAL CIRCUITIMISC.
I herehy affirm that I um exempt hemline Commcmis License Law for the
TEMP. METER OR POLE INST.
following nevem. (Section 7031.5. Business and Professions Code: Any city or county
which requires a patent to construct, alter, improve, demolish, or repair any suucturc
"
,Hecto its issurnce,alre requires theapplicant far such penniu.fileasigred treatment
POWER DEVICES
,but he is licensed Personal o the provisiare of the Contractors License Law (Chapter
9( commencing with Section 7") of Di vision 3 of the Business and Professions Code)
or that he is exempt hetefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
hot more than five hundred dollars ($500).
❑ I,asownerofthe Wipeay,ormyemploymswithwagmutheirsolecompensadm,
SWIMMING POOL ELECT RIC
VALUATIO�
�% 5A9 13�—
�j l
STORIES TYPE CONS'I'RUCI ION
OUTLETS -SWITCHES -FIXTURES
(�
NEW RESIDENTIALELECIR_SQ, FT.
will do the work, add the structure it not intended ocuffered forsale(See. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property whobuildsor improves derreoa.and whod«ssuch work hirrosforthroughhia
own employees, provided that such improv nentsme not imendedoroffercd forsale.If.
OCC. GROUP
RES. UNITS
T
however, she building., Improvement it sold walim ov,car.f,ompletim. theowner-
builder will have the burden of proving that he did not build in improve for purpose of
QTY. PLUMBING PERMIT PER
❑ I, as owner nfthe property,ameuclusivdyconhacdng wiNlicenuJ contractors to
FLOOD ZONI3
APN
commart the project (Sec. 70th, Business add 14ofessiom Cade) The Contractors
License Law does not apply loan ownerofpropeny who builds orimproves Hereon,and
PERMIT ISSUANCE
whocommcts fur such Projects with aconuactogs) Interned purtuartothe Contmaores
License law.
ALTER (G)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this moron
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT #
Owner Data
WORKMAN COMPENSATION DECLARATION
DRAINS - FLUOR, ROOF. AREA, COND.
SCHOOLTA% Y N_
❑ Iherchy affirm thetlhavee ccnificate of contscmmself-insure, oreccrlifitete of
Weakens'C.mpemed ion Insurance or a certified copy thereof (See Jg00, Leb CJ which
FN7L)RES-PER TRAP
RECEIPT#
PARK FEE Y N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS ��
covers all employee's under this penNt.
Policy#
RECEIPT #
BUILDING DIVISION 1.S
PLANCHECK PER
Company
GAS - EA. SYSTEM -OVER 4 (EA)
❑ Cenifede.,yisherebyfumished.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE,
❑ CenilieJ copy is fled with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FLH
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 201
ENERGY FEE
(Thut.ethm. mednot be completed if Ne pcainit is forum hundred dollats($IITB)
or less.)
WATER HEATER W/VEM'/LLECTR
I cenify that idthe Emmmruncc of the wurkfor which this permit is issued, l shall
not employ any puma in any manner sops m hcco_;ielJrct to the Workers
PAID
WATER SY5HBxkTREATING
a
Compensa I'C.traru Dm- l —lh�i �—�NK,99
'l
Date Reccira0
Ap 17i tD ( ,�^. O V
NOTICETOA LICANT: If, ttt ng this Ccnificate of Exemption, ydu should
NEWRFSIDENTIALPLMB. SQ.FT.
TOTAL:
become subject to tire or e Workers Compensation provisions of the LabCode, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING FEE
SEISMIC 17EE
CONSTRUCTION LENDING AGENCY
1 hereby affairs tom them is n corewaiod lending agency for the perfommnce of
the work for which this permit is issued (Sec. 3097, Civ, C.)
IznA<r'c
A :
ELECTRIC FLP:
Name
Ixnders AddressQTY.
MECHANICAL PERMIT FEE
. —
PLUMBING PER
M
1 cenify tbm 1 have mad this application and sate Not the above infomation is
correct. I agrcc to comply with all city and county ordinances and state laws relating to
ft'sili—
MECIIANICALFEF.
PERM SSUANCE
bulldingco®huction, and hereby aothmlre representatives of Nis city toemer upon the
above-mentioned properly for inspection purlwxr.
CONSTRUCTION TAX
ALTER ORA TO MECH.
(We) agree be save. indemnify Add keep harmless the City of Cupenin. ag
liabildies,judgmems, costs and expenses which may in any way accrue agony City
AIR HANDLING 1T(TO I0,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING U 1'(OVRR 10,000 CPM)
S Intonate of Appl icure/Cmurucmr Date
HAUSTHOOD(W/ CT)
PAID
ING UNIT LOQ BTU)
HAZARDOUS MATERIALS DISC.OSURE•
Data Receipt#
Will the applicvnt or future M1uilding xcupunt store ,handle hezmdom material
as definW by the Cupertino Municipal Code, Chapter 9.l ,and the fieahh enA Safety
L 7TH' 1 ( VGR BTU)
TOTAL:
VE A 1 (SINGLE RBSID)
Code, Section 25532(a)'1
❑ Ye. ❑ No
I ILER-COX"(311POR Iw,txro RTD)
ISSUANCE DATE
Will the applicant drfutum buildingaccrimmuseequipme or&' emit
hazerdnus air romamimmu as defined by the Bay Area Air ualiry M ement
Dieddl
8
BOILER/COMP(OVER 10(,0001ITU)
11 Y. 11 No
NE E.SIDRNTIAL MECH.—SQ. IT.
1 have read the hazatdom materials myuimmrnu ondtt Cha ter 6.95 of the
California l lealth&S' ryCnde, gemians 255(15, 25533 and 25574. 1 nderstandi that
pct
'LW o 199
#v y4+kW.
V
ift ilJlogdoesm c randy heveetenan6 that it is my rcsponsibili mnmify the
ccupan .f the reyui ma which must be met prior air i ounce of a 4rlificate of
)
CII /
V �� . fINO
o-
ISSUEDB .
OWVI Nadhorized agent Use
Tl
OFFICE