2682414OC
�
dt
NF-.QL
Os`
HOZ—r
4�YH�c
JCC:
a^yoI
xME
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO- a tiING=F. AI.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO,
26824
#GILDING ADDRESS: GO ����� UNITp LOTH
SANITARY NO.
APPLICATIONSUBMITTALDAtE
I
OWNERS PHONE:
CONTRACro '9 NAME: LIC NO:
N/C
❑
CONTROL#
N�
ARC T/ENGINIiFR: C
i1ONIACT:
A�D H
A T, �AIJ
PHONE:
SiQ�G p (� ,s -Z
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BL EL[ PLUMB MECH
❑ ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I an licensed under provisions o f Chapter 9 (Commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7000) of Division 3 of the Business and Profusions Cade, and my license is in
full face and effect.
0 LicemeClaas Lmis
PANELS
UP T0200 AMPS
Date Common
1201 - 1000 AMPS
ARCHITECTS DECLARATION
3 1 senders and my plans shall be used as public records.
a
OVER IOW AMPS
SQ. FT. FLOOR AREA !I/SQ. FT.
�J
SIGNS EI.ECfRICAL
J Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License law for the
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
a following reason. (Section 7031.5, Business and Profusions Cade: Any city or county
which requires a Permit to concoct, alter, improve, demolish. or repair any maroon
prior to its issuance, ulso requires the applicum for such permiuo Ble asigncd smmment
POWER DEVICES
Cthat he is licensed pursuant to the Provisions of the Contractor's License Law (Chapter
9(commencing with Section 90M)of Division 3 ofthe Business and Professions Cade)
nyapptherefrom and the bnisfor bjthe ailegedexemant to civiny l of
C athat he 31.5bexempt
Sartion any applicant for apertnie subjects the applicommacivil penity of
• not
not momownfiafthe mN4 ylurmyemp.
o ❑ Lnownk,andt pmperty,e is cnmployedmOfeTeguutheifle (Sec. compcnness
will do and ado Business
structure is mors
SWIMMING POOL ELECTRIC
VALUATION l C
�I� J
OUTLETS -SWITCHES -FIXTURES
NEWRESIDENTIALELECTR SQ.FT.
STORI
TYPE CONSTRUCTION
foshe ,imk,
e: Lot,
and Profusions Code: 9Te Contractors License Law does not apply tom owner of
Lio Lownotapply. to a
own eny w ye bo it n or improves thereon, and who das such work N rose eror ehmugh his
nm earofdopletio,for ole.r-
employees ping
OCC GROUP
RFS. UNITS
however, the building m i
or improvement ie sold within oneyem ofcompletion, the owner -
builder en ofpmcrn
will have the burden of proving that he did not build or improve far In a of
PLUMBING PERMIT FEE
le.).
❑ I,amwnerofehe propmy,am exdnivelyrontmcting with licensed Co...en
FLOODZONE
APN
Construct the project (Sec. 7044, Business and Professions Cade) a Cmdracmr's
License lawdounot apply town owneroflmpcny whobuildsori rovuthercon,and
P MITISSUANCE
whomntra forsuchpmjmc withacentmctor(s)lime p mtothe Convacmta
License Law.
AL -DRAIN&VENT-WATER EA
( )
FEE SUMMARY
❑ I oro eumEt under Sm. , B & P C for this reason
BACK *W PROTECT. DEVICE
OUTSIDE
SANITARY Y N
RECEIPT#
Owner Dat°
DRAINS- OOR, ROOF.AREA, COND.
WORK "ANC NSATIONDECLARATION
SCHOOLTAX Y N
❑ Thereby affimrthef lh a cenifmme of cCounno TelGins ,or to of
orkeri Compenmtionlns ce aaceni1ed copy eherco((See. Jwhich
RECEIPT
FIXTURES PER TRAP
PARK FEE Y N
-EA.S TEM -1 TNG 40IITLEfS
coven ell employee's under is Permit.
RF.CEIPTN
BUILDING DMS NFEES
Company
Company
G .SYSTEM -OVER 4 TA)
PLANCHECK FEE
❑ Cenifiedcopy is hereby f ished.`iiiA
❑ Certified copy is fled wiN ¢city ins 'n /� a
GREASE/INDUSTRL WASTE INTERCEPfOR
GRADING FEE
-4�GREASE
CERTIFICATE OF EMPTION FRO
TRAP
SOILS FEE
COMPEN TION INSURA
SEWER - SANITARY - STORM EA. 200FL
ENERGY FEE
(This
(This section need not he complete It
or less.)
XII
WATER HEATER W/VENT/ELECTR
I certify that in the perfonrunce ofibe k for which this
not employ any Person in any manner sec to became ro
PAID
Compeamtion Lawsof California. Date
WATER SYSTEM(IREATING
Date Receipt is
Applicant
NOTICE TO APPLICANT: IL after making this C am of Exemption, you should
NEW RESIDENTIAL PLATE. SQ. IT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a construction lending agency for Ne performance of
the work for which this permit is issued (See. 3WO, Civ. CJ
TOTAL:
ELECTRIC FEE
Len fres Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read this application and state that the above information ie
correct. I agree to comply with all city and county ordinances and scale Iowa relating to
PERMIT ISSUANCE
M
MECHANICAL FEE
building construction, and hereby audamirs mprcarmatives ofthisdry to mterupon the
above-mentioned property, for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
(We) agree to save, indemnify and keep harmless to City of Cupertino against
list, iliti judgments. costs and expenses which may in my way neem¢ against said City
AIR HANDLING UNIT (M 10.000 CFM)
in eoftheg it ofthis quit.
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
PAID
Date Receipt
.911 m APPliCA t
HAZARD S A E LS DIS RE 0 Y
HEATING UNIT (TO IOO,On(1 BTU)
IIn icant or Intuu building acupant store a handle heasuchas materiel
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,tXM)BTU)
TOTAL:
VENTILATION 17AN(SINGLE RESID)
R71 rex O
Cade, Senior 25532(e)P
❑ Yee ❑ No
'
ISSVANC �� ATE
BOILER- COMP(SHP OR ICBMI) BTU)
Will thea licamorfuture buildin acv rot sex ui
PP 8 P A pm it Quality Management
t
h imm,l sea coir comuminants uv defined by the Puy Area Air Quality Management
16Vi[I'I
a,� O
!W`J �.a
j
BOILER - COMP(OVER IfD,IXq BTU)
❑ Ves ❑ No
Cnaa materials 550uircmems under Chet un erst of the
I have read the Safety
lie Health & Safety Cade, Section and 25534. 1 that
NEW RESIDENTIAL MECH.' SQ. FT.
9Q'
a�
CIA
y ser V(JI•CIi I1
if the building dues not to nand
if buil have a stmt,
ad, that o is my responsibilityuancoato notify the
it is
merently
occupant of the rcyuircmemx which must be ten prim to issuance of a Certificate of
et of
2D
Occupancy.
ISSUED BV:
Owner or amhorised agent Data
TOTAL:
OFFICE