28174APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILD1 G-ELP.CI'RICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION RUILDING PROJECr IDENTIFICATION
PERMITNO. ^ �S �N
LSV! I
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMIITALDATE
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(./-2, W,,�9 �anG ITaC-� LOT#
OW E SNAME: PIIONI
CONT CI R:S RAMC; . LIC NO:
N/C
❑
CONTROL
_
CIIITI:CI'/1%NGINEF:ff. LICN ):
ADDNI S:
CONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE
RUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE
/
❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION
Sectionhereb)Montht Ivision am licensedmmenei se with
I hereby uffDi that I emfthe Bu under andcmylicenseis inwith
Business andlrofesstnns Cnde,(commencing
i ons apter Code. and
Professions
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Riepl��
PANELS
full force and eft
Licenm Class Lic.N
r
UPT0200AMPS
Dae Contractor L
201 - 1000 AMPS
-
ARCHITECTS DEC, TION
1 understand any plans doll Jenard as public records.
OVER I" AMPS
SQ. PI'. FLOOR AREA
S/SQ. !T.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 herchy air,. Nat I am exempt from the Coowcmrs License Law for the
TEMP. MEI T;R OR POLE INST.
following assume. (Section 7031.5, Business and Professions Code: Any city or county
which rcgm rs, a permit to construct, alter, improve, demolish, or repair any structure
prim eq
to its issuance,alm requires the applicant for such Pit file a signed statement
POWI?RDI%VICES
pnmuant m the provieinns of Ne Gmtrn:mrs License Law (Chapter
that he is nci ng withDivision 3eOfthe Professions Code)
Hadn.
man
SWIMMING POOL ELECTRIC
VALUATION
he is exempt therefrom =if exemption. civiny l violation of
or alleged exemptio
romans the harmstonbect. the
Section703man by anydred dollfar apermit subjectsoho npplicum mucivil penahy of
Section 70 exempt a, spot
OUTLETS - SWITCI BS- FIXTURES
not more own five hundred dollars yemp.
❑ LaownernDhepmpeny,ormyemployeeswith wages evheinolecampensatioa
NEW RESIDENT 'IAL F.LECTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will do the work,and the structure is not imendedorofferW forsle(Sec. 7044, Business
and Professions Code: The Contrictoes License Law does not apply to an owner of
I
property who builds tnimproves thereon.snd whodoes such work himmlforthroughhis
own cmployms,provided that such improvemenaae not intendedorofPoted forsle.If.
OCC. GROUP
RPS. UNITS
TOTAL:
however, the building or improvement is mid within one yearnfcompledon,the owner-
builder will have the burden of proving Nm he did tut build an improve far purpau of
QTY. PLUMBING PERMIT FEE.
dale.),
❑ I, as ownerafthe property, am exclusively contracting with licensed contractors to
ROOD ZONE
APN
answer the project (Sec. 7044, Business and Ponfiessions Code:) The Contractors
License Law does not apply to an owner of property who but Ids or improves thereon,end
PERMIT ISSUANCE
whoconbacts l'orsuch projects with a curnowar(s) licensed purmanOo the Contractors m Law.
Licen
pI:TER- DRAIN &VI?NT-WATER (EA)
FEB SUMMARY
❑ I um aatnpt under Sec. B A P C fur thio reason
SACK FLOW PRO'ITC9'. DEVICE.
" '
SANITARY Y_N
RECEIPTa
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑
Workera'Compensation Insurance or a certified copy thereof(Sec. 3800, Lab C.) which
FIXTURES-PI%R TRAP
RECEIPTp
PARK FEF. Y N
GAS - EA. SYSTEM -1 INC. 4 OfID.ETS
covert all employee's under this permit.
Policy N
RECEIPT a
BUILDING DIVISION PERS
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PL.ANCHECK TEE
❑ Cerifiedcopyisheubyfumished.
GRFASEIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION MOM WORKERS'
GREASETRAP
SOILS ITE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2WFE
ENERGY FEE
(Ilii, sectionneed not he completed ifthe permit is fosse hundred dollars(SIM)
or less.)
WATER HEATER W/VENT/F.LELTR
I certify that in the tarfotmunct, ofthe work for which this permit is issued, l shall
not amploy any prom In any mmner so as to femme auh,lucl to the Workers'
AID
Cnmpenxntinn lows of California. Date
Appltcunt
WATER SYSTEvIRRI?ATING C.
Data RecciptN
NOTI CE TO A PPLICANT:If, after making this Cenilicdrof Excoriation, you should
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
became subject It, the Worker's Compensation provisions of the Labor Code, you must
comply with such provisions or this permit shall be deemed evoked.
BUILDING ME
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm th on. is a canmuetion lending agency for the performsnce of
the weak for which this permit is Issued(See3097, Civ. C.)
I' /^
ELECTRIC FEE
Lender's Name
I
QTY. MECI'IANICAL, PERM IT PER
PLUMBING FEE
Lders Addmse
en
I certify that 1 have read this applici amen mJ state tout the some information is
sect. l agree to comply with all city and county ordinances and state laws relating to
PERMITISSUANCE
MECHANICAL FEE
building construction. unit hereby authoriu representatives of thiscity to enter upon the
i hovcmcntitmed progeny far inspection purposes.
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Catarina aglnst
es, costs and expenses whichney in anyway accrue against said City
Ilahiltticstjudgmnt
AIR HANDLING Ilbfii. ,old CPM)
emo,cruecmTtbcgmni If of this nett.
GUNIT LOVER to,"CW)u
EXHAUST HOOD fW/DUCI)
PAID
Signa reol pbcant/ ontractor
HEATING UN[t(TO I(Iq BTU)
HAZARDOUS MATERIAL DISCLOSUR s
Date Receipt N
HEATING UNIT ( F. 1 h TO)
AL:
Will the applicant or future building occupant store or handle hazardous moil
as defined by the Cupertino Municipal Cade, Chapmr 9.12, and the Health and rely
VENI'ILAT 'A GEE RCSID)
Cah, Section 25532(87
❑ Yes ❑ No
WIII thcepplicantorfuwmbuildingwcupmo useeyuipmenturdevica whichcmit
I eR C P(31IP OR 100,0008
QSJUfNCE ATE
i/
ILER- COMP(OVE 1 ,IXgB
hazaNnua air cnntominmts as defined by the Bay Area Air Quality Management
District?
❑Yes ❑ No
saU,s-
-CY YflVtl 12
1995
EW RESID TIAL. SQ. FT.
have read itsmaters is nual order
1 hove rend the huruNaus materials requiremcros under Chapter of the
lune,lan6.95 o
x//.1111
ys '1�, / 1
Sa1I T Uf-
Califo l'ety Coda .25533 amu that
LUN EHI1N
if the building Boca not currently have a tenant, that it is my responsibility to notify the
ecupant or the requirements which must Its, met prior to issuance of a Certificate of
Occupancy.
ISSUED BY:tI� _
Owner or mithoriuJ agent Date
TOTAL:
OFFICE