26990APPLICANT TO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B I,DI . - RICAL
BUILDING DIVISION APPLICATION/PERMIT B PLUMBING -MECHANICAL. BUILDING PROJECTIDNN'1IPICAL
PERMITNO.
6 9 9 0ON L
26990
IILDING ADDRESS: L►�'EE�SS:
1012-2, CoLAY -14V6// ivV E UNIT# LOT#
SANITARY NO.
AQPIACATIOONNNSSUUBBM�ITTyAALDATE
l��_ V_♦
5WIRS ME: NE—
U
CONTRACTORS NAME: a LIC NO:
wtj %7-
NC
❑
CONTROL#
AR CHITECTFNGINEER• L NO:
ADDRESS:
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BL ELECT PLUMB MECH
PERMIT ISSUANCE
11 0
LICENSED CONTRACTORS DECLARATION
Ihemhya Bisthatmu I amlicensedundernd Prifesofrs Chapter la, (commencing with
Section of Divis on 3 of 0m Business wd Professions Code, end my license is in
APPLIANCES -RESIDENTIAL
1 . ` JOB DESCRI ON
J
-!�`�
PANELS
full Pomo sand effect.
a sand
License Class Lie
UPT02W AMPS
�,a8
Date Contractor
VV
2BI-IIXXIAMPS
ARCHITECT'S DECLARATION
1 understood my plans shall be martins public records.
SQ. FT. FLOOR AREA
E/SQ. FT.
OVER I0J0 AMPS
SIGNS ELECTRICAL
Licensed Pro(essiomJ
OWNER -BUILDER
SPECIAL CIRNIT/MISC.
m the ORATION
from law for the
1 hereby effmt thin 1 am exempt Pram the Cocoons
TEMP. METER OR POLE INST.
Co s: An,
7031.5, Business and Professions Cods: Any city., county
whichfollowing uiresa(Section
repair any vrvuum
which requitesn p<omit m construct, da,p improve, h Permit to ammen,
its of
mqu the
permit to file.License
'
POWER DEVICES-
licensed pursuant the Co
of the Contractors Liccnu law (shaper
that he Provisions Law
Y(c.mmencing with Section 7") of Division3afthe Business and Professions Cade)
9 (c he is licensed puna do 7th.) of Division
SWIMMING POOL ELECTRIC
VALUATION
or that be is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any mpplieant far a Permit subjects the applicant m u civil penalty of
OUTLETS-SWITCHES-P1%TURES
not more than rive hundred dollars ($500).
❑ 1,mownerofihepropeny,ormyemployeeswithwagesastheirs.[.compensation,
NEW RESIDENTIAL ELECIR S
STORIES
TYPECONSTRUCTION
willdothe work, mathematician, is not immrdcdor.fl'eredforame(See, 7(J44, Businss
and Professions Code: The C.mran.ds License Law does not apply to an owner of
property whohuilds.rimprovea thereon, and whodu,simehwmk himselfonhroughhis
dcdo
ownhowever.
OCC GROUP
RES. UNITS
,v
T r
pletio ,threat.. r-
however. the Fun ding mden ofpmemissold a didnoneyear of completion, the owner-
the building rimprouchimprovementsarenayrour
builder will have the burden of proving that he did not buimmimprove for purpose of
QTY. PLUMBING PERMIT EEE
actle.).
❑ I,mowneroOM1e property,am exduxiv<lyconvectlng with licemedconomcsors to
Nssss. FLOOD 2oNE
APN
oosome, he project (Sec. 704q Business and Professions Cci'Me Cmara cur's
License Lawdmanot apply loan owner.fpropertywho builds or improves thereon,end
PERMIT ISSUANCE
whecaorwas for such projects with sectarianism) licensed pursuant in the Commemla
license aw.
l
pLTP.R- DRAIN &vFM.WATER (EA)
FEE SUMMARY
❑ I em exempt under Sec, , B & P C for this meson
BACK FLOW PROTECT. DEVICE
O 1
SANITARY YN
RECEIPT#
Owner Data
DRAINS - FLOOR, RODE, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
I hereby affnnthm l have a certificate of exorma mself-imme, ora certificate of
'�'em'CompcertifiedFlXI'URES
ensasion Insurance or a copy thereof(Sm. 3800, Lab C.) which
severs all employee's under this Permit.
Policy #
RECEIPT#
- PER TRAP
PARK FEE Y N
RECEIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM-OVER4 LEA)
PLANCHECK FEE
❑ Cerofied copy is hereby fumishW.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM F,A. 20(1
ENERGY FEF.
(this sermon need not becompleted ifthepermit is for one hundred dollars ($100)
or Iran.)
WATER HEATER W/VENT/ELECIR
I certify that in the performance of the work for which this permit is issued, l shell
not employ, any person in any manner so as t. become .object to she Workers
PAID -
Compensa,ionlawsofCalifomin. Dam
WATER SYSTEMTRFATING
Data Receipt#
Applicant
NOTICE TO APPLICANT-, If. after making thH Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject o the Workers Compensation provisions of the Labor Cale, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEF, ro
SEISMIC FEE `
CONSTRUCTION LENDING AGENCY
I hereby affirm the, them is a movemo on lending agency for the pafurmance of
the work for which Chia permit ie issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Leodcr's Num,
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Address
I certify shat 1 have mad ,his application and mutation the above information is
red. [agree to caa,ly with all city and county ardiumbers Indiana, laws noloan, to
PERMIT ISSUANCE
MECHANICAL FEF.
building comwction, and hercbyeuthorize mpresemasives.f this cirymcnnor upon dte
above-mentioned property for inspection purposes.
CONSTRUCTION TAX
ALTER OR ADD TO MECI I.
(We) agree to save, indemnify and keep harmless the City of Cup,nino against
liabilities,judgments, costs and expenses which may in my way accrue against said City
AIR HANDLING UNIT (TO 10/100 CFM)
AIRHANDLING UNIT(OVER 10,000CFM)
conseyue of grantingof,hi'permit. i, 21,
(awf•(y•(�,�
1
EXHAUST HOOD (W/DUCT)
PAID .
Signature of ApplicanUC.mrectter Date
HEATING UNIT TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt Is
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will the applicant or future building occupant store or handle hazardous material
ea defined by the Cupertino Municipal Code, Chapter 9.12, and she Health and Safety
VENTILATION FAN (SINGLE RESID)
Code, Section 33533(.)7
❑ Yes ❑ No
ISSUANCE DATE
Willtheappliwamrfumrebuilding.ccupantuue uipme tordeviceswhichemis
l,mlma, air commune aau as defined by the Bay Area Air Quality Management
,.,t? -
BOILER- COMP(3HPOR 1011000 BTU)
BOILER-COMP(OYER 100,000 BTU)
NEW RESIDEMDAL MECH.—SQ, FT,
,, ❑ Yea ❑ No
1 have read the hazardous materials re im emensa under Chapter 6.95 of he
SEP 12 1994
California Health & Safely Code, Sections 25505.25533 and 25534. 1 understand that
if the building does nes, cum en,ly have a normal, that it is my responsibility to notify the
occupant of the ax, imments which must be met prior to issuance of a Certificate of
CII r Vr "re ,fix•
Occupancy.
(�..�J) .�
ISSUED Byl; � a
Ownermindhoricalsi Data
�
OFFICE
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ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATION
VALUATION
BVILOING
U (J�
OWNER'S
NAPE
orvE
FEESUMMARY
BUILDING
ca MiRwcTOR s
xA E
LIC. No.
PLAN CHECK
FEE
CONTRACTORS
ADOREss
PHONE
SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP
ELECTRIC'^"
LIGHTING FIXTURES
PLUMBING
PPLIANCES-RESIDENTIAL
PANELS
MECHANICAL -
SIGNS
TOTAL
SIGNS TRANS.
SPECIAL CIRCUIT
EMP. METER OR POLE INS.
vBRMrr VALIDATION
P4 -1/®
ILEC).
MOTORS SEE FEE SCH.
SERVICE CHANGE /1
TOTAL
OTV. PLUMBINGPERMIT FEE
BLDG.
GE
PECK.
ALTER -DRAIN & VENT -WATER (EA.1
BACKFLOW PROTECT. DEVICE
r^%
b
DRAWS -FLOOR, ROOF, AREA,COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1
GAS - EA. SYSTEM-OVER4(EAl
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS- I INC 5 V.B.
LAWN SPRINKLERS - OVER 5(EA.)
SEWER -SANITARY -STORM EA. 200ft/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
PLIANCE
R HANDLING UNIT (TO IR
HANDLING UNIT IOVER 1Op00C.F.M.)
HAUST HOOD (WITH DUCT)
ATING UNIT (TO 100,000 B.T.U.)
R
ATING UNIT (OVER 100.NTILATION
FAN (SINGLILER-NNP13
H.P.OE 100,000 B.T.U.)
ILER-COMP 10W,, .
IOO,OOD BTUI SEE REE SCxI
_-
TOTAL