25078 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOXI '--- AL PERMIT NO. n C 7H
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION - BUILDING PROJECTIDEN'12 5 0 1'IFICATION. '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
L d UNIT# LOTH 11 _M 13
OWNERS NAME: PHONl C TRACTOR'SNAME: LIC NO:
�t SfA'•^ . / / e D� NIC COM'ROL M
ARCH ]NEER:ag.J AZ Q ,Ce LIC NO: ADDRESS: ze ❑ 7
CIPHONE
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S.7Lo
CONTACT PHONC:
QTY. � ELECTRIC PERf . PeB - 'a BUILDING PERMIT
�g•INFO, -
T P- `.
Z PERMI'I'ISSUANCE BLDG
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENT'AQWz1. LOB OFSCRIPDON
FJ00 Ihereby vfirmtbal arri3.f be usinss and irofesions Code9nd mmecense ail. � �
u100 full burcemo)of Divisionlof the Business and Professions Code,and my license is in PANELS
FyZ full force and effectplfL
1F.44.. License Class Lic.p UP TO XNI AMP. or\ `
an 4 a Dae Convacmr III l 201-I" S
Fye ARCH[rECTVE 11 '
�� S mCLARATION SQ.FT.FL0OR AR11SoynyFT.
y A3 BA +V
�C Iundooand my plans shell be used n public records. T
n
pEW ICA1.
I.icensN Professional
LL G OWNER-BUILDER DECLARATION .P ,CIRCUI MI ��
1 hereby of Iran mat 1 am exempt from the Conaacmr's License Law for the
W 3C) following minor,(Section 7031.5,Business and Professions Code:Any city or county 1EIP.MEIL R INST
�J which requires.permit to conatruc6 alter,improve,demolish,or repair any awcwrc
;!(Y� prior to its issuance,aha requires the applicant farauch permit to rile a signed smtemem P) ER DB C '
W <0 the,he is licensed p........he Mvixim,id the Contmcmr'a License Low(Chapter SWIMMING LF. CIRIC
o•Lo�C 9(cammencing with Section T000)of Divixion3mf the Business and Professions Code) VALUATION
�-,Q nectar teisexempuherefrI and tM1a basis fnrthealleged exemant to Any violation of OUTLETS-SWIT IRS-FIXTURPS �� ^ n 1
CZY Sec' n]OB LSby anyappRcantfmapewit subjects the opplicum toecivil penahy of ("
�T. remnn five hundred dolle,s(E500). NEW RESID AL ELEM S .IT.
yy�`L'0 ownerofthe propony,ormyemploymswimwUmmtheirselecampensation, Q STORIES TYPECONS'IIIUCTID
y3. tlldo m•work,and the structure is not imembilaroffered forsule(See.7044,Business
and Professions Code:The Contractor's License law does not apply to an owner of
property whabuildsmimprovesthemm,andwhodoeuuchwork himmlfoechrough hia
ownemployms,pmvided that such improvementsare not intendeduroffered Russia.If, ry C .GH IJh 'S.0 ITS
however,the buildingor immoventant is sold within one yearofmmpleion,the owner. e. rn
builder will have the burden of proving that he did not build or improve for puryos of 1 +.
60
s❑)1,as ownerofthe progeny amexclusivelyrombacang with licensed contractors t QTY : > ' t .pLUMBING PERMIT • ' uVl D-. API
rnnsrcun the project(Sec.7844,Business and Professrovs Cade)The Conrtact
License Lawdoesnot apply loan vwnerofproperty whobuildaonmprovesthsovdd,and PERMIT ISSUANCE D TE
who contmetsforsuch projects with acmwat0r(s)licensed pursuant to the Conwcaoes ALTER C
License Low. (HA) FEE SUMMARYY-
❑ I am exempt ands Sec. ,B&P C for this rcosnn BACK ROW PROTECT.DEVICE a I'. R FE
SANITARY YN
Owner Dam RECEIPT#
tom' )j'S DRAINS-PLOOR,ROOP,AREA,COND. SCHOOLTAX Y_N_
WORKMAN COMPENSATION DIiCLARATION
❑ 1hemtyaffiwthat l have a certificate ofcousennoself-insure,me eenifita¢0f FIXTURES-PER TRAP RIiCEII"I'#
jkWorkero'Compansation lnsuranceor a cenifedeopy thereof(Sec.3800,Lab C.)which PARK F131: Y N_
l 88 it
Covera all employee's under this permit GAS-CA.SYSTEM-I INC.40UTLGfS RECEIPT#
til ''Policy# BUILDING DIVISION PEES
Company GAS-EA.SYSTEM OVER 4(PA) PLANCHECK FEF. 2
❑ Certified copy is hereby famished.
❑ CenitieJ copy is fled with the city inspection Aivisioo. GREASIVINDUS''I'RLWASTIi1NTERCePOR GRADING FEE
CER'I'IFICATE OF EXEMPION FROM WORKERS' GREASETRAP SOBS EEE ( e �.
COMPENSATION INSURANCE
(niliccumnnucd not be urmpleul iflhepewit is Racine hundreddolles(SIIX) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
mrlcss.)
leardlydim inthe permwanceofmewmrk forwhich thispermitis issued,lshall WATER HEATER WIVENryELECTR T,•f L�13
not employ any person in any manner so m m become subject to the Workers pplp 1 s L_5
z Compensation Lawsof Cvifomia. Date WATER SYSTEM/I'RE- TING Date Receipt#
7 37:9
Applicant
0 � NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
H .. heonmesuhjacuoahv Wvrkees Compensation pmvisim,. the Labra Code,you most
a ' forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PEE 181 /r
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the performance of
fJ Qthe work for which this pewit is issucd(Sm.3097,Civ.C.) L ELECTRIC FEE
Cooties Name ,<.-
0 F Lenders AAdresa t�TY. '*. J MECHANICAL PERMIT` x FFh yg PLUMBING FED.
L) 1 certify that I have read this applanation and state that the above information is kY f'"o t,_' :5
corral l agree in comply with all city and county ordinances and stale laws slatingto PERMIT ISSUANCE rat MECHANICAL PER
.Fi fA building construction,and hereby authorix spssenwtives ofthis caytoenter upon the
L) 'z aMrve-mentionul progeny for inapation purposes. ALTER OR ADD TO MECU. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of CuMnino against
liabilities,judgmcnts,costs madespensas which may in my way accooMainst svd City AIR HANDLING UNIT(TO 18,000 CFM)
in consequent$�'f the Rprumg of this K
`` i / _ _ e73;/Jr
y� AIR HANDLING UNIT(OVER IO,tI(p CPM)
St Aof ApphlccoutContmemr /,i/� ate C- AUST HOOD(W/DUCO a�_/s(M.PAID J_I`—`Ft��l—
I IAZARDOUS MATERIALS DISCLOSURE' HEATING UNIT(TO 100,000 BTU) Dmc Receipt
Will me applicant m future building occupant same or handle locations material HEATING UNIT(OVER 1 W,(gp B'TU) TOT L:
as defined by she Cupertino Municipal Cade,Cooper 9.12,and the Health and Safety
Code,Section 25532(0)^
❑Yea 0N VENTILATION PAN(SINGLE RESID)
BOILER-COMP CHIP OR 100,000 BTU) ISSUANCE DATE
Will the acomm mrfumrc handing by the useequipmir Quality sanagement r /F '
rmrd a pants as JefineJ by the Buy Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) #Y
/�r'ricR s air con ami
1 ❑Yes ElNo NEW RESIDENTIAL MECH.—SQ.Ff. NA Y /` 1993
1 have mad the hicousous materials requiremcros under Chapter 6.95 of the ,rI/j sY•Vf
California Healm At Safety Code,Sections 25505,25533 and 255J4.I understand ma CA 1,Ur
if the building does not currently have a tenant,that it is my expansibility to notify the ! VVrChI�
occupum of tile requirements which must he met prior to Isionime of o Conaficale of
Occupancy. /�/
Ownerm oolvnaedegant Date T ISSUED BY
t