25177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO mDING-RLE PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MRCIIANICAL 25177
- -BL(U)ING PROJECT IDEN'1'IVICAT'ION -'
9UILD[GAD 051 \ C UNIT# 1.0110
SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS PHONE: COS A B: LIC NO:
a— NIC CONTROLp
RCN 1'E T/F:NGINEFR: LIC NO: ADD ESS: ❑
coNTACT: PHONE: §lS3:GYYk', :} BUILDING PERMIT INFO
F,EECTRIC PERM IT' FEC
G4�. L. ►�$ `� 1g ♦l 2YT "
PERMIT ISSUANCE LOG T PLUMB MECH
Ni
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-REBID L OB DESCRIPTION
no&Z, Ihereby affirm dmJ am licensed underpmvisionsof Chapmr9(co mcingwiN
[000 Section 700d)of Division 3 orthe Business and Professions Code,and my license is in PANELS
Iy61C ml l force and effect.
F UUZ CCLLJJ Licence Class Lie.# UPT0200 PS
y=y Dam Contractor 201 I PS
zOo, ARCHITECTS DECLARATION V AMPS SQ.FT.FLOOR AREA VSQ.IT.
O Z—O 1 undersmnd my pinre shall be uxJ us public records.
Qua I.icensedprofessionel mom1
L OWNER-BUILDER DECLARATION PECIA U �� r
FXO U 1 hereby uffirn that I um exempt from the Condition License Lou for the
W following Mmnn.(Serfom?031.5.Business and Professions Code:Any city or coumy TEMP.M TE IE INST.
ti.QJ which requires a Permit to Conswct.Aller,improve,demolish,or minor any srue—
!>} prior In its issuance,won myvires the appliewo harsher Permit file asignedvatemem POWER D CES
-CY<Oz that he is licensed pursuaul to the pmvisions of the Contractor's License Low(Chapter
axa eLL 9(commencing with Section?")of Division 3ofthe Business and professions Code) SWIMMIN6 POOL ELECTRIC 1
8/� VALUATION
W_rn roa
that he is therefrom and the basis for the alleged exemption.Myvioledannf OUTLETS �
CSection7031.5 by any applicant for a permit subjects the applicant oa civil peelry of `/n `Gv
not more than five hundred dollars($500).
ClNEW RESIDENTIAL ELECfR _SQ.F1'.I,asownerofthepropeny,mrmyempinyeeswithwagesm(beirsolecompensadon, STORIES TYPECONSTRUCTION
d _ will do Nework,and theslrucwmis not imendedoroffered forsale(SCcJ0C4,Business
and Professions Code:The Comrsctors License Law does not apply to an owner of
propeny who builds or i mp roves Merton,and who does suc h work hi mself or through his
empinyecs,provideJ NntxuchimprovememsnrcnotimendedoroffereJ forsale.If. OCC.GROUP - RES.ONI'TS
however,the buildingor improvement is sold within one year ofcompletion,drowner- T AL
builder will have the burden of moving that he did net build or improve for purpose of
sale.) auk r !. s f r . . x g}e*
[1aso
I, woerofthe propeny,smexcluxively contracting with licensed contractors to Q 'n. PLUMBWG-PrERMIT N2 h,f ERE, FLOO ZONE APN
o ilo.,the project(Sec.]004,Business and Profesvons Crdr1 The Contractor's PERMIT ISSUAN✓=E
License law doos not apply oar owner o f propedy who bui lds or i m proves da mon,and
who contracts for such projects with a conmamr(s)licensed pursuant o the Contractorsp1.TCR-DRAIN&VE WA R f"
License Law, (' ) FEE SUMMARY
❑ I am exempt under gee. ,B&P C for this rcawn BACK FLOW PROTECXW.Vka b I T I E F RC
RY Y—N
-
DRAINS
Data DRAINS-Fl.00 ,ROOF. ND. RF.CEIPI'#
WORKMAN COMPENSATION DECLARATION OL TA yN
❑ Ihereby nffrm that lhave acertifiwm of console to self-imum,ora cenificamid FlXI'UREg-PER RECEIPT#
Workers Compensation Insurance or Acenified copy Nemo((Sa.3800,Lab C.)which PARK Y_N
covers dl employee's under Nis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS R EIPf#
Policy# tlU1LDING (VISION
Company GAS-EA,SYSTEM-OVER PLANCI{ECK PIoL O
❑ Comfieicopyisherebyfumished. -
❑ Camfiadcopyis filed with On, inspccdon division. GREASFANDUSTRLWAST'EINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This lection neM rotbecomplemd ifthe Permit is for one hundred dollars(SIM) SEWER-SANI'T'ARY-STORM EA.200FT. ENERGY FEE
or less.)
l codify that in the performance of the work for which Nis permitisisstud,(shell WATER HEATER W/VENT/RLECR
not employ any person in any manner so as In become subject to the Workers'
Cnmrn
psation Lawsof Califorom. Date WATER SYSTEM/TREATTNG PAID
Z - D Rcceiptp
Applicant
O0 NOTICE TO APPLICANT:If,after making this Cerificao of Exemption,you should NEW RESIDENT IAL PLMB. SQ.IrL :
O] become subjectto flue Worker's Compensation provisions of the Labor Code,you must TO'fA
a ; foMwidt comply wide such pomnliorr or this pemdt shall be decreed revoked. - BUILDING -aI
Lla Q CONSTRUCTION LENDING AGENCY SEISMI
Z I hweby affirm Nnl,hem iso construction leading agency for the performance i f "L91 I
V O the work for which this permit is issued Star.TN],Civ.C.) TOTAL: EL IC IEE
Undies Name
0 Lendcra Address Q yMNC,IANICAL PERIv11T' t a A; *,"+3�FEC PLUMBING FEF:
I celvfy that I have read Nis app]cm un and xum Net the above nfomuoon a, ° 'c
4 correct.I agree to comply with all city and county ordinances and sum Iawsm1,1ngto PERMIT ISSUANCE MIiCHANICALI :E
building viamm don,and hertbyamhodm repremwdvesnf Nis dtyornmrupon Ne
L) Z alnve-mentioned pmperty(or inspection puryoees. ALTER OR ADD TO MECH. CONSTRUCTI TAX
(We)agme m save,indemnify and keep harmless Ne City of Cupertino against
0abilitiw,judgme 1,cosuamdexpemes which may in any wayucerueagainnsaid City AIR HANDLING UNIT(TO I0,0(0 CFM)
in consequence ry# grnn'mg nf`iL _
1 `` 'f' Y —& (
, ?s�'7 AIR HANDLING UNff(OVP,R IO.ap CFM)
Srgnamreof AppbcnnVContmnor Date EXHAUST HOOD(W/DUCU
PAID
HAZARDOUS MATERIALS DISCLOSURE HFATING UNIT(TO 10.0110 BTU) Dm Rmcipt#
Will the applicant m future building cam,nm sort or handle Idowdo is ma end
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health unit Safety HFATING UNIT(OVER 100,000 BTU) I-:
Code,Section 25532(x)?
❑Yes 0N VENTILATION FAN(SINGLE RESID)
Will theupplicamorlature buildingoccupanmscequipment ordevices which emit BOILER-COMP(3HP OR 1(1(1,000 BTU) IS ANCE DATE
hazardous air earthw rens as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(101 BTU)� g�g iut8ct? 13 Yes ❑No P A D
NEWRESIDENTIAL MECfI. gQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the As�� ��
ifthe uil ing dh s Safety Code,have
a s 25505,23533 and 25534. 1 understand Nat S p
ifthebui8ingdoesnot curCWl .Sveamnamt,5,it is my 33md25omsibilon tonmtity the . y
ccupum of the rcquiremems whicM1 must be met prior to issuonce of a Certilicam of "Nn /T
Occupancy. CITY y;`, uv
Owner or auozed agent DateISSUED BY:,