25441 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nLDINC.FITUTRTCA PERMffNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� 5 ^ ^
BUILDING DIVISION BUILDING PROJECTIDENTIF'ICATION L J LI 4
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
2- 014'1C 5T UNIT. LOT
OWNERS NAME: {� PHONIC: CON ACTOR'S ML': N -SZ LIC NO:i NIC CONTROLM
I
of ARCHITECT/ENGINEER: LIC NO: ADORES a W — Lel-5 a 4--rcG,
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIA JOB DESCRIPTION
CZ I hereby affirm that l sot licensed underpmvisionsofChapter9(commencing with
00 Section]000)of Division3 ollhe Business unQPmfusions Cate,and my license is in PANELS
p UE fullf .nd effect r t�JQ�r�
{mUyp aPOOL
se Clots Lic.p //)�� UP TO 2MA S
y 6 Date Contrunnr N lQ0.) 201-100l
=l4 ARCHITECTS DECLARA 10 OVERSQ.FT.FLOOR AREA
OO Z.N.,0 1 understand my plans shall be used as public recants.
rLr ,w SIGNS ICAL
ALicensed Professional
M< OWNER-BUILDER DECLARATION CIR
pXX'04F I hereby aRrm that 1 sot exempt from the Contractors License law for be
uI��Na following mason.(Section 703 L5,Business and Professions Coda Any city or county INST.
N J which requites a Fontan to construct,alter,improve,demolish,or repay any sanctum
WW�2 'do, its issuance,also rcquims the applicant for such permiuo fileasigned statement POWER DEVI E
,pJ'p py that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a KCLL 9(commencing with Seeder70W)of Division 3 odds,Business and Professions Code) SWIMMING LELE IC e� VALUAT12!p ►
m-„N er tlnn h70315b lM1ercfI uI finad the Permit suheallegedexempsnn.Aiviny tpern of LHfS-SW C -PERTURBS � ��
F 6 Section]031.5 by any.Pplicantfara Fannin subjecuthe applicentmacivil pevlty of sJ�.iV
nal more Ihan five hundred dollus(5500).
W ❑ I.asownerofthepmpny,ormyemptoyeeswiNwagesmtheirsolecompensadon, N 0.ESIDENTIA ELP,CI'R _SQ.IT. STORIES TYPE CONSTRUCTION
a3� willdoiheworkand NertrvclumisnmintendMaroffcredforsate(Sec.7o44,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
property who builds m improves thereon,and whodoes each work himself or through his
own employma,pmvided thm.such improvements menotimendedorofPomd foreale.If, OCC GROUP RES.UNI IS
however,the building or improvement is sold withinoneyearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
sale.).
❑ I,asownttofthepmpAy,amexclusivelycnnMclingwithlicensedcontrcimto QTY. PLUMBING PERMIT FEE Fl,OODZONE APN
onsa44
uct the Project(Sec.70 ,Business and Professions Cade:)The Comramors
License Lewd notapplytomown ofpropenywhobuitdsorimpmvests n,end PERMIT ISSUANCE
who contracts forsuch projects with acontmaa(s)licensed pursuant mthe Contmcmes
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
E] I am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE Y N
Owner Dale RECF.IPTp
DRAINS-FLOOR,ROOF,ARG,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm dust l have a cenificam almost m self-ireure,ors certificate of FlXTURFS-PER TRAP RECEIPT.
Workers Compensation lreurance or acetified0,copy lherenf(Sm.38Lab C.)which PARK FEE Y N
covers all ernployees undtt this permit. GAS-EA.SYSTEM-I INC. OUTLETS RECEIPT#
Policy. BUILDING DI IO FEES
Company GAS-F.A.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumished.
❑ CeniUed mpy is fled with the city inspection division. GREASBONDUSTRI.WASTE I RCEFfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASLTRAP' SOILS FEF.
COMPENSATION INSURANCE
(This section need not becomptetd ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-S ORM EA.200FT. ENE
or lima.)
Icertify that in the Performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/pt
not employ any person in any manner so as to become subject to the Workers' PAI
Compensation Laws of California. Dale WATER SYSTE1,bTREATING ate Bossing
0 Z+ Applicant
z Q NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ. TOTAL:
r 4 become subject to the Wmkels Compensation Provision of the Labor Code,you muss
> forthwith comply with such provisions or this permiireaft be deemed revoked, BUIL NG FEE
G (� CONSTRUCTION LENDING AGENCY SF MIC FEE
Z 1 hereby affirm that thea is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which his peanut is issued(Sec.3097,Co.C.)
� .y Undoes Name t LUMBING FEE
Q F Lenders Address QTY. MECHANICAL PERMIT FEL
U I certify that I have mad this application and sate that the shove information is
correct.I agree mcomply with all city uta county ordinances and state laws mining in PERMIT ISSUANCE CHANICAL FEE
Lo) building construction,and hereby auNmserepreseaudver ofdhis city matter upon the C STRUCI'ION TAX
U Z aMwe-mentioned progeny for inspection purposes. AUMRORADDTOMECH.
We)agree to save,indemnify and kap harmless the City of Cupertino against
IiaM1ilitics,judgmcnts,costs vnd espenseswhich may in any wayammeagairut.aid City AIR HANDLING UNIT(TO 10,000 CFM)
rnnmque I g ti of th pc
AIR HANDLING UNIT(OVER 10,00(1 CFM)
oe Signa VCmdrucmr V Dale // P.XIIAUSTHOOD(W/DUCf) PAI
HAZARDOUS MATERIALS DISCLOSURE handl
ABATING UNIT(TO 100,000 BTU) Date Receipt#
Willthe applicantin.M.or ei,i,.l Care,
9,nr and to Heardousntuenal HEAT ING UNIT(OVER 1011,000 BTU)
u defined by the Cupcnino Municipal Code.Chapttt 9.12,and the Health uW Safety
Code,Section 25532(.)4 VENTILATION FAN(SINGLE REBID)
ElYes ❑No
ISSUANCE DATE
Will theepplicnmor fnmrehuildingaccupnm usceyuipmenmrdeviceswhichcmlt BOILER-COMP(3HP OR IW,(gO BTU)
hou
DistNaus air contaminants u defined by the Bay Area Air Quality ManagementBOILER.COMP(OVER 100.000 BTU)
Dismict4
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A a
I have read the hazardous materials requirements under Chapter 6.95 of the
C.litomia Heellh&Safety Code,Sections 25505,25533 and 25534.1 understand that AUG q
if the building does not currently have a tenant,that it is my responsibility an notify the
rceupant of the requirements which must be met prior to issuance of a Cenificam of
Occupancy.
CI.
Owner or amhonred agent Dam TOTAL: ISSUED BY: