25548 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x ILDI -LLF.CTNI AL PERMITNO.
BUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, n [ C /I Q
BUILDING PR(3jEC1'IDENTIFICATION L J J 4 o
BUILDING ADDRESS: `` SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
O UNIT# LOTp
O 6RS NA/M!. Q� PIICQNJ'G4(TOR ^ NIC CONTROL p
NGIN LIC NO: AMpMRa4SM1M1//� O` ❑
fT: ,Mew 3
CONTACT: PHONE: BUILDING PERMIT INFO
M� QTY. ELECTRIC PCR I FEE
BLDG. ELECT- P B MECH
L PERMIT ISSUANCE I�rM(
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-R AL JOB DESC PTION 1-1
n Fdz I hereby offitm that am licensed underprovisions ofaspter9(commencing with
1400 Section of Division lid the Business and P scions Code,and my license is in PANELS �^
t Bl fullforea and anile ♦,-T11
aZ I,icen Lia.#. �"• UP T02
yQ
Data Cantrac�. 24'-1000 'S
=...TECTS DECLARATION O 1 MPS SQ.FT.FLOG PA WQ,FT.
Z O y a
OZ-0 I understand my plans shall W used as public records.
= N CTRICAL
License)Profexsinnal
6 OWNER-BUILDER the Con TION SP,CIALCIRCUIT
�HlU I hereby affirm that 1 am exempt from the Camases Co e:Any
Lew for the
30ot following reason(Section]031.5.Bminess and Professions Code:Any city or county P.ME O BIN
C �; which rryuires a permit to constmct,Wer,improve,demolish,or repairany suucture
$ro}2 primoiu issuance,also requires the applicant for such permino File n signedsmtemem POWE S
p0 that he is license)pursuanuothe provisiom of the Conwcmr'e Licenx Lew(Chepmr
d0.0ff 9(commencing with Section 711130)ofDivision 3 ofthe Business and Professions Cok) SWIM# ELE IC ��^ VALUATION —
yl❑y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of (07
not
tZ> Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLPTS- TCHPS-FIXTURES u
S�pQ not more than five hundred dollars($500).
t'•.0 NEW RESIDENTIALELECIA _SQ.FT. STORK TYPE CONSTRUCTION
22
C3I,uawnnoftbepmpcny,ormyemp]oyece withwagcsustheireolewmpeneetion,
a3will do Newark.Cde:The Cute'snot's License
La a does not
to an Business
and Professions Cale:The Comrumr's License Low does not apply m an owner of
pmpenywhobuildsor improver thercan,and whodaessuchwlMc himsdforthmughhis OCC.GROUP RES.UNITS
n employees,provided that uch improvements ate not intended or offered for sell'1 L
however.the building or improvement is sold within oneyear ofcompletion,theawner- TOTAL:
builder will have the burden affirming that he did not build or improve for purpose of It
rule.). QTy, I:UM G 8
ElLu ownerofthe pmpeny,aro exclusively conaaming wiN licensed conaacton to OD ZONE APN
P
mounter the project(Sec.7044,Business and Professions Code:)The Contracto's PERMIT ISSUANC
License Low does not apply m miAnerofpopcny whobullds orimpmvasthemeonand ( )
who contracts for such projects withamnvanods)liccnscd pursuant tothe Contractors ALTER-DRAIN&VENT-WATER(FA)iq, FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW ROTP. OUTSIDE S
ANITA YN
Owner DowRECEIFrp
DRAINS-FLOOR,ROOF.AREA,CORD.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX V N
❑ Ihertby affirm thmlhave e<Mificate of cansentroeelGinaurc,o..ambficturof RECEIPTp
FIXTURES-PER TRAP
Worken'Com nsntiu9j �p��nifiW copy thereof(Sec.31m).Lm C.)which PARK FF.E Y N
coversPolicyp1c &sf J`+- /' GAS-EA.SYSTEM-I INC.4000."S RECEIPT'k
///�'[[GG�R X77 !� BUILDING DIVISION IEFS
Company nils !_' s GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKFEE
❑ fwtified copy is hereby furnished �+v
Ri"Cenifted copy is fled with the city inspection division. GREASRgNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICA]'E OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not W completed ifthe permit is for one hundred dollars($HXB SEWER-SANITARY-STORM EA.200FT, ENERGY FEE
or less)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELEM
not employ any person any manner so as to become subject to the Worked PAID
Compemmionlawsof California. Dam WATER SYSTEMfTREATING Date Receipt#
0 Z Applicant
0 NOTICE TO APPLICANT:ILifter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
r7 y became subject to the Workers Compensation provision of the Labor Cade,you must
5 forthwith comply with such provisions or this permit shall W deemed revoked. BUILDING FEE
W 5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that theme is a construction landing agency for the perfosmonce of
V O the wok fm which this Fermis is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
Landers Nanta PLUMBING FEE
� U Lender's Address QTY. MECHANICAL PERMIT FEE
W I certiy that 1 have read Nis application and nam tMt the above information is MECHANICAL FEE
mrrcm. l agree to comply withal]city and county oninanecaand state laws relating m PERMIT ISSUANCEIrt
y bui]dingconwcdon,mdM1ercby authodu reprtsenutives of Wecity venter upon the CONSTRUCTIONTAX
(; above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
r
ee to save,indemnify ad keep harmless be City of Cmmino against
Iwbi]itin,judc
uses wh' manywryaocmeagainaseid City AIR HANDLING UNIT(TO 10.000 CFM)
nconmqueul th r g hie pe t. 04 L43
AIR HANDLING UNIT(OVER 10,001(i
Signaue of ApplicanVCommemr I D e EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt is
Will the applicant or furore building acceprnt store or handle Incautious materiel HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cala,Smlim 25532(n)]❑Ya o VENTILATION FAN(SINGLE REBID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will Ne upplicanmrV.MW!
gacupentuseequipment ordevicee whichemit P AID I py
hawdom sir co=m= d bythe Bay Arce Air Quality Management BOILER-COW(OVER 100,000 BTU) VDistrict] ❑Ycx NEW RESIDENTIAL MECH. 9Q.FT.
1 have mad the hazardous materials requirements under Chapter 6.95 of the SEP 14199
1. eaIth&Safety ale,Sec' ns 25505,255 sad 25534.1 understand dot y
"ifutobuirdin •m ¢nam,that i responsibility to notify the , 1silaUt"G11111 met e ort issu o coif o! V., D e TOTAL: 19SUEDBY
OFFICE