25435 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINODIcuINr.-11 . PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 25435
BUILDING ADDRESS::: SANITARY NO. APPP+LIIC/ATION BMITTALDATE
✓ J UNIT# LOT#
y( /U q 3
OWNER MF:: HONE �� C ' CfOR'gNv EO LIC NO% UIl 1
NIC CONfROLa
ARCH]ITiCT/ENGINEER: LIC NO: ADDR ❑
s r
CONTpaT: PHONE: - 4' BUILDING PERMIT INFO
QTY. ELECTRIC PERMI FEE
BLDG LECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-TUERDWAL LP JOB DESCRIpypH. -
Qwz I hereby effort that Iamroof
licensed under pvisionsChapter9(commencing with
FY�N10z,0y) Suloo ]0 )ofDv' J of the Busines ad R ((ss!ions Coe. d my licenx is in PANELS
bE full frceandefe
it
Lice. Cl Lic.# d IIP T0200 a' sV�
m« Dam Conbacmr IOQP AMPS
F,z ARCHITECPS TION SQ.FT.FL RAREA S/SQ.FT.
z Ori'0 1 understand my plans shill h seed u public records. VE AMPS S� �a
<coP4—SEi] NS ECfR AL
Qy2
'� I.ic<nvcd Professiorul
W,Y�� OWNER-BUILDER frmEC Contractors
S CIAL CIt
NNIt.t; 1 hereby mf that 1 war,U.exempt from the Contractor's License Law for the'
toy following rcuon. ermlion 003 L5,Business e. end a..de nif Code:My can mouct a TEMP.METER R MST.
W M>o whichrets unto a permit m ro o;the,alter,improve,demolish,file
repair any awmuro
Y� that he
islissuan«.olsore,to
theapplicantof thesuch CopenrdOo License
La smmmmt POWER DEVI
y�j 6p 9(cheis licensed pursuanttotheprovisionsof the Ce Business
Lianse Lown.Culler
Y(commencing with Smfion]0)0)ufDivision 3 of the Business end Professiam Cade) SWIMMING POOL ELECTRIC VALUATI
JW�m or that he is exempt hemfrom and the basis for alleged exemption.Any violation of
�4� Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of OUTLETS-SWITCNFS-Fl%Tl11tE5
not more than rive hundred dollars($500). PT.S RESIDENTIAL ELECIR .
K� w C3I,mownaroftheproNe y,ormyemployeeswithwagcsmtheirxlecomNmabon, NEW Q STORIES TYPECONSTRUCTION
a w111dalhework.mdlhesmclumisnollmmndWmoRexdfmule(S«.]BM14,Busfntes
and Profusions Code:The Contractor's Liceroe Law does not apply.an owner of
property who builds or improves thereon,and who does such work himselfor through his O G OU NITS
wnemploym.p videdrhmsuchimpmvemernsuenotirnmdedmoffexdforsale.If.
however,the building or improvement is sold within one yemnfcompletion,theowner- '
builder will have the burden of proving that he did not build or improve for purpose of - r
sale.). QTY.' PLUMBING PERMIT FEE D .O - N
❑ Les the project
(Sec. ny,701am exduss and Pridessicur C de:)The Comctarslo „W.. . _,(.,w'
amwm the projut(Sec.n an o Business and y whosims Code:)The mencon,anc
License Law does not apply menownerofpropeny whobuildsmimproveasherem,and / PERMIT ISSUANCE {DIE
whocomracts fresuch proj.m with.com emodid Ilcensrdp.....ine Cormicmrs ofLicense Loss ALTER-DRAIN&VENT-WATER IEA) FEM- MMARY
❑ 1 am exempt under Sec. ,D&P C fm Nis reason BACK FLOW PROTECT.DEVICE OITISID -
SANITARY YN
\ Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
WORKMAN COMPEJJSATJON DECLARATION SCHOOLTAX Y N
I herebyaffirm that l have a cerificam ofcomenuo self-imum,or a cenificamaf FIKTURFS-PER TRAPRECEIPT#
mken'Compensation lmurance me cmificd copy thereof(S..3800,Lab C.)which PARK FEE Y
coven ell employee's under ii a i1 RECEIPT#
P GAS-EA.SYSTEM-1 INC.4 0OfLETS BUILDING DIVISION
Policy p
Company GAS-EA.SYSTEM-OVER 41EA) PLANCHECK FEEslit
❑ Cenife copy is ercby famish
rq IL
Nrl CeoifW copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING ME
/ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbe completed iflne Permit is for one hundred dollars(S100) SEWER-SANITARY-STORM EA.200PT. ENERGY E
or less)
I certify that in the performance of the work for which this Permit is issued,i shall WATER HEATER W/VEJJT/ELECIR
not employ any Person in any manner an ao to become subject to the Workers' PAID
Compensation"wsof Califomia. Due WATER SYSTEWME,TING Dam Receipt#
O z Applicant
zz�-1 0 NOTICE TO APPLICANT:If.dmr making this CeniBcate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
C` rn become subject.the Workers Compensation provisions of the Labor Cade,you muse
forthwith comply with such Provisions or this Permit she11 be deemed revoked. I BUILDING FEE
nWi Q
CONSTRUCTION LENDING AGENCY SEISMIC FEEblic—
Vz 1 hereby affirm Nm there u e co.wction lending agency for the performance ofELECTRIC FFP
Q the work for which this permit is issued(Sec.309],Civ.C.)
r lender's Name
u. {" Lenders Address QTY.. MECHANICALPERMIT FEE PLUMBING FEE
0
0 V I certify that I have read this application and slam that the above infonm6on is a MECHANICAL FP.E /a
correct.Iagrecmcomply with all city end courtly ordivn«s end stem laws relating to PERMIT ISSUANCE. rG
ybuilding concoction,and hereby authorize rcpracnmtivo impost city mentor upon the CONSTRUCTION TA
V Z above-mentioned prop,ny for inspection pmpwes. ALTER OR ADD TO MECH.
(Wo)agree to save.indemnify and keep hmmlus the City of Cupertino against
liebilities,juJs gra ts,ensu andexpenses which may inuny way xcmeLgeinis aid City AIR HANDLING UNIT(TO 10,000 CFM)
in can q� flhe moor thiy.fte ---^ r// � AIR HANDLING UNIT(OVER 10,000 CFM)
i °
Signammof ApplicantlCmamaxr Det, EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T0100,000 BTU) Dam R eiptIt
Will the applicant orfumm building occupant store or handle harardous material HEATING UNIT(OVER 100,0010 BTU) TOTAL-:
as defined by the Cupenim Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)?��_�,,,,____////```` VENTILATION FAN(SINGLE RFSID)
❑Yes '74. - 1 UANCE DATE
v Will the applicant or future building«cupurn use equipment mdevi«a which emit BOILER-COMP TRIP OR 100,000 BTU) � A � D
hazn.ons air contaminants as defined by the Bay Arca Air Quality Management BOILER-COW(OVER 100.000 BTU)
District?
❑Yes -- No NEW RESIDENTIAL MSCI I. SQ.FT. AUG 1 p s„__
1 have read the hazardous materials mi iiremem %Z3
s under Chapter 6.95 of the s e
California Bearish&Safety Code,Sections 25505,M533 and 25534.1 understand that coV
ifthe building does not currently have a tenant,that it is my responsibility. Ery m, Vf �V�CrI111Y
«cupanl of the rc Is which..in be met prim 1°issuance of a Ce fc of
Owner or emhonxJ egcm Pat, 31 TOTAL: ISSUED BY:
O