25961 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '- � PERMITNO.
BUtt.DING DtVIS10N APPLICATION/PERMIT PLUMBING-MECHANICAL n C al
HUILD PROjEC'r IDENT5IFICATION L 1
BUILDING ADDRESS: @�(������y�.\ SANITARY NO. APPLICATION SUBMITTAL.DATE
�OW �0 V/*'-�"� - UNITg CfOLOT#
O 5 D ONE: C R'S NAME: LIC NO:
a S{^ NIC CONTROLn
�ARCHMCT/ENGINEEU .LIC NO: DURESS:
Z!�AC.�s� I7P �T7��K8O El
CONTACT: ^an�HBr� � �,. ,i. „•-4 Y C PERMIT. FEE '`> BUILDING PERMIT INFO
/R ` 7 �- HIM FI ECj PLUMB MECH
sr PER 1 ANCE 25— �K A
LICENSED CONTRACTOR'S DECLARATION IANCES-rfliftlifiAL
KZ TOB DESCRIPTION
I hereby affvmthat l sat licensed underprovisionsof0hapter9(commencing with
00
Section Division Sof the Business and Pmfessiona Codmandmylicenseism PANE (fir
y�W{--; full tome and effe t.
QZ`Rf Liccnse Class Li c.N � �•T8 UP 2 PS 1 1
ti G o- Date Cortme 1- AMPS z�
ZOIrtra3 AR ITECTS DECLARATION V 1000AMP5 SQ.FT.FI.00 AREA S/SQ.ff.
O Z^q -- I and a be uud an Public records.
2-y m - IGN58LHCIIFICAL
Q4U Littns Pro es nil OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
%Oy 1 hereby affirm that 1 am exempt from the Commerce's License Low fore
m 3 LL oP4 following mama.(Session 1031.5_Business and Professions Code:Any city mmu TEMP.METER OR POLE MST.
C��:S which requires a permitto construct,alter,improve,demolish,or repair any structure
HNtyprionmuufl
}7 its issuance,Msorequites the appliesmfor such peo easigned statement POWER DEVICES
�pjCOp that he is licensed pursuant o the provisionsof the Conlrectter's License Law(Chapter ALUATION
dyo� 9(cununencing with Section]OW)of Division 30fthe Business and Pmfeuiom Code) 5 MMRJG POOL ELECTRIC y
or that he is cxcmpt rherefromand the basicfor dowdleged exemption.Any violation of sl/�
CZQ Section 9031.5 by anyappiicant fora permit embjectsdu applicant wa civil penalty of LETS-SWITCHES-FIX9'URES
� q not more than live hundred dollars(3500). NEW RESIDEMIAL F.LECfR _SQ.PP.
yy ❑ I,asownerafthepropeny.ormyemployeeswithwagesastheirmlewmpensadw, STORIES TYPECONSTRUCDON
y3� will dothework,ande:The Curmactotimm�ense Law does not apply to
own Tress
and Professions Code:The Cnnmemrs License Trow Jas not apply to an owner of
property who builds m improves dtarwn,and who does such work Idmrelf m through his
own employecs,provided that such improvementsarc nmimendcd oroffered hassle.If.
OCC.GROUP RFS.UNITS
however,tMbulldingorimpmvementiswidwiNinoneyemofcompletism,theowner- O A ♦,
builder will have the burden of proving that he did not build or improve for purpose of
s Ie.).
❑ I,as owneroOM1e propeny,am exclmivdy contract gwith licenscdwntedamw QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and professions Cade:)The Contractors PERMITISSUANCE
Li cense Law does not apply to an owner of property who bui Ids m improv w Thereon,end
whocondo.'fersuch projects with acontrwou(s)licensed pursuant wthe Contracwrs ENG
('ALTER-DRAIN&VT-WATER
License low. ) FEE SUMMARY
UOT
❑ 1 am cxcmpt under Sec, B&P C for thio reason BACK FLOW PROTECT.DEVICEI 1
SANITARY Y N
Data RECEIPT M
Owner WORKMAN COMPENSATION DECLAUVTION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL.TAX Y N
❑ I thereby affirm that l have a certificate ofconsentto self-insure,or a cenificam of IgXT .PER P RECEIPfp
Worken'Compenution lnsumnce oracertifiedcopy lherwf(gce.38f1(I b ) ich. I 40UTLETS PARK FEE YN
RECoven all employee'under this permit. p....� //.\ BUILDING D VEI'ION FEES
Policy 4
n Y - �s/i G S 1EAlIS EM 4(EA) PLANCHECK
Cmiftedcopy is hereby fumiahed. J
❑ Certified copy is filed wiN Ne city tupection division. ASTE INTERCEPTOR GRADING FEVV
CERTIFICATE OF EXEMPTION FROM WORKERS'DATE - SOUS FEE.
COMPENSATION INSURANCE l
(This section need not be completed Brie permit is forams,hundred dollars(SIM) SEWER-SANITARY-STORM EA.200F1'. ENERGY
orlesa.)
Icmify thatm theperformanceofthc work fmwbich thispennit he issued,l shall WATER HEATER W/VENTILLECTR
not employ any person in any manner so as w become subject to the Workers' PAID
Compensation Lawsof Califrmla Date WATER SYSTEM/IRHATING Dale Re'
Oz Applicant
Z 0 NOTICE TOAPPLICANT:ILaBcr,making NisCmiflcawof Exemption,you should NEWRCSIDENTIALPI.MB. SQ.FT. TOTAL:
p3 become subject to the Worker%Compensation provisions of The Labor Code.you must BUILDINGI .E
forthwith comply wiN sucb previsions or Nis permit shill be deemed revoked. �a
/^a CONSTRUCTION LENDING AGENCY SHISMI F '
z I hereby amnn that there is a conawetion lending agnwy for On,Iffotmence of HLH
U Q mi
the wool,for which this pmt is issued(Sec.3097,Co.C.) f
D7 Lender'a Nems, - - Pl BING
0 Lmdera Address QTY•.r; MECHANICAL PERMIT FEE
1 certify that 1 have teat this stylish..and mate that the above information.ta[ Ls e..x`4"` A06—
Ccancer, legrce to comply with all city and county ordinances Moistens laws rclaingw PERMITISSUANCE CHANIC FEE
buimingconnrvetinn,and hereby auNoriss rtprcunutiv<aaf 0iacirywemmopon the CONSTRU IONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agrtt t vs,,indemnify and k«p harmless the City of Cupertino against 55 1
liabilities,judg ntv,costs
We nscs whichrear manywaya<emeagilmtsid Cary AIR HANDLING UNIT(TO 10,000 CFM)
in ronseyue of the Bmntin this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sig ure oOaG%HAUST HOOD(W/DUCOfApplicant/ ntdm
PAID
HAZARDOUS MATERIALS DISCLOSURE HHATING UNIT(7)D 10),000 BTU) Dam Receipt
Will the applicant or future building occupant store or handle haeardous material HEATING UNIT(OVER I BLOW BTU)
as defined byline Cupenino Municipal Code,Chapter 9.12,and the health and Safety
Cade,Section 25532py1 VENTILATION PAN(SINGLE RESID)
Cl Yew C1 No
ISSUANCE DATE
Will the eppliamorfmurebuilding occupant useequipmemordevicet whichemit BOILER-COMP(311P OR but"BTU)
hezardom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.0021 BTU)
ismct7
Cl Yes ❑No NEW RESIDENTIAL MECH. " SQ.FT. q�T
I have ressm ts
ad the hardomaterials requiremenunder Chapter 6.95 of the .41
California Heath&Safety Cede,Sections 25505,25533 and 25534.1 understand that /eM
if The building does not currently have etermnt,Thm it is my responsibility to nmify,The •I M
cupent of the requirements which must he met prior w issuance of a Certificate of �e CY
Occupancy.
Cly y
Owner or anthadssd agent Date ISSUED BY:
OFFICE //ryV