25968 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPERTINOB I.DI -b...,T .RICA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDF.NFIFICATION 5 C O
J v o
BUILDING
ADDRESS: �s �n �7, SANITARY NO. APPLICATION SSUUR�MyjPTAAL DATE
1 I(/-7 6. Dr–Amr–A rJ�Vp• UNIT# LOT#
OWN S NAME: u ` PHONE: CONTRACfO NAME r ��I� C� N/C 1,CONTROL///p
RCHITECT/FNGINF.ER: LICN AD to 'ETI DJ Tl
ZAV ^ / 0 7�p L/
CONTACT: PHONE: Y/ BUILDING PERMIT INFO
//��,,�(/� /J r1 J QTY. ELECTRIC PER T FEE BL
%I✓�J (i4 I. 41 PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RPSID L / LOB DESCRIPTION
pyt, Ihereby affirm that l am licensed underprovisions ofail'ter9(commencing with
FJ OO Section 70007 of Division 3 of the Business a d Pro easioas Code,and in license is in PANELS
1Fa–WV full fotrc and effect.
nse /T )
LiceCl77���� Lic.N UP .2-g1A
ComruD 201.1 MP •�1— 'F
1–yZp V�,// ARCHITECTS DECLARATION O 1 P SQ.ET.FLGO R REA WSQ.FI'.
zo�W Ion wed my plans shell be usetl as public records. SI S E CAL ��Z
6 gwa Licensed Professional OWNER-BUILDER DECLARATION 1 CIRCUITIMI.
CXOd1 hereby affirm that I am exempt from the Connector's License Law for the
W 3 wt; following reason.(Section 7031.5,Business and Professions Code:Any city orcounty TEMP.MC •R OR
L E�ON; which requires n permit to cnnitrun,alter,improve,demolish,m repair any swctum
�;!(}� prior to its issuance,also requires the applicant fm such permit.file o signed suement POWER DEVICES
��4O the he is licensed puuuanuo the provisions of the Contractors License Law(Chapter
y q� SWIMMING LE ,-S
LLo 9(mmmeis exemith Section ZDndfee Division 3 aIle Business and Professions Code) �Zj VALUATION ,,``U
XW�an onhet he is exempt therefrom uW Ne bazis for Ne alleged exemption.Any violedon of OTL 5-S HLS-fl DRE$ ' J � ' � ' V
�ZQSection 703 L5 by any applicant for a permit subjects the applicant a civil pemalty of J
$ not in.'ban five hundred dollars($500. T ' 5 .FT.
Cm [II.mownerofthepr ,ty..,.yemployceswithwegesm,heirselecempensation, NEW RESIAL ELE Q TORIES TYPE CONSTRUCTION
will do the wmk,and th. uause is not handed.,offend for.1c(Sec.7044.Business
and Profe-mr.Cade:The Conwcur's License law does nm apply a on owner of
property who buildsorimproves thereon,and whodoes suchworkhimselfor throughtis
ownemployces,pmvided'hntsuchimpmvementsmmtinmnd oroffeudformic.IL G– GR Tj' S.0 Tg
however,the building miorprovement is sold withinoneycuofcompinion.the owner- TO
builder will have the burden of proving that he did not build or improve for purpose of
fie')' QTY. PLUMBINGPERMIT FE DQD ON APN
❑ I.as ownemdtheproperty,amexeWsively contracting with licensedcont.ctors to LII
construct the project(Sec.7044,Business and Professions Code:)The Cinnamon's PERMIT ISSUANCE TE '
Licenmf
selnwdoesnotepply toanownepropenm y whrbuilds improves themorrand
who contmc's for sack pmjects with a contractor($)licensed pursuant.the Contactors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Oa. DRAINS-FLOOR;ROOF,AREA,COND. RECEIPT
_ WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm Nat l have o certificate ofconsenuo self-houde,ora ceni0cmc,of FIXTURES-PER TRAP RECEIPT#
Workera'Compenmtion Insurance or a verified copy theenf(Sec.3800,Lab CJ which PARK FEE Y N
coven all employaa under this permit. GAS-EA.SYSTEM-I INCAOUTLETS
OUTLETS RECEIPT X
Policy# BUILDING DIVISION FEES
Company GAS-RA.SYSTEM OVER 4(EA) PIANCHECK FEE Cff-If
r
❑ erified copy is hereby furnished.
enified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
C17RTIMCATC OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Cons section aced not be completed if Ne permit is for one hundred dollars($100) SEWER.SANITARY-STORM P.2IXIFT. ENERGY FEE S0,
or less.)
I certify that in the pertorrandoofthe.,itfar which this permit is issued,].hall WATER HEATER W/VENT/ELECTR
not employ any Person any manner so as.become subject to the Woriand No PAID
Compensation Lawsod California. Data WATER SYSTEM/TREATING Data Receipt#
Z Applicant h
z Z
NOTICE ican TO APPLICANT:IL nfaftermking athis Certificate of Exemption,your should NEW RESIDENTIAL PLMB. SQ.FT.
�+ f/] become subject to the Workers Compensation provisions of the Labor Code,you mus'
t' fmtbwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE / r9�
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm don the.is is construction lending agency for the perfomunre of
U O Ne work for which this peanut is issued(Sec.309],Civ.C.) T ELECTRIC
Lenders Name
U !enders Addrns QTY." MECHANICAL PERMIT FET: PLUMB, 1
U 1 certify the'I have read this application and sate than the above Lmmmation is MECH A 'F.
cancel. Iagsecm y ith all city and county ordinances and state laws relating u PERMIT ISSUANCE
ybuilding cams tion,and eseby malroriumptesenlatives ofthis cityso cmdrupan the C04MUCVONT
U z
diicox�
nedpmpe for'mspe ion par ses. ALTERORADDTOMF.CH.
toe e,in auif d k p hum s the City of Cupertino against
gore costs despn to ichrm a my way acerueageinst said City AIR HANDLING UNIT(TO If."CFM)
f the ga ng of
AIR HANDLING UNIT(OVER I0,000 CFM)
Sign raid ApplicarWContuctm 'Dad, EXHAUST HOOD(W/OUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100000 BTU) Date Receipt p
Will the applicant m fold.building occupant sure or handle haaardaus materiel
as defined by the Cupertino Municipal Cade,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)? -
El Yes 11 No VFJJTILATION FAN(SINGLE RFSID)
S C DATE
Will the epplicantmfuture buildingaccupantusecquipmenmrdeviceswhichemit BOILER-COMP(3HP OR 1(0,00 BTU)
Judaism,air communion;as defined by the Bay Are.Air Quality Managemem BOILER-COMP(OVER 100.000 BTU)
El Yee ❑No FEBNmin? NEW RESIDENTIAL MECH. SQ,FT. EB 11994
1 have read the Fuurdaus materials«quiremenu under Cheptcr 6.95 of the CIT;3:OF ! UPF-h I IN(
Colifn has.
Health&Safety Code,&ctiom 255a5,25533 and 25534.1 understood Nat CITY VVapnmrynifydooccupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Oncrinmauthmi.ed agent Da. L: ISSUED
OFFICE