25928 APPLIMIT TQ FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
/ CITY OF CUPERTINOPLUMBINGI RI A PERMIT NO.
MECHANICAL
BUIIAINGIVISION APPLICATION/PERMIT tlU1LU1NC PRUJFCTIDENE
25928 J92o
45LDI'ND AODRF.55:^ I11SANITARY NO. APPLICATIONSUBMDTALDATE
{J /�� Ly� UNITM LOTgS AMI?: PHONE: C TRACfOR'S NAME: IC NO: 1
�:I a N/C CONTROLM
1 TE "INHIL �s LIC NO: AD F ❑
f , FI¢� sed
f' ONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
w BLDG E PLUMB MECH
tT� �. � PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hembyaffvn that l am licensed underprwisionsofClupter9(commencing with TOB DESCRIPTIONoy.woZt� Stmtiom 7")of Division 3ofthe Business and Professions Code,and my license is in PANELS
p(zr full force and effect.
H Li Lic.N UP T0200 AMPS /\LOOR AR
me Contractor 201-I"AMPS
,z Os-0 ARCHITECTS DECLARATION OVER 10010 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z—O I ondetsmnd plans shall be used as public records.
Fy W SIGNS ELECTRICAL
Q9�Q Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
N0.0.'' y V 1 hereby affirm that 1 am exempt from the Contractors License Law for the
W v_ following reason(Section 7031.5,Business and Professions Cada:Any city menthol, TEMP.METER OR POLE INST.
which requires o Permit in construct,alter,improve,demolish,or repair any structure
Prior to its issuance,also requites the applicant for such permit to File a signed statement POWER DEVICES
Wy,6O that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter i_
ayW 9(commencing with Section 7")of Division 3 of the Business and Pron VALUATI�{
fessioCode) SWIMMING POOL ELECTRIC G=/
y or that he is exempttherefrmm and the basis for the alleged exemption.Any violapon of OUTLETS-SWITCHES-FIXTURES I'� �a
rya Section 7031.5 by any applicant for a pernitsubjects the applicant w a civil Penalty of /—J/�/y V/�
c)
W
net more than five hundred dollar.($500).
C11,mownemfthepmperry,ormyemplo mwithwagesustheirsolecompenmsion, NEW RESIDfiMT1AL ELGCfR —SQ.Ff. STORIES TYPE CONSTRUCTION
p. will do the work,nnd the stnctuu isnot intendedmraffered foxatlif ec.7044,Business
and Professions Cale:The Contractors Liana Law does not apply to an owner of
property whohuildsmimpmvea thereon,sndwhodoessuch wnrkhimselforthrough his
ownemployms,providedthatsuchimpmvementsamnotintenddmoffemdforsale.If. OCC.GROUP RES,UNITS
however,the buildingor improvement is sold within oneyem ofcompletion,theowner- TO
JAW
builderwill have the burden of proving that he did not build or improve for purpose of
aide).
❑ I.a sownerofthepmperty,amruc
exclusivelycontting with licenced contractors m QTY. PLUMBING PERMIT FCE - MOOD ZONE, wPN
' conaract the project(Sec.7044,Business and Profeasiona Code:)The Contractor'sLicense Law dcesnrn npplyman owncrof property who builds orirnpmveiflaso ,and PERMIT ISSUANCE
whnemntmrtsfor auchpmjectawiNacmnuver.da)licemedpumuanuothe Convectors
ALTER-DRAIN&VENT-W TF ) FEE SUMMARY
License Law.
❑ 1 nm exempt unAer Sec. B&P C for Nis rcastm BACK FLOW PROTECT. E. OUTSID 'FS
SANITARY Y N
Owner DamRECEIPI'M
DRAINS-I1.00R,ROOF,AREA, OND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I.career,Co affirmthmlhrance or
camfie consenter of(See.38,or Lab C.)which FIXTURES-PER TRAP RECEIPI'M
mker'Compensation Insurance oracmifiedcopy Nereo((Bec.3300,Lab C.)which - PARK FEE YN
corn all employee's under this Permit. GAS-EA.SYSTEM-1 INC.4 01 IT RECEIPT M
Policy N BUILDING DIVISION RES
Company GAS-EA.SYSTEM-OVER 4 TA) PLANCHECK FEF,
❑ Certified copy is hereby furnished:
❑ Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING RE
CERTNICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FFA
COMPENSATION INSURANCE
(This section ned not be completed if Ne Permit is fmone hundred dollars($100) SEWER-SANITARY-STORM F.A.200FT. 1IGY RE
mless)
I certify that in the performance ofthe work for which this permit is issued.I mall WATER HEATER W/VENT/ELECfR .I
not employ any person in any manner sin as to become subject to the Workers Pr )
ZCompcnsation"waof Califomia. Dam WATER SYSTEMiTREATING Date Receipt
Applicant (
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
� , became subject to the Workers Compevmion provisions of the Labor Code,you must BUILDING RE
.. forthwith comply with such provisions or this permit shall be deemed revoked. I
(E. CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm Nat there is a construction lending agency for the performance of
O the work for which this permit is issied(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
Lenders Address QTY MECHANICAL PERMIT FEE 'PLUMBING PER
W I certify than I have read this application and stem thin the above Information is T MECHANICAL RE
>" a building Iagree mcomply
and wiNJlcity h and countyordinanceseeand state laws enter
gbe PERMIT ISSUANCE
U Z building construction.iianeand hereby
,ses1 duresates.vas ofthie cirymenmr upon the CONSTRUCTION TAX
L) z above-mentioned propertyfor inspection purposes. ALTER OR ADD TO MEGII.
(We)Mm udgmntsave,indemnify and keep harnalemy
the Cityz/VofCupertinoagainstCity
liabia ,judgmento,granand exp<nus which may in any way accrue minima said City AIR HANDLING UNIT(To IB,tNlO CFM)
in uenw of the granting of N' permit
AIR HANDLING UNIT(OVER IO,OIX)CTM)
Signmum of APPI'mNCon aim Dem EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt
Will the applicant or future building occupant stme m handle haurdous matenal
as defrnd by the Cupertino Municipal Cdr,Chapter,9.12,and the Health mrd Safety HEATING UNIT(OVER 100,0011 BTU) L:
Code,Section 25532(q?
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theepplicantnrfmurcbuildingmcupantuuequipmentordevicee whichemit BOILER-COMP(3HP OR 100,(KKIBTU) '
haaetdomair commutation as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,IXq BTU) A '
❑Vea CI No NEW RESIDENTIAL MEEfi. SQ,ff.
1 have reed the haurdous materials requiremems under Chapter 6.95 of the FEB 17.199
California HaaIN&Safety Code,Sections 25505,25533 and 25534. 1 understand that 4
if the buildingothe requirements
mentacurrently have which
m stbamho h is my responsibility oility m notify the CITY
occupant of the requirements which must stand.tett poor m issuance of it Cto nocam of CITY! u/-
Occupancy. VUr
Owner or emhodudegent Dam TOTAL: - ISSUED BY:
OFFICE