25869 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PIG•-'MECHANICALBUILDING DIVISION BUILDING PROJECT IDENTIFICATION PERMIT No.
2 J O C J
BUILDING ADDRESS: C.�PoaZT, JJ Ch �t-�. .s r SANITARY NO. APPLICATION SUBMITTAL DATE
Ioy34 E4sr tsTa�s D� (
UNITN I,OT# 1,,-qIy
OWN:RSNAME: PHONE: CONT CTOR'S NAME: LIC NO:
J i o MA2K 153-'1�IbO �ra.i I o lv�- NIC CONTROL#
�ARCHITECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERPT EEE BUILDING PERMIT INFO
LD E LT P U MIiCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-REBID
poll l hereby ofBnm thin Ism licensed mmn,rovinionsofChuptar9(commencing with JOB DESCRIPTIO
�00 Section2000)of Dlviston3 ofthe Businessond Professions Code,andmy licenseisin PANELS
CUF full force and effect.
FZu1 License Class Lic.4 UPT0200AMP5
u,<0- Dae Cmatmesor 201-1 x
/O"IK ARCHITECTS DECLARATION 1 PS, SQ,FT.F RAREA $/SQ.FT.
0 P_, 1 understaM my plans shall be used as public records. 4t./�JJx
LougZ �V
~YLou Licensed
Professional S NS CTRICAL
-Kcsa OWNER-BUILDER DECLARATION SP CIAL CIRCUR/MISC.
X06U 1 hereby arum that 1 am exempt from me Convectors License Lew for the
Fa 0 y following reason.(Section 7031.5,Business and Professions Cade:Any city m county MP.METER OR POU INST.
,� which requires a permit to convect,alter,improve,demolish,or repair any mucwrt
'uW�1YS prior to its issuance,also requires the applicant for such parmfuo file a signed statement POWER DEVICES
C DO Nat he is licensed pursuant io Ne provisions of the Cmtr of s License Law(abler
°d m 9(commencin with Section 7000 fDivision 3 ofthe Business and Professions Code SWIMMING POOL ELECTRIC
KCLL gni )n ) 17 V ATI N�
or thin heiscxcmpuM1erefrom and the basis for the all<gW exemption.Any violation of OUTLETS-SWITCHES-FlXTlBtES 1��1 �
Z Q Sectione Iran
by ivy applicant fore permit subjects the apPlicam m a civil penalty of �� L
X20 not m1. omn Evehupmr nallan(yempl an, NEWRESIDENTIALELECTR S .FT.
LY E_o ❑ oThe wnemnheproperty,urmyempendecswithwmlforstheiXce.comp.nsiness —SQ.FT. TYPE CONSTRUCTION
3n—° will Jo Thework,andthehe Contlsnotins kende Law
ntapply to anocLL owner
and Professions Cade:The Cmmreefmrs License Law does not apply to an owner of
property who bei Ida or i mproves thereon,end who docs such work himxl f or through hi s
employees,provided thaterelt improvements armor intended muttered forsale.If, OCC GROUP RES.UNITS
however,the bulldingor improvement is sold withinone yearofcompletion,theuwner- L
builder will have the burden of proving that he did not build or improve for purpose of
sale.). TY. PLUMBING PERMIT
❑ Las ownerofthe,ect(Smperty,umesdusivelycorofesiiosCorrectficamaxi
The Contractor's Q FEE FLOOD LONE APN
mend the project(Sec. no Business and ywhosinns Cale:)The Ccm n, is is
Licenselawdocs such poyro with mormactpeny whosed prow mpm the thereanand PERMIT ISSUANCE
whence Law.
such projects with aconwnor(s)Iicensed pursuantto the Contractor's ALTER EA FEE SUMMARY
License Low. ( )
❑ I am exempt under Sa. ,B ffi P C for Nis reaves BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF, COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that l have acertifcae ofcnnxnnoself-insure,on artificam of FIXTURES-PER TRAP RECEIPT#
Wo lam Compensation Insurance or a cenifted copy thertof(Sec.3800.Lab C.)which r .PARK FEE Y N
coven all employed a under this permit. GAS-EA WTE0.4
SM-1 INL I UIREC #
Policy# I BULGING DI ISI FEES
Company SYSP M-OVRr9A❑ Cenifiedcmpnherebyfaminhed. GAS T _
PLANCHECK FCE
❑ Certified copy is filed with the city inspection division. OREASM USTRLWkSt 1 RC1: OR GRADING FEE r"a
CERTIFICATE OF EXEMPTION FROM WORKERSGRA SE TRIIATEOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifihe pvocit is for one hundred dollars(TEXT SEWER-SANITARY-S'I'ORMEA.200FT, ENERGY FEE i
mless.)
I artily that in the perf.ce.fNe work for which This pc nit is issued,)shall WATER HEATER W/VENT/ELECTR
not employ any .on in any,manner so as to became subject ns the Worker' PAID
z Compensatioulawaof Califomte. Date WATER SYMbIr MATING Da cccipt#
Applicant
z O NOTICE TO APPLICANT:If.after making Nis Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT.PTOTA1.
' 11) became subject to the Workers Compensation provisions of the Labor Cade,you must
04 > forthwith comply wi th such provisions or this permit shall b<deemed revoked. BUILDIN
0. O CONSTRUCTION LENDING AGENCY SEISM rEE
5 z I hereby aft that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097.Civ.C.) TOT �# ELE RIC :E r�
Lender's Nam.
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
0. 1 certify that I have read this application and stain that the above information is
coned. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FE
F-' building convection,and hereby auNorice rryreaenmovesofthisclty to enter upon the
U z above-mentioned property far inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TA
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilid dm areclstsandexpenses which mayinany way accrve againa soilCityMVE��TIONFAN(SINGI
NG UNIT IQOIXI CFM)
yes Ne-graining of thin permit.
t££ // NG UNIT(OVER 10,W CPM)
it inn. .� Q I _a_"y-
Stgnumreo A mmmdor DateOD(W/DUCry
PAID
HAZARDOUS MATERIALS DISCLOSURE IT(TO IW,UW BTU) Dae
Will the applicant or future building occupant wore or handle hazardous material
as defined io the Cupcninn Municipal Code,Chapter 9.12,and the Health and SafetyIT(OVER 11X),0!1(1 BTU) q
Cade,Section 25532(x)1
❑Yes 0N N FANISINCLE RISID)
Will Ivor Coocminam. re building by'hentesu An.Aentmdeviceswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
azmdous ur cmntaminants as defined by the Bey Arca Air Quality Management BOILER-COMP(OVER 1010,00"BTU)
iuricu
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IT. ppi�pp pp
1 have read the fornicate materials requirements under Chapter 6.95 of the P A 9 D
California Health If Safety Code.Sections 25505,25533 and 25534. 1 understand that
it the building Nus not cunmly have.mmam.that it is my responsibility to notify the FEB
occupant of the requirements which must be met poor to issuance of a Certificate of E �(T�1 A
Oc.npaney. /� I v - 3 1s�7J/J�e4
Owner or amhonced agent Date 'TOTAL: 1$$UEDBYf r.`v'K T. Y )
OFFICE