25138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOBUILDING-h. A. PERMIT NO,
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 25138
BUILDING PROJECT IDENTIFICATION
BUILDING AUpDRLSS: SANITARY NO. APPLICATIONSUBMITIALDATE
0I {0 I I IG✓G UNIT# LOTH
O ERSNAME: PHONE: CyON_TRAC(OR'SNA E: LIC NO:
O�Ot� K ZZav /,y (�� (� G 0 ZS NC +++acts CON TRDLN
RCHITECT/ENGINEER: LIC NO: ADDRESS:/ ❑ / O
SZ VYN Nf g 1_ ST SAI I L
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEC BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
' PERMIT ISSUANCE -00 1Q( JCI El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL /Ij 1-� JOBDESCRIPTIONDESCRIPTION
p4.Z I hereby mfimr Wan l am licensed under provisionsol'Chapter9mommrncing with
LL100 Section?B00)Of Division 3 ofthe Business and Professions Code,end my license is in PANELS
F-sD full form end effect Q�j O e
"I'm Isss Lic.# 1-I"A M 5
Dem �IG 20
ITECTSCTS D
F y ZDECLARATION O I P SQ.FT.FLOOR AREA $/SQ.PT.
Z0'- 1 understand my plans shall Is,toed mds
us public rtr .
Fy�'W -
Y�
Licensed Professional SE ICAL /
OWNER I Am emILDERm the CoATION S ,C CIRCU lfi�Jrz a a D
%OyF 1 hereby affirm that I am exempt from the Genion Cs Lodine law for she
W Eb 4 ma following mason(.it to mmama Business and improve,
de Professions Code:Any city .county P.METE E NST.
Fp to J which rcquims a permit do crnswch ober,improve,demolish,or rcpsir any swmurc
�jW V� priorto its issuance,also requires the applicant forsuch pednWo file aligned smmment POWER DEVI
�j�E<p That he is licensed punuens ro rhe provisions of B¢Commcmr'a License Lew(Chapter
4qC 9(commencing with Section 7000)o(Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC V ATION
ended he is emunInhemfrom and the basis for dia.1wged exemption.Any violation of2 . 00 11000
I-,¢ Seaton 7031.5 by any apili.ant for a permissubje,ta ds. pplica n I...vol penelry of OUTLETS-SWRC'HFS-FIXTURES
.SaS not more than five hundred dollars($500).
C� ❑ I.mrwnerofthepmpay.ormyempinyeeswithwagesmdheirwlewmpensation, NEWRFSIDENTIALELECTR _SQ.FP. r STORIES TYPECONSTRUCHON
y,q� will do the werk,andtM swcwre isnot imm.dedoroffered Roselle(Sm 2044,Business
and Professions Cade:The Corarmum'a License Law does not apply man owner of
properly whobuildsorimprovea Nercon,andwhodeassuch work Nmuifmthrough his
own employees,provided that such improvementsem not inters&dmof(eredformle.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within me you of compldien,the owner- TOTAL: .J
builder will have the burden of proving that he did me build or improve for purpose of
h).
❑ I,mowncrof the property,amexdusively conwming wiWlicemedconmonorsdo Qom' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Iawdoesnof apply wanownerofpropcny whobuiIdsorimprovesWercon.and
whommmctsforsuch projects withamntractods)licensed purman0o die Conmacmis ALTER License Law, DT WMA)) FEE SUMMARY
❑ 1 am exempt under Sm. .B&P C for this mason BACK FLOW PROTECT'.DEVICE DE FEES
SANITARY YN
Owner Dom DRAINS-Fl.00R,ROOFAREA, RECEIPT#
I' WORKMAN COMPENSATION DECLARATION , , . SCHOOLTAX Y N
❑ Ihcrcby affirm thatlheveecenifi<meof consenuo self-imurt,or am"ifcamof RECEIPTp
mpema
Nmker.'Cotion Insurance or acenifed copy thertoFE
f(Sm 3900,Lab C.)which FIXTURES-PER TRAP PARK E Y N
ECEIP
coven all employee's under this pcnnil GAS-EA.SYSTEM-]INC.4 OUTLETS RDIVISI I'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(FA) PLANCHECK FEE
❑ CertmedcapyishewhyfamiOcA
❑ Cenifed copy is fled with the city immudion division. GREASEflNDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is forone hundreddollace(SIW) SEWER-SANITARY-STORM PA.200FT. ENERGY FEE
o Tess.)
I cerifytht in the performance of We work for which this permit is issued,)elan WATER HEATPA W/VENT/ELECTR
not employ any person in my manner so As to become subject to the Workers' PAID
Compensation Lawso(Califonsia. Dam WATER SYSTEM/TREATING Dam Receipt-
#-zApplicant
NOTICE TOAPPLICANT:ILefier making this Certificate o(Excmptian.you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL: 16
IA become subject to the Worker's Compensation provisions ofthe Labor Cod,you muat
(onhwith comply witheuch provisions or this pmrmtshall be deemed Invoked. BUILDING FEE 2-S-0
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihembyaffirm monhem iso construction leudingagency,far the tomformunm.1' .Da
U O We work for which this pdmit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
LL PLUMBING FEE
F LendIA Amity
Address QTY. MECHANICAL PERMIT FEE
U I.edify that I have mad all application and sec¢That An abovews information is MECHANICALFEE
0. budding Iagrtcroon,comply
and with tllcirysad mpowerminamcmanddam lawerdatingw PERMIT ISSUANCE
building construction,and hereby auWorixe repmsrnmtivm of Nis city meb¢r upon the CONSTRUCTIONTAX
U .^7y i
ioned pmpeny for Tnspecumn purposes. ALTER OR ADD TO MECH.
agree m save,indemnify and p harmless she City of Cupertino against
dgmen .cmuandexpense h Wma 'a any ymcmeagainst said City AIR HANDLING UNIT[1'O 10,000 CFM) Licote aft Agranti o(Wie
spa AIR HANDLING UNIT(OVER M."CFM)
Sigmmm of AppiumnVCa wcam Iq
Date EXHAUST HOOD OVIDUCT) PAID ssr�?`gtl
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant inoMunbupdl Cash,ng Chaarat pter 9.12,
handle hawth Andilous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
os defined by the Cupertino Municipal Cie,Chapter 9.12,and the Healed and Safety e/
Cade,Section 25532(a)? VENTILATION FAN(SINGLE RESID) 8-
❑Yee ❑No
BOILER-COMP(3HP OR 100,001 BTU) f!AN fIbATE
Wd"heapplicanlnrfutumbuildingmcupant ueeequipmenmrdevicmwhichemit ,A 11 �L/
eardous air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(100 BTU)
strict? ElYes ❑No NEW RESIDENTIAL MECH.—SQ.FT. MAY ^2 R v 199QQ
3
1 have mad the hamrdous materials requirements under Chapter 6.95 of she f l
California Health&Safety Cade,Sections 25505.25533 end 25534. 1 understand that Vj11 VI ,Jr'CIIIIIVU
if the building does not currently have a tenant Was it is my responsibility to notify Ne
uccupunt of the mquimmen8 which must Ise mel prior to issuance of a Certificate of
Occupancy. .
Owam.'ruthodudagent Date TOTAL: ISSUED BY: VCLI