25364 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIJUJJAIINU-l rRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING.-MECHANICAL,
BUILDING DIVISION BUILDING PROJECTIDENT'IF'ICATION 25364
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMfITALDATI
2l0" 2 TF_,1rP 2:? �3
UNIT'of LOTp
HERS iA%F:: � � PHONE: CONTRACTOR'S NAME: NIC CONTROL It
xRCHI'1'EC'1'/LINOONF.IiK: LIC NO: ADDRESS:Jp N� �J G�ril
V ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L F PLUMB MECII
PERMIT ISSUANCE /�
LICENSED CONTRACTOR'S DECLARATION y El
APPLIANCES-RF,SIDENTIAI
OKZ (hereby effimtthatlam licensed underprovisionsofCbapmr9(armmcncingwith JOB DESCRIPHON
FF100 Section 7")of Division Sof Ne Business and Professions Code.and my license is in PANELS
W full force and effca. a
Fj Licen Clats_��Lic.p f� iSA 7 UP TO 200AM ,
m=y P Commetar 201-1IXpq fl
ZQNZ ARCHITECTS DECLARATION 0 R pS SQ.Fr.ITO RARFi $/SQ.FT.
OZ—C) I understand my plans shall be used as public records.
r-nt 1 CIRIC
QY7, Licensed Pmfessiamtl
all
Ewy< OWNER-BUILDER DECLARATION SP:CIAL CIRCUI !
XOiU I hereby affirm that I am exempt from the Contractors License Law for the
tn3n-rat fullowingreasoa(Semion]03 LS,Business and Professions Cade:Any city or county TEMP.METER OR POL ST.
F'a so which respires a permit to consmn,eche,.improve,demolish,or¢pair any swmure IVq'
,WYE priortois,iomaree,alsmm,nes theapplic tfmrsuch permiao flea signedsmtennom POWER DEVICES
WK<O that he is licensed pirsuonuothe provisions of the Cmarecho license Law(Chapter
aX°� 9(commcneing with Section 7000)of Division 3 of the Business and Professions CadSWIM1IMING POOL ELECTRIC e) A TT
W_y or that he is excmpuhcrefromandihe basis for thcallegcd exemption.Any viclationof
FZY Section]031.5 by anyapplicant for a permit subjects the applicant too civil pewlty of OUTLETS-SWITCHES-FIXTURES
AZO¢ not more than five hundred dollars($500).
K F-o ❑ I,aauwnerofthepmpe y,ormyemployceswithwagesastheirsolecompensatlon, NEW RESIDENTIALELECIR _SQ,FT. STORIES TYPECONSTRUCTION
y3°.° willdaahl,wark.and thecae Contractors
Laos rdosenntappy.7044,Buainea
and Professions Code:The Convectors nd who Law dces not appy
m w owner of
owncrywhobuildslirimprova Hereon,and who aressuchwork aroffiforthroughhis
empinyeea.pmvideJ thauuch improvements are not imm�ded mrofferea fmsole.lL OCC.GROUP NES.UNITS
however,the buildingor improvement is sold withinroe yearn
earofcamplebon,theowner- A
builder will have the burden of proving(list he did nor build or improve for purpose of
sale.),
❑ I,as owncrofthc property,am exclusively contracting with licensed commemorator QTY' PLUMBING PERMIT FEL FLOODZONE ppN
consumer the project(Sec.0044,Business and professions Code:)The Contractor's
License Lowdoes not apply to an ownero(property who buildsm improves Nercon,and N PERMIT ISSUANCE
whonammcm forsuch projects with a cornmetons)licensed pursuanuo the Contractors
License Low. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ lam exempt under Scc. ,B&PCfor this reason BACK FLOW PROTECT.DEVICE. OUTSIDE TEES
e c Owner Dam SANITARY y_N
WORK MAN COMPENSATION DECLARAtION DRAINS-FLOOR,ROOF,AREA,COND. RF,CEIPT#
SCHOOL TAX Y N_
❑ Ihmebyansaiihatlhavnceor aficnified pythe sf(Seeure,orace C.)wld of
Wmkcn%Com FIXTURES-PCR TRAP 'E I'l'M
covpeyee'snler this ecord. ified copy(hereof[Sec.3g00,Lab C.)which pgBK SEE - N
cry all employee's under pl,onit. GAS-EA.SYSTEM-I INC.4 OU'IT,ETS EIPI'N
B' ,DIN DIVISIO
Co.,.,CmGAS-EA.SYSTEM-OVER (EA)❑ Cenifed copy is hereby famished. ( PL H .KF
❑ Certified copy is filed with the city inspection division. GREASWINDUSTRL WASTEINTERCEPTOR G ADIN FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF,ASETRAP OILS FE
COMPENSATION INSURANCE
(This section need not be completed (the permit is formal,hundred dmllan($IW) SEWER-SANITARY-STORM EA.20BFE GY 'E
or less)
I cl,nify that in Om perfmmnmeeof(lie work for which[his permit is
do[,hall WATER HEATER W/VENT/ELECTR
not employ any person in any moaner so as to become subject to the Workers' ID
zCompenwuon Lnws of Culifomiu. Dat (I
e WATER SYSTEMREATING
Apolicwt Date RecciptM
O
z O NOTICE T'O APPLICANT:If.after making this Certificate of Exemption,you should NEWRESIDENT[ALPLMB. SQ.IT.
F .-i become subjecno the Workers Compenm(ion provisions of be Labor CoL.you..It TOGA
7 forthwith comply with such provisions,or this permit shallbe deemed revoked. BUILDING FEE
g Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ih,mbyaffinn(hatthe,,isaCmnarnelimn lendingagcncy forth,performance of
L) O the work for which this permit is issued(Sec.3097,Civ.C.) (TO'I'A . ELECTRIC PE
Lender's Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING E
CIa 1 certify that 1 have read this application and state that the above information is
H4. comet.[agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICA FEE
rn buildingeonsvuction,and hereby iuNonze opresenmtivesofthis city to enter upon the
V Z move-meminned property finneseCtion purposes. ALTER OR ADD TO MECH. CONSTRUCT[ NTAX
(we)agree on save,indemnify and keep hartnlas the City of Carolinian ugainv
liabilities,judgments,costs and expenses which may in any way imemewgaimtaaid City AIR HANDLING UNIT(TO 1Q000 CFM)
in conscyuence of the gmming of this permit.
71Z-^ AIR HANDLING UNIT(OVER 10,0110 CFM)
tgnamre of Applican4Cenaa ate EXHAUST HOO13 W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1W.000 BTU) Date
in
Will the rpPlicanl(it future building mcupam store or handle hazardous material
as defined by the Cupertino Municipal Code,Cheerer 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T
Cala Section 25532(a)'/
E)Yes 11 No VENTILATION PAN(SINGLE RESID)
Will Oheapplicamorfuwrchuilding occupmu useequipmemordeviceswhichemit BOILER-COMP(3HPOR IM."BTU) ISSU CEDATE
hazardom an arnluminente as defined by the Bay Amo Air Quality Management BOILER COMP P A
Disvie,7 (OVER 1w,"BTU) A
8 ❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT. JULve mad the hazardous materials mcluiremems under Chapter 6.95 of the _RISI
Califamia Health&Safety Code,Sections 25505,25533 and 25534.I undcmtand thPYat a
if the building does nm currently have a mnam,that it is my respensibility to notify the
umeupant of the napircmenm which must be met poor m issuance of a Certificate of
Orcnpwey. CI/ 1y
ur (i✓JFr-
Owner nr amhonetrillium Date
TOTAL ISSUED BY:
OFFICE
r