25188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF'CUPERTINO 'BUM MIG- jVIC'TRICAL FERMI'I'NO.
APPLICATION/PERMIT r1.USIIIING-MECHANICAL. 25188
II UILDING DIVISION IUILDING PROJECT IDEN'e1FICATION
BUILDING ADDRESS: 22-337 SANITARY NO. APPLICA11O1N SURMIITAL.DATE
NIL Cl'rl UNITX LOT If
OWNIERS AAE: PHONE: CONTRACTOR'S NAME: LIC NO: hlO CONTROL#
` SI ZSZ- of OwYtct''
0 RCIfITECr/F: F..ER: LIC NO: ADDRESS: ❑
roNTACI: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PE 1 FEE
BLDGPLnB MUCH
PERMIT ISSUANCE ELE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-Rl- E AI.
mwz I hereby affirm that l mor licenaeduaderpowisionsofChapter9(commencing with IOtl UESCHII'1'ION
WOO Section]000)of Division 3 of the Brodressand Professions Code.and my license is in PANELS
��fF fullforec and effect.
QFZW License Closs Le. U 2 MPS
m=y Dam Coal.,, I 2( - AMPS I SQ.Fr.FLOOR AREA $JSQ.FT.
Fye, ARCHI rECI-S DECLARATION O IINIBA S
Oz— IundmmwA my plum,hull focused as public records. I /r.s � `foe
Frnt.41 IGNSE f`J 'V\�� Gam.,(
<��d Licensed Professional
�q==< OWNER-BUILDER DECLARATION SI'IECI I. IH lll'1'/M
pxx,O LO I hereby Orion thin I um csentpt from the Convector',License Law for dM1
al'3 LLy milowln Section?031.5,Basile,,and Professions Code:An t t TEMP. TER POLIS INST.
g reason h Y city orcounty y
f'.LLJco 4 which requires a pcmtit to consumer,alter,improve,demolish,or repair any soucturc
co
to its i antes,also re then cam for such tto file a signedstatement POWER DEV ICES
prior quires pp pract
'MO
Nm he is licenscJ pursuunl¢uhc provisions of the Contractor License Law(Chapter SWIMMING POOL ELECTRIC d a.P' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) VALUATION/'
w=m orthm he is esanpt theormenund the busix for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �••Y
L.za Section]031.5 by any applicant for a permit subjects the applicantto a civil penalty of
nos than five hundred dollars(55
—O mom an unred 110).
NEW RESIDENTIAL ELEM _SQ.PT. SIORINS TYPECONSTRUCTION
o' ce
❑ I,nsownerofshepropenY•mmYemplDyecawidhwugesaetheirsolemmpen,tion,
1'T— will do the work,and thesWsturc flood mtendedoroffcrtd forode(Sm.7044,Business
and Professions Ctde:'ITe Contractor's License Law does not apply In an owner of
property w lin bu it ds m improves Nercnn,and who docs such work himsel f or 1lvougM1 hi s
employees,pmviJM ahem such improvements urcnadinrended oroffered 6rsale.IL OCC GROUP HF3.UNITS
however,the building or improvement is sold within one yearofer mplemon,the owner-
builder will have the burden of proving that he did not build or improve for purpose of O L
'`ale')' QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ I,ssownerofthe propenY,mn<sdusivelycrnunning with licensed convenors to
ontmm the proles(Sec.7844,Business and Professions Coded The contractor's
License Lawdoes not apply wanownecrfpropenywho builds m improves Ncrcon,and PIERMIT'ISSUANCE
whommmcts for such pmjects with accommetor(s)licensed pursuant mthe Contractor s
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C fm this reasonBACK fI.OW PRO TEM.DEVICE. OUT>DI: � I S
SANITARY Y N
Owner Data DRAINS-I1.00R,ROOFAREACOND. RECEIPI'X
WORKMAN COMPENSATION DECLARATION , ,
SCHOOLTAX YN
❑ Thereby affirm thwlhnveatcnif¢'aide of cosset to self-insure,oracenificarc of FIXTURES-PIJiTRAP RIECFEIPTN
Workers'Compe,otion lnsnmaceorambifedeopy thereaf(Sec.3800,Lal,CJ which ARKIEE Y—N_
covers all employees under this permit. GAS-P.A.SYS'T'EM-1 INC.4 OU'1'LISfS RECHI I'lX
Policy If J BUILDING DdVISIOa TEES
Compony GAS-EA.SYSTEM OVER 4l EA) dMalpiK FEF.
❑ Cenilied copy k hereby famished.
❑ CenificA copy is fled with Nc city inspection division. GREASE/INDUST'RL WAS IF INTERCEPTOR ING FEE
CIERTII'ICA'I'IE OFfyiUMP ION FROM WORKERS' GREASETRAP SOILS FSI?
COMPENSATION INSURANCE
(This section need nm be completed ifthe pconat is for one hundred dollars($100) SEWER-SANITARY-ST ORM IEA.20(dFT. ENERGY IEE
ar less.)
I terrify that in the performance of the work for which this Mount is issued.)shall WATER HEATER WNENTAILECTR
not employ any pawn in any manner w as to boom,subject to the Worker, A
Compcnmtionl.awsuf Celifomia. Dme WATER SYSTHM/1'BIEATING Dam RociptX
Q z Applicant
z 2 NOTICE TO APPLICANT:It.after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
I" ^ become subject to the Workers Compenmtion provision of the Labor Code,you muss
forthwith comply with such Provisions or this pandit shill be deemed revoked. LDING IEE �
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby offirm that them is a construction lending agency for the performance of
V z the work for which this permit is issued(Sec.309].Civ.C.) TOTAL: IC FEE
Lender's Name
u' F Iendcrs Andreas QTY, MECHANICAL PERMIT FEE P1. B
V 1 canify that 1 have read this application and stare that the above information is IIANICAI.
W oared. I agree to comply with all city and county ordinances and Stam laws relating to PERMIT ISSUANCE
building construction,and hereby uniform representatives ofthis city to enter arsonists, 'IR UCfIONTA
V z above-beaioned pmperry for inspection purposes ALTERORADDTOMECIL
(We)vgrte to save,indemnify and keep limbless the City of Cupertino against
Iiabiliticsjudgmcnu.co..sts andexpcnws which may in any way ammougainstsaid City AIR HANDLING UNIT(TO 10,0010 CFM)
in wow fthia pertnid.
O AIR HANDLING UNIT(OVER I B4O1M CFM)
S' nnmrcn A s nI1 mrmb Dam (EXHAUST IIOOD IWNUQI]
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 11N),0001HU) Date Recetp#
Will the applic rm or future building occupant store or handle havardon,material
rix defined by the Cupertino Municipal Code,Chapter 9.12,and the Ileahh and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL-:
Coda Section 25932(x)'1 VENTILATION PAN(SINGLE RL'SID)
❑Yes ❑No
ISSUANCE DATIE
WilDhexpplicam or fummbuildit,cccupants,mprproveamdeviceswhichemit BOILER-COMP I314P OR I00,000 BTU)
sardous air cnntmninanD as defined by the Bay Arta Air Quality Management BOILER.COMP(OVER IW.WO BTU)
)itdcTt
Cl Yes ❑No NEW RESIDENTIAL MECIL. SQ.FT.
I have lead the hmardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand Nat
ifthe building docs not currently have a teren.that it is my responsibility to notify the
cupant of Ne rcyuirtnrems which mea be met prior to issuance of a Cenifiuue of 0
Occupancy. L'//y('
Owmeroramhorrzcdegent Data TOTAL: ISSUED B(r f
lNv