25859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB nt."'of.^.t'Te,rRICc' PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 25859
BUILDING PROjI?CI IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DA'IT
UNIT LOT# 1�2
I? SNAME: PI[ONE: C IRACTOM'S NA LIC NO:
G H a N/Cetot, CONTROL.q
�ARCI TECT/ENGINEER: LIC NO: ADDRES : wI ❑ .
CON'I'ACf: PHONE: I ' U
'rfs ` BUILDING PERMIT INFO
s.QTY. ELECTRIC PERMIT FEE
4B"-a2:11 c" BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLAMATION APPLIANCES-RESIDENTIAL
CetiIhacbyaffinnthat l am m
licensed under provisiormofChapter9(comencingwith 10B DESCRIIT N
�1300 Section 7")of Division 3 of the Business=it Professions Code,and my license is in PANELS ����
fan force and effect.
FZW License Class Lica UPT02MAMPS
w j y Dam Cmmmnmr 201-1000 AMPS S PT.FLOOR AREA $/SQ.PI.
'<Oy? -ARCHITECTS DECLARATION OVER I"AMPS Q
0 y_G 1 understand my plans shill N,used as public rxords.
w SIGNS ELECTRICAL
Qyy ,',j Licensed Professional .
KKw
Q OWNER-BUILD DECLARATION SPECIAL CIRCUR/MISC.
XOaU 1 hereby affirm that 1 am from
exempt from the Convacmr's License Law for the
wafwFi following mason.(Section 7031.5.Business and Profemions Cade:Any city or county TEMP.MIETERORPOLEINST.
which regaire.,o genas ro conswct,alter.improve.demolish.or repair any swcture
;!IY� prior to its issuance,aha requires the applicant for such permit to file a signed statement POWER DEVICES
w a:
a_n p that he is licensed pursuant m the provision of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC \\
dao 9(commencing with Secdon]OW)ofDivisian3ofthe Business and Pvfession Code) ^ \f' ,VALUATION. \
x_^,y
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
�yQ Seetion 7031.5 byanma
y applicant for ape n eahjemOUTLETS-SWITCHES-FIXTURES
athe applicant to a civil penally of \\
nut more than five hundred dollars($50(y. \
C F_C1 ❑ I,mownerofthepmpenY.Ormycmployee"withwagnmtheirwlecomp Pion. NEW RESIDFMIALELECTR S Q'PT. % F' PE CONSTMUCI'ION
a3= willdo the work,and the suucturc isnot intendedcroffervd forage(Sce.]Oaa.Business \
and Professions Code:The Contractor's License Law does not apply to an owner of P
property whobuildsorimpmvesiherron,and whodoes such work himxlfnrthrough his ,
mployees,providea Nro
at such impvemno
entsarel intended orofferad formle.If, HES.UNITS
e
however.the buildingor improvement is sold withinoneyear ofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for puspox of
PLUMBING PERMIT FEE IT.00D'l,ONE AYN
❑ 1,m owner of the propertam exclusively contracting with licensed QTY.contractors to
y,
oisttuct the project(Sec.70,P4,Business and Profession Code:)The Contractors PERMIT ISSUANCE
Li cenx law does not apply to w owns of progeny who bu ilde m improves therms,end
who commons for such Projects with a contractors)licensed pursuant to the Conusetors ALTER-DRAIN&VEST-WATER(EA) FEE SUMMARY
Licence Law.
❑ I an exempt under Sec.' .B&P C for this anon OUTSIDE ITES
BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Dam RECEIPT'S
DRAINS-FLOOR,ROOF,AREA.GOND.
WORKMAN COMPENSATION DECLARATION - SCHOOLTAX Y N
❑ Ihcrcby affirm that lhave ecertificate ofconsent to self-insure,oracenificate of PIXTURFSI'ER TRAP RF.CIiIPT'#
Worker%Compenwtionlnsumnceoracenifieacopythemof(Sec.3800jah Cd which PARK PEE Y N
cover"nl�C�d L RECEIPT"
Policy jff e�y O� GAS-EA.SYSTEM-1 INC.40IITLETS BUILDING DIVISION FE[S
Company// •`I GAS-EA.SYSTEM-OVER O(EA) PLANCIIECK MEC3Certified copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. ORE- SFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not M completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-S'I ORM F.A.200FT. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this Permit is issued.l shall WATER HFATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' -
PAID
Z Cnmpcncationlawsof Califerma. Date / WATER SYS'I'EM(IRFATING Date Rcccipt#
Applicant NEWRESIDE•NTIALPLMB. SQ.FT.
0 O NOTICE TO AP141CANT:IL Mer making this Certifinm of Exemption.you should TOTAL:
^ become subject o the Workers Compessation pmvisionsofthe labor Code,youmnt BUILDING HE
LU
forthwith comply with such provi"ions or this permit shall be deemed revoked.
LU Q F SEISMIC FEE
0. CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a mntructian lending agency th
for e prfmmmme of
TOTAL: ELECTRIC
U O
the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Namc D" PLUMBING IIiE H Lender's Address QTY. MECHANICAL PERMI'P FEE
U I cenify that I have rad this application and shote that the above information is MECHANICAL ME
>" crmid. lagrectocomplywithallcityemlmunty rrdithonces and state laws rehting to PERMIT ISSUANCE
F" a' huildingconstruction,and herehyumhorirc rcpresenmtiveaafthis citytoeuterupondre
N CONSTRUCTION TAX
V Z aMrvememionprogenyto,inanpurpose". ALTER OR ADD TO MECH.
Ve)agree e m"ave,indemnifyify and keep harmlcx the City of Cupcnino against
iahilit s,judg Is.c 1i uundcxp xsw ich may in any way accrveegalntsaid City AIR HANDLING UNIT(TO 10.0013 CFM)
n quem nihe 4.wing f spent AIR HANDLING UNIT(OVER IO,(IWCFM)
Signature of ApplicanUContmc r Date EXHAUST'HOOD OV/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,00)BTU) Date Receipts
Will ihcapplicamor future building occupantslmrc ser handle huxurdous material DEATING UNIT(OVER 100.00)B-I'U) TO'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)?
❑Yes El No VENTILATION FAN(SINGLE RESID)
BOILER-COMP PHP OR I0JOR0 BTU) P ISASU'NODE DATE
Will the ucamanuvfmu s building by the Bay Area Air Quality
Mwhich emit �/�
hmaMous air contaminants n defined by the Bay Arca Air Quality Management BOILER-COMP(OVER IW,000 BTU)
District? JAN 2
❑Yes 1:1 No NEW RESIDENTIAL MECH. SQ.FT. ¢ 1994
1 have mail the haumdon materials requirements under Chapter 6.95 of the /s rc JY
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that 4a1�Y UI' ka
if the budding does not currently have a tenons.that it is my xsponibilay to notify theLUNta l I INV
occupant of the requirements which must M met prior to issuance of a Cenificam of
Occupancy.
Owner or amhamd agent Dam TOTAL: ISSUED BY:
OFFICE