25291 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO TTILDR-O-hLEU MIC'. PERMITNO.
APPLICA'T'ION/PERMIT PLUMBING-MECHANICAL. /�5^/N
BUILDING DIVISION BUILDING PROJECT'IUEN'I'IFICATION L J L y
BUILD NG ADDRESS:
_ZA 19�7 4- , 04/ C 4 VAE SANITARY NO. APPLICA'DONSUBYTTAL DATT
`k G H NE UNITM F LOT
OWNERS NAME: PI{ONE: CONTR CfOR'S NAME; LIC NO:� )ate NIC CONI'ROLp�RCHITI:Cl/FNGINEER: LIC ADD O: Z2023 S:
CONTACT PHONE: s '
b3-z�n 4y
�gg 'ry )t{JAEPERMIT
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rose ❑ BUILDING PERMITINFO
a _5S"IffiO YC% .
BLDGLD0 ELECT PL MyCH
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PERMITISSUANCE IJr /I/ebAF-
LIC ENSEDCONTRACTORS DECLARATION pPPLIANCFS- ID I TOB DESCRIPTION
C=Z lonchyaffi an that l am licensed underprovisions of Chep¢r9(commencing with
P0[0= 5eC11011 ID1)0)nI Dlvlsi 3ol heBusiness and Prafe,sima Cooddee,and my license is In pp
ty V U TUR force and effect 3oq 3 1 D O
Fy W Liccnse Cl e s Lic.M tt
yQy Dom Contractor aG 47NJ 201 MPS
1-yZ —ARCHITECTS DECLARATION O AMPS SQ.FT.FLOOR ARE SISQ.IT.
70,,_ I understand my plans shall o used m public records.
Fj
$ Sot 2,3g
$i✓y hiccmW PndwsionW 3 ELH 1
"=W6 OWNER-BUILDER DECLARATION SP C.
xOs. 1 hereby affirm that 1 sm exempt from the Cmaractofs License Law fm the
413ay following reasam(Scnion]OJLS,Business and Prmfcssiona Code:Any city or counry TE R POLE INST.
�u,uO which....nOs a permit m contract,one,,improve,demolish,or repair any structure
yr43a� prior to its issuance,also requites the applicant for such permit to file a signed statement PO DE
W�' O that he is licensed pursuanno the provisions of the Contractor's License L,w(Chapter
Q
X. 9(cmnnteneirg with Scctior](mE of Division Sof the Business and PmCode) SWIMMING POOL ELECTRIC VALUATION
W_,, or that he is eaempnhcrefmm and the basis for the Nleged e.emption.Anyvioletion of OUTLETS-SWITCHES-FIXTURES
L F G Section 7031.5 by any applicant for.permit subjects the applicant to a civil pcnelty of
520 not mom than five hundred dollars($500). NEW RESIDENTIAL P,LECIR S .FT. �
� ❑ hasnwncndlhcproperly,mmycmpl9yxswith wagcxnsthcireolecompensetion, Q n ST'1\R "YPI'. (J(1(Y UCI'ION
e.3— will do the work.and the structure isnot intended mofferai forsale(Sm.7W,Business 11 n 1 j � 'J\
and Professions Coe:The Commerce's Licenae Law does not apply to an owner of
property whobuild,or improve,toman,mdwlmdoe...ch work hintwlfor thomgh his iOJ p �TES4;U�'ITS
ownemployms,providedthat such imprnvcmentateenot intenddeorofferedfoisale.If, J
however,the building mimpmvemern is mldwithin one yearofcompletiun.theowner-
builderwill have[be burden of proving that he did not build or improve for purpose of
ote). rv..
❑ 1.wownerofthcpmpeny,amexclusivelycont tingwiNlicenxdcontfactonto Ql'Y. PLUMBING PERMIT FF, PN
onetract the proicen(sec.7844,Business and Professions Code:)The Cmntrecmra
License Law does not apply man ownernfproperty who builds or improves thereon,andPERMIT ISSUANCE -
whoconimnaforsuchpmjmiswithaconuactor(s)Iicmn punuattotMCmn dors
License Inw. ALTER-DRAIN&VP1JT-WATER FAA) FEE SUMMARY
❑ [am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dote DRAINS-FLOOR.ROOF,AREA.COND. RRCEIPI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
"❑ I hereby affirm that l have a cenificme ofconscrt to self-insure,or a certifies¢of FIXIURES-PF.RTRAP RECEIPT#
�.Workeri Cnmpensetion hssuancemecenifiW copy thercuf(Sw.3gW.1sb CJ which �� PARK FEE Y N
meas all employee's underthis pt.i,. GAS-EA.SYSTEM-I INC 4 01IILETS RIiCCIPT#
Policy# � BUILDING DIVISION FEES
CnmpanY GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK PEE
❑ Cenificd copy is hereby furnished.
❑ Cenifiedcopy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE '
C17RTIFICATE OF FXEMPTION FROM WORKERS' GRP-ASETRAP SOILS FEE 0 "�
COMPENSATION INSURANCE
(Dtissection need not o completed ifthe permit is for one hundred dollars(S100) SEWER-SANITARY-STORM EA.2001T. ENERGY ITE
n leas.)
I certify thmin Ne performanceofthework forwhich Otis permit is issued,l shall WATER IIHATER WIVENT/ELF.CTR
not employ any person in any m as to become subject to the Workers' PAID
Compemation LnwsmCelifarm.. Dam so WATER SYST'EM/fREATINC Date Receipts
O z Applicant
z 2 NOTICE TO APPLICANT.if,der making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Workces Compensation provisions of the Labor Code,you must
funbwith comply with such previsions or this permit shall be deemed revoked. BUILDING FEE 2.
a (� CONSTRUCTION LENDING AGENCYSEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of
u O the work for which this permit is issued(See 3097,Civ.CJ ELECTRIC PEE L.
Lenders Name
O U Lender's Address QTY. - MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have readmit application and state that the move information is
>" Lk7 c rrect.I agrce to comply with all city and county ordinances and state laws relatingm PERMITISSUANCE MECHANICAL hf:1i
(•-' building construction,and hereby authonaa representatives of this city to enter upon the GONSTRUGDDN TAX
V z uovcmcnliunul"misery for inspection puHnses. LTE-RORADDTOMECH.
(We)agree m save,indemnify and lose,harmless the City of Cupertino against
es.judgments.matsand cxpcnaeswhichmayinanywaymenneagairrawdd City AIR HANDLING UNIT(TO 10,000 CFM)
inco equmceofthegantingof ' permit.
AIR HANDLING UNIT(OVER 10,tt10 CFM)
Sign r<mf Applicvnt/Cumractn Date EXHAUSTHOOD(W/DUC)
PAID
I1AZA SMATF.RIALS DISCLOSURE IIEATING UNIT(10 imulaI BTU) Date Receipt#
Will the applicant or future building occupant store or handle hasallous mammal HEATING UNIT(OVER IpO.UD)BTU)
as defined by the Cmrr inn Mamci}+a 1 Code.Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)4 / VENTILATION FAN(SINGLE RFSID)
❑Yes C9 0
BOILER-COMP(311P OR 1011.000 BTU) ISSUANCE DATE
Will thcupplluvnmr otos huilit M by he Bay equipment Quality arnlipemlt q A g�
arallou.a wr comaminamx m defined by the Buy Arca Air Quality Management BOILER=COMP(OV13R I W,IXIp BTU) P_ {J
a
Viet] ❑Yen NEW RESIDENTIAL MECII. SQ.FT. ®C{,/1
j ,a 19931 have read the huanlous matmiah,requirements under Chapter 6.95 of the G R a
�
California Health k Safety Code,Sections 25505,25531 and 25534. I understand that /�
i1'the buil di ng docs not currently have a tenant,I hat it is my responsibil ity to not i fy the CI r (Jr
mcup mine requirements which must la,non prior to issuance of a Cenifieate of ('L'f-Ciy I Ily
sees mtcy jrjY,
Owneror flmnzrd agent DD**m 'A.: ISSUEI]BY. `-t/aw(M1 1