25044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ITfi:GIN7;-F: i A, PERMITNO,
CITY OF CUPERTINO rLUMB N MECHANICAL. n C O A /�
BUILDING DIVISION APPLICATION/PERMIT G J 4 4
111111.IIINO PROJECT II1RN'fIFICA'fION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMfrfAL DAPI;
S%%2Aa 'mow ' Q'r# 9-"E-A
OWN S ME: PHONE: CONT 'Tyl!!i D{f1 A}{y: _ LIC NO:
I✓��`/'/—/V� NIC CONTROL^per/
�RCHITF.CT/ENGINEER: LIC NO: ADDRESS: ❑ V
wNTACf: PHONyQ. Q-I'Y ELECTRIC PERMIT FEE ` ` BUILDING PE IT INFO
L IL —•C� _ R BLDG CI+OT PL MB E
LAIL
ls1)�A NrJ[\
LICENSED CONTRACfOR'S DECLARATION APPLIANCIS- 'SID 'IAL
wz I hereby affirm that l am licensed underprovisions mChaprar9(commencing with JOB DESCRIPTION
P012F. Sorting7000)of Division 3 m ile Busincsaand pudidwi...Cale,aularohomedisin PANELS ��--/ �
FZW Licfailensc C�def4vy�Lic.Y - • ,`w� up TO AMPS SJV 1
y Qvai Date—�I IT�1-ITN'_�i Contractor 21 - AMPS
F y Z ARCHITCCrS DECLARATION ER 1000 AMPS $Q.FT.FLOOR AREA S/SQ,FT.
Z Orn— I endenand my plans shall be used as public retards.
OZF tgiI SIGNS I.ECTRIC L
L.,=< Licensed Professional
L.,=< OWNER-BUILDER DLCLA ION 51'ECIA CI CUI $C.
KOa V I hereby affirm that 1 am exempt floor the Co nor's c e W or the
W Say following reason.(Section 7031.5,Business and Profeasio. c:An or ounry TEMP. OR PoLCI
Fts_.0Q which requires a permit m consg.t.mt..improve,demolish,or mpg ny grocare
K�Q� prionoitsissuance.alsomquiresthe applicant for such permit I filessi Jstmement I'OWC I31%VICES
�m0p that he is licensed pursuing to the pmvisiom of the Contmetor's License law(Chapter SWIMMING OL CL[CI'NIC VALUATION
a P'o�y 9(commencing with Section 7")of Division 3 ofthe Business and ProfeasionaCMe)
WL,, ruling he is exempttherefrom and Ne Ends for the alleged compiun.Any vinl.tinn of
FZG Section 7031.5 by any applicant for a Permit subjects the applicom toe civil penalty of L -SWITCIf15-fIXTURFS
not mare than five hundred dollars($500). RPSIUINfIAI.ELf:CfR SQ.FT.
K m ❑ I,esownnoflhe prnpeny,ormyemployeeawith w�g�m0ei...lecompemation, SIORIES TYPECONSTRUCHON
pW„3_ will do the work,and the structure is not intended or offered for sale(Sm.7014,Business / I
and Professions Cade:The Comacmr s License Law does not apply to en owner of
property whabuildsorimprovesibereon,sodwhodoes such work himselforthmigh his NA
ownemploydes.pindvided that such improvemertsare not intendedoroffcted fonds C1� G/IROSIp TS t
however,the buildingor improvement is gold within one year ofcompletion,dnowncr TD o 61/' P H
builder will have the burden of w proving that he did not build or improve for purpoof V
axle')' QTY, PLUMBING PERMIT - FE ^At30D Zo pN
❑ Luownerofthepropcny,era entlusivelycommning with licence)ennveann to LAIC
onstrum the project(Sec.7044,Business and Professions Code:)The Contractor's License Lawdoesna apply man ownerofproperty who buildsmimpowe.mermn,and PERMIT'ISSUANCE.
whocontact,for such projects with.ecommnr(s)licensed Panama raphe Contractors
License Law. ALTER-DRAIN&VEM'-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this reason BACK MOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,RODE,AR ,C N RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
-El I hembyaffirm that l have a certificate ofcoreent to self insure,or a certificate of FIXTURI3S-I'ER TRAP RECEIPT#
Wmkers'Compensation Insurance oracertified copy tbereof(Sec.3gt%I,Lab C.)which s' PARK PEE Y N'
rs all employeds under this permit. GAS-HA.SYSTIN-I INC.4 OUTI.HI S RECEIPT#
Policy# BUILMNGDIV NFEE9
Company - GAS-HA.SYSTI?M-OVIiR4(EA) PLANCHEC
❑ Cenifedcopyishenchyfumished.
>L—Cenified copy is filed with the city inspeetiat division. GRCASFJINDUS9'RL WASTE INTERCEPTOR GRADE
CERTIFICATE OF EXEMPT ION MOM WORKERS' GREASETRAP S FF.E
COMPENSATION INSURANCE
(Ills sootior real not he caapleted inhe permit is far one hredcaldol Ism(SIEnd) SEWER-SAFE'PARY-STORM EA.200F. ENP.ROY PEP, ire E,—
in Irs..)
'mors..)
Icertify that,.the penfnormare of the work far which this orron,is issued,Is fall WA1'Ii12 I I EATER W/V IiNTIELECIR
of employ any person to any numner so as to become suhJml to the Workers' PAID
Compensation luwsnf Calif..ia. Date WATUR SVSTEMURIATING Date R«e t# 1
zZ Applicant
� NO TICE TO APPLICANT If,after trading this Certificate of Exemption,ynuxbauld NI?W RESIDENTIAL PLMB. SQ.FT. TOTAL:
F rte+ cdconu uhfard m the Workers Compensation pmvisimm f the Labor Code,you most BUILDING FEE q
� , forthwith comply with such provisions or this perail.diall be deemed revoked 6
YD re
CL, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
11 Ell
z I hereby affirm that them is a construction lending agency for the Performance of A ELECTRIC FEE
U O the work for which this permit is issued(Sec,3097,Civ.CJ
Lenders Name O PLUMBING PEE h Lenders Address QTY. MSCI[ANICAL PERMIT' FEE" g '
U I certify that 1 have read this application and state that the above information is MECHANICAL,FEE
>" Ci.1 correct. l agree to comply with all city and county ordinances and sate laws refining to PERMIT ISSUANCE
F^ Q' building construction.and hereby solitudes repreaemati ves of this city to enter upon the
L.) z above-mentioned rr for ins coon ALTER OR ADD TO MECII. CONSTRUCTION TAX
grope y if keep has.
(We)agree nt save,indemnify and keep harmless the Cityen against
against
Lm 1
liabilities,judgmemnccac ags,coats andexpenses which may in any weyainst said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR DANDLING UNIT(OVER Ig000 CPM)
Signaare of Applicant/Cantrdcon Dam "HAUST I[OOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"BTU) Date Rae' #
Will the applicant or future building occupant store or handle hgmNona material I IHATING UNIT(OVER IWAS)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,uad the Health and Safety 46
Code,Section 25532(a)?
❑Yes 1/]�No VENTILATION PAN(SINGLE BESIDE` BOILER-COMP(7HP OR 100,000 BTU1 ISSUANCE DATE
Will the apPlicanmr forum building«cuPant use eyvipmem or devices which emit
mous air consummating as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Fri
❑Yes /m No NEW RFSIDEM'IAL MF.CH.
I have read the Safety,
Code,
materiels 5505.255 3 i under Chapter 6.95 of the -mss r N
California a ma &Safety Code,Sections 25505,gremanti25534. 1understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
«cupant of the begin en which ust bo act prior to issuance y e C nifica¢of ' 1'1 _ fy
v . "l/'7�93 vV r
Own authoriuAagent r Dmc TO' ISSUED
0