25886 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ INTILDINU-EL'C'I'F AL FLESH NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 25886
`BUILHIN(3 PROJF.C'f 3D6NTIFICATION "
BUILDING ADDRESS: ' / ` p SANITARY NO. AP^PLICATION SUBMITTAL DATE
/0'� 3 / EL/PE \�. UNIT# LOT# 2,
WNERS NAM :-Meryl PPl Ma MO NG:�,Z�E� CONTRALTO%NAME: IC NO ��
l "I ,'I K g NIC CONTROL#
_ \RCHITF.CT/F. NfiEk:
J Zell, 71 ylqi;
-ONTACC PHONE:377 7 QTY. CCEC7RIC PERMITS - ,FEB BUILDING PERMIT INFO
o-15 PERMIT ISSUANCE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DF.SCR PION
ptyy I hereby affirmthat l am uans
licensed derpecabioof Chaprer9(commencing with
00100 Sedipn700o)of Division 3d the Business and Professions Code,and my license is in PANELS /��/�
K,Zw full forcoandeffat. UP TO 200 AMPS PM
IV/1
d�y W License Class Lio.# 1 VY
maM Date Contmctor 201-1000 AMPS
F y ARCHITECT'S DECLARATION SQ.IT,FLOOR AREA S/S M.
OZ—Q OVER TWO AMPS
O R•.,O 1 understood my plans shall be used es public records. (/�
QI"'a SIGNS ELECTRICAL V�Q
Licensed Pacessionnl 'T
PeLL Pg u�u11< OWNER-BUILDER DECLARATION PECIALCIRCUH'/MISC.
�OyF I hereby offimt that I am exempt form the Coromandel License Law for the
following reason.(Sedion'I031.5,Business and Professions Code:Any city memory TEMP.METER OR POLE INST.
which requires a permit in evalmueq altw,Improve,demolish,m repair avy wroame
7WNN prior toils issuance,alsorequires Ne applicant for such permit o file asignedsmtement POWER DEVICES
WWQO that he is licensed Immort to the provisions ofine Contractor's License Law(Chapmr
�W Wors 9(commencing with Section 9000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
0 or 7031. b Gherefmmnt f the permit subjects
An ^ �O
WMrn P g pion.Any of UTLCTS-SWITCHES-FIXq'URE,S S
Section01 ore than
v any applicant for a penult eubJects[ha applicant m e civil penalty OF
2 22 not more fiv fthepT perty.or myemp. NEW RESIDENDAL ELECTR _SQ.FT. I
❑ oasosork,a theestructy.ormationsyedord red forsthe(Sec,c0mpnsation.Business STORIES TYPE CONSTRUCTION
Wy3_ will dorbowon,and, The Contcture ractor
Law
atImSec,ad ammerof
.ad property
wh ons Chadldsor The Contredors Cleanse Law rices not apply to an owow is
property whobuilasorimpmvesch improvements
apes such work himselforthrough his
employees,provided that such impis,old itsarenot intendcdurpffered the. . OCCG OU ♦ > S
however,wthe
llhave the burden of emend that he di inone t build or improve
thef •\—`Y`
a,-
builder will have the burden of proving that he Jia not build or rmpiove for porpos f
mie.) Q7aY- y fY ti
PLO MBINO,PERMIT r FEE' : 1 O Z NE APN
❑ I,asowner oflbo property,am exclusivelyrommucting with bcensede0ntrache t
,boner the project(SCC 70LI Bas rasa and Professions Cwie)The Con[racto
LCense Law does notapply roanownerofproperty whobuddswimpri thereon,and PERMIT ISSUANCE a—
wboventraetsforsuch projm¢with acunhactor(s)licensed pursuant to the Contractors ALTER License Law. (BA) :PEES MMAItY -
❑ 1 nm exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE, OUTSIDE FEES
SANITARY Y N
Owner Date pRAINS-FLOORROOFAREACOND. RECEIPT#
, . , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm thatlhaveacertifcab of conunuo self-insure,aracrnifica[e of FIXTURIS-PER TRAP RECEIPT'#
Worker9'COmpensutipn lnsumnpeor.conlBCd copy,thereof(Seo.3800,Lab C)which PARK FEE YN_
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS LIFT#
Policy# ION FEES
Company GAS-FA.BYSTEM-OVFB4(GA) PLANCH FE
El Certified copy is herehy furnished
❑ Certified copy is filed with the city inspection division. GRFASE/INDUSTRL WASTE INTERCEPTOR GR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FE
COMPENSATION INSURANCE.
CNis section need not he complcbd ifflepe.,III is for one hundred dollars(S100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or les )
I certify that in the perf0mtcoca the work hichth' permitbaluedlsball WATER HEATER W/VENT/ELECTR
note ley any person in any m ter se a/r/[he Workers PAID
Z Co nsa nn- �/ WATER SYSTEM/M'R TING Dore kecci [#
Ali tit
Z NOTICETOAPP C T:If,after rKaking this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT, TOTAL:
HV) become subjecn0 the Workers Compensation provisions of the Labor Code,you most
forthwith eomply with such provisions orchis pmaritshnll be deemed rcvlked. BUILDING FEB --
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hurehy affirm that there is a consvuction lending agency for[hc performance of I ELECTRIC FEE
(� the work for which this permit is issued(Sec.3097,Civ.C.)
W Lenders Name77—
Lander',
n _
� � Lader,Address QTY i „M�CFYANICAGPERtvI1T r )�{y QHT+ PLUMBING FEE
I cert fy that 1 have read this application and state that the above information' `"c x s
correct. lagree to comply with ell city and county ordinances and sorra lows relining to PERMIT ISSUANCE MECHANICAL FEE
Vj building construction,and hereby authorize representatives ofrhiscity 0 enter upon the CONSTRUCTION TAX
V above-mwnionedpropery for inspection purposes. LTERORADI)TOMECH.
(We)a tea m save,indemnify end kcep harm) of Cupertino against
liabilities,' 16mems,cosy at�<xpem hichm many era crurag ainsI 'd City AIR HANDLING UNIT ITO 10,000 CFM)
g oft
3 AIR HANDLING UNIT(OVER 10,000 CFM)
ignamret App cant/Contrector Dab EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Reclipt#
Will the applicant or future building becupant store or handle hazardous material
as def tied by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(x)'! VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will the applicantorimurc buildingoccupant usersquipmemordeviceswhichemit P A ^\
amNous air contaminants sa defined by the Bay Arca Air Quality Management BOILER-COME(OVER 100,000 BTU) L/
tisvid9 NAR
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT, NAR 1 G' 199
1 have read the hazardous materials requirements under Chapter 6.95 of the „ tJ y{�d
California Health Code,Sections 25505,25533 and 25534. I rnderstand that Curur• T
it the building dues not currently have a cormcthat it is my responsibility mmary the - (r
ur zrl,He )
eupmn of the requirements which must be met prior I.issuance of a Certificate of
Occupancy.
Owner or authonzed agent DmeT0'f L: ISSUED BY:
OFFICE