25053 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IsFL
PER.MIT NO. 0
BUILDING DIVISION APPLICATION/PERI:11T ' PLUMBING-MECHANICAL
�BUILDING PROJECT IDENTIFICATION,
BUILDING DRESS: S,15D'ARY NQ APPLICATION SUBMDTAL DA
( AAj UNIT# LOT#
C{1N as
PHONE: ACTOR'S N`A��/ LIC NO:G39 `.C CONTNTROL p l�
...,• j LIC NO: � JO �V� �� ❑
CO ACT: PHONE: Aie' •xti. /*'+=••+ t r +
ow`' T zPEE{G.". "' BUDDDTG PERMIT INFO `
P
F+��s 4• LDG ELECT PLUAfB MF.CH
PERMIT ISSUANCE -Y
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
M.z I herebyaffirm that lam licensed mak,rovisime.dCbepter9(commendng it
WFCC Section 7")ofDivision 3 ofthe Business and Professions Code,and my license is in PANELS
y Z OF+ _
full fou and effect.
vFiQy
Date Connector
Class Connector 201.II000AM S • lYD `e✓
I-'r z ARCHITECTS DECLARATION OVER 1000 SQ.FT.FLOOR AREA VSQ.t•T.
c Z= 1 understand my Plans shall be toed as public records. I ^/ r/J� �f�
Ftnl_1: SIGNS ELE L (O � Ys 3�
25 L❑ Licensed Professiunal VVV I
�zJa OWNER-BUILDER DECLARATION SPECIALC IT ��
"c, 1 hereby dOtm In.,1 soneaempt from the Contractor's License Law for m<
�i> - following mason (Section7031.5.Business and Professions Code:Any city or county TEMP.METE OR T.,
yJ which requires a permit to Consumer,alter,improve,demolish,or repair any structure
=WiM prior to us issuance,also require the applicant for such permiuo file a signed suemenr POWER DINT
W=<0 that he is licensed pursuant to the provisions of the Connector's License Law(Chapter
a ZRT 9(commencing with Section 7")of Division 3 ofthe Business and Professions CadetSWIMMWG LE CfRIC VALUATION
0,that he is exempnherefrom and the basis for the alleged exemption.Any violation of s,
f z4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I1TLE1'S-S WIT -FIXTURES
—Q not more than five hundred dollars(5500). . fv
g,1 ❑ I,asownerofthepropeny,ormyemployeeswithwagesastheirsolecorn emanNEW RES[pAL ELECfR 5 FT.on. Q SIURBIS TYPECONSTRUCIIO
a3=e willdo the work,and thesnucture is not intended proffered forsale(See.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improve thereon,and who does such work himself or through his
employees.provided that such improvementsamnot inrendedoroffereJ forsde.If, OCC.- GgOUP ES.UNITS
however,Ne building or improvement is sold within one yeaaf completion w
theon V1rl
builder will have the burden of prov ng the he did not build or improve for purpos f L
. leJ. 12Ty a4G' PLUMBING PERMIT t^' x E .t : Fl.oOD ZONE APN
Ig I,as ow er of the Propeny,am exclusively connecting wiN licenxd canuseto to ;p ,3- �x y..un.�r• fyi.I 3s. .-,r�s:.,_
nocr thenprejecr(Sec 1044 Business and professions Cale)The Contractors
License Law does not apply to an owner of propeny who builds or improvasthareon,and PERMIT ISSUANCE
who courtiers for such prolecrs with a corrosions)licensed pursuant to the Contractors ALTER IEA) ikYaf's""`
License Law. E SUMMARYL,�,.flv„s',xa`si:'.
❑ 1 am exempt under Sec. ,B&P C for this reawn BACK FLOW PROTECT.DEVICE OATS DFEES
SANITARY Y_N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTY
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ Ihereby affirm that l have a certificate ofconsenuo self-insure,ore comficau of RECEIPT#
Workera'Compensetion Laurence orecertified copy rhneof(Sa.J800.lab C.)which RES-PER TRAP PARK FEE Y_N
oven all employee's under Ws Permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIFT#
PolicyN BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifcal copy is hereby famished.
❑ Certified copy is filetl wit to Ciry inspmdon division. GREASETNDUSTRL WASTE INTERCEPTOR
i
G FEE �r
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP E ��
COMPENSATION INSURANCE
(This section madnot be completed ifdre parotitis for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.'_00FT. FEE
or less)
Ic Yt nc with this Permiti 'sued,lshail WATER HEATER WNENT/ELECfR
not c lova y m \a „i(✓ orkeK PAID
Z Comp sa ali Dae WATER SYSTEM/IRGTING Die Rbod
Applica
z O NOTIC t isc tate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FIL TOTAL:
f" rn becomesibjcetuide Workers Co. tons Clubs,Labor Code.you must
� 5 fonhwirh comply with such pro visions or this nett shdl bet deemW revoked. G FEE a
rVy G\ CONSTRUCTION LENDING AGENCY FEE
Z I h by ff,.tache.is a conn coon lending agency for to pa fasnanc f V
V Q thew k f which this pe.ius issued(Sec 3097,Civ C.) T C FEE Z
Lende'.Name y Y i NG FEE
F Lens, Add a QTY :-�*dtMECHAMCAL PERMIT . n FEB �.
L.) I certify tar I have read this application and insisted Bis,above information "^"IY '' 't-111111 -" " Y "" F'==*-'"'•tcif
correct.l agree m comply with all city and county ordinances and stars laws relating to PERMIT ISSUANCE ICAL FEE
CA building construction,and hereby summons,rcpmsentutivesofthis city m enter upon the _ ITTION AS
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. -
N <' r `
(We)agree to xave,indemnify and keep hordes me City of Cupertino again
Iiabilimies.judgmenus,costs and expenses which may inany way aacroeagainst said Cin AIR HANDLING UNIT(TO 10,000 CFM) s 1
in cnnuquence of to er nfALimXAgR!
AIR HANDLING UNIT(OVER 10.00(1 CFMI
Si marc IlcanV mticm Da EXHAUST HOOD(WIDUC19 4M111UANCE
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,WD BTUI Will the applicant or future building occupant store or handle hazadommmed:dUEATING UNIT(OVER IW.IXNI BTU)usdefinedbytheCupeni Municipal Code,Chapter 9.12and to Ileahh und SaferyCade.Section?5532(x)'! VENTILATION FANSINGLE RESID,�uWill thea licammlmurc buildin BOILER-COMP(JHP(JR IIXLtXX)BTII) DATE
pP building meeyuipmenmrdevices which emit
aurdous or inflationtx as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,01X)RTU)
El• :. ct7 _
yes NEW RLSIpF.NT1AL M[CII.
P
I have real the baradous mammals reyuiremenrs under Chapter 695 of the
California Health&Safety Cure.Sections 25505.25533 and 25534.1 understand that �q
it Nn bnildingdncsnacurtenlly baveatenant.tw itis mYrespnnaiM1iliry mnnulythe IflA3f � � IJ
xupanl nl the Inst a of a J
It (
•HilC! 1
Own t Dec ISSUED
M7!"l_