25432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' ' ING.I.. N APF.RMI'I'N0.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25432 5 /I �] /�
BUILDINGDIVISION IIUILDIN(;PROJECT IDEN'I'IFIUAT'ION J 4 J G
BUILDING ADDRESS:NAME .J/l p/(] ,'k
SANITARY NO. APPLICATION SUBMITTAL DATE
—�llN'9 LD
OWNI : r 1 PHONE: CONTRACTOR'S NAME LIC NO: l
NG" G U N� 7Z,1-3 1 N/C CDNTRUL k
RCHI'IECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONF: QTY ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
BLDG ELITIM PLUMB MECII
PERMIT ISSUANCE �(� Nf'I
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDEM'1 L
]amlOB DESCRIPTION
MCC) lh7000)i Divisi n31 licensedBasin.,
asin ,Laid isioneirms Coter9(commencing with S
Foo Section]WB)tif0ivision3ofteBusinusanJProfessionsCode,anJmyliccuseisin PANELS "2 still CIO L✓a
F fall rossmad se CiesefrecL IIP TO 200 lf1DO
License Class Lic.# L rel/
m n Date Commerce 201 hoo I'
Z 8-NKK ARCHITECT'SDECLARATION VVNISR15AMPS SQ.111'.FLOOR ARIA $/SQ.Ff.
OZ—C) I understand my plans shall be used as public records. ® B ss R
F'yW IGNS ELECWRI L \V�
6y� Licensed Profe,o.rall
Ky�WOWNER-BUILDER DECLARATION SPECIAL UT/MIS
FxI OaF 1 hereby afrom that I am exempt firm the Commoners License Luw for the
m34 U
0 following arcane.(Section 7031.5.Business and Professions Code:Any city orrumd THMP.M (IR )I,liP T. V
'S O which requires a permit to construct.alter,improve,demolish,or repair any swenurt 2
Prior mise issuance.aRnre mea (cant(,such Uofilensi eJ statement POWtiRD VICES DATE v
qtromad o h nn pract sn
syC�pK 9(comIla,le isrcial with
Seen..ohepmvisiomof the Ile Ho tors License Law(Chapteropur
C. eLL 9(rommencing wire Semion]rKKpof Division Sof he Business and Professions Cale) SWIMMING PoOL ELELTRI ygLUATYW/
_rn or that he is exempt herefromand the basis for thealleged camphor.An,,Intuition Uf OUTLETS-SWITCHES FIXTURES (� U V
t K C Section]031.5 by any applicant for a permit subjects the applicant o civil penalty of C 7 -/"
out mom than five hundred dollars($500). l
X
3C ❑ I,asowneroftepropeay,ormyemployttswihwugesmheirsolectimpcnsation, NEW RBSIDIiNTIALBLECTR5 .FT'.
— Q STORIES TYPE CONS'1'RUCTION
willdo the work,andthe swcture is not intenJcdoroffcred furole(Sec.764q Business
and Professions Code:The Contmcmrs License Law does not apply to un owner of
property who builds or improves theater,and wildcats such work himself or ihrough his
emplayeex,pmvidnlhnt such impmvemenuare noeimendedoro(fared tarsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcompletion,prowler. TOTAL:
builder will have the burden o(proving that he did not build or improve for purpose of
El 1
❑ ,a ownen)fhe property,umexclusivdy contracting with licenxd conwemrsm QTY.� ','PLUMBING PERMIT' � PEG I�LOOU LONE AI'N
conscript the project(Sec.9M4,Business and Professions Code:)The Contractor's PERMITISSUANCE
License Law does not upplyto an ovnmerofproscry whobuilds or improves thromr.anJ
who contracts for such projects wit acommacums)licensed pursusnuo the Commences
License lawgLTER-DRAIN&VGNT WATER(EA) FEE SUMMARY
.
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UT.IDE P-
SANITARY YN
Owner Dam DRECF.IPI'#
RAINS-FLOOR,ROOF,AREA,CORD.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX VN
w❑ thereby off rat tutlhavicecertifcme of conunuo self-insure,macertificrm of RECEIPT#
W akera'Compensation lnsuranceorucertifedcopythcreof(Sec.31100,Lob CJwhich FIXTURESPER TRAP PARK FEE Y N
overs all employee's under his permit. GAS-IM.SYSTEM-1 INCA OUTLETSNVrlfT#
Policy p BUILDING DIVISION FEES
Company GAS-IA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ h
Certified copy lahereby(umishul. V
❑ Certified copy is fled with the city inap«tion division. GREASIjINDUSTRI.WASTH INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPT'ION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
TT'hissectionneed not hecampined ifthe permit is for On[huodreddollars(SIM) SEWER-SANITARY-STORM EA.200 p. ENERGY MEvo
or less.)
I ccnify that in the performance ofte work forwhich this permit is issues,Islid[ WATER HEATER W/VENT/FLECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Z Cmepcionamn Taws of Califomia. Date WATER SYSTEM/TRHATING Date Receipt#
Applica n
z0 NOTICE TOAPPLICANT:If.after making this CertificateofExemption.you should NEW RESIDIINFIALPLMB SQ.FT. 'TOTAL: 76 . F{
F V] become subject m he War&r's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permitshall he deemed revoked. BUILDING FEE a aO
VJ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE aV V
7 z I hcrebyufOrn hm there iso construction lending agency for the performance of
L.1 the work for which this permit is issued(Sen.3097.Civ,C.) TOTAL: ELECI RIC FEE
Lender.a Name
prr Lenders Address QTY. MECHANICALPERMITT FGE PLUMBING FEE
L) t certify that L have read this application and seal,that the above information is
0. come[,l agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCEfO MECHANICAL FFconstruction,y building construction,and hereby authorise -"
reprnmentivesefehis city to eneerupon the V CONSTRUCTION TAX
U y above-mentioned pro,my for inspection purposes. ALTER OR ADD TO MECH.
^� (We)agree transit.indemnify and keep harmless the City of Cupcnino against
Iiabilieies,odgmcros,cosu endexpensea whichmay many wayaccme againstsaid City AIR HANDLING UNIT(TO ILJ(I CFM)
enfeheji, mpmfthiepe 0. ^ )
in con > AIR HANDLING UNIT(OVER 10,00)ChM)
Signa reo ApPlica Cnmm pare IiXHAUST HOOD(W/DUCT) PAID
IIALARDOUS Mingp ALS smatem SURE
f1EATINGUNITF0 IM,y BTU) Date Receipt#
Willtheapplicantnrfumrtcipall Code.Cantsmrcor handle Health and mcdul HEATING UNIT(OVER 1W,0M BTU) TOTAL:
us defined by the Cupertino Municipal Cede,Chapter,9.12,and the Health and Safety
@sde,Section 25532(n)] {k.. VENTILATION PAN(SINGLE RESID)
�No
❑Yea Iu
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will he appliammrfumm building«cupaneuuequipmcntardevicexwbich emit �k
hamdous enrollments an enrlments as defined by he Bay Area Air Quality Management BOILER-COMP(OVER 1X1,000 BTU) r pp A
Gimlet?
❑Yes No NEW RESIDENTIAL MECH.—SQ.FI'.
1 have read the haesrJuus commonly requirements under Chapter 6.95 of the AUG 9 1993
California Heald&Safety Cade,Sections 25505,25533 and 25534. T undersmncithat
if the mildingpiles nuuu�eee urremly hove a tenant that it is my responsibility Inutility the
«cuprm of qu menu which must h t prior eo issuance of a Cenificnl,of Cl i Y U't CUI'cly I uvU
Occupant a //
m Vf c
Owers th,rized aTOTALISSUED BY.
u�
OFFICE