25674 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO INTI KICA' PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEJNII PICATION
BUILDING ADDRESS, SANITARY NO. APPLICATION SUBhUm AL DATE
)—weg S UNIT# LOTH
OWNERS�S�N PHONE: CO NAME: LIC NO: N� CONTROLp
TECTB3NGi�.,W^_01- ! w LIC NO: ADDRESS: _
Iwo
CONTACT: PHONE QJ-E. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�1 4 a�k� BLpDfG ELECT P UM M
F ,�9�y PERMITISSUANCEAl
`IIIA`
LICENSED CONTRACTOR'S DECLARATION
coez I hereby affirthat l am licensedunderprovinions of Chapler9(o
cmmencingwith APDL CPS PSI
m L
TOB DESCRIPTION
P400❑ .Seek.70%X0 of Division 3 of the Business and Professions Cade,end my license is in
FKUCJfull force and effect.
FZw Licenx Claws Lic.N200 AMPS
rn�NDale Cmim"m 201.1000
Z D,z ARCHITECTS DECLARATION OMR I SQ.FT.FLOOR AREA E/SQ.FT.
OZ—O Iundentand my Plwsshell be used uPublic reroNs. �O1
r 4!r,
5 (CAL
Licensed Professional
L r,;z6 OWNER-BUILDER DECLARATION 5ALCI IT/MISC. �-
0.xOyF 1 hereby M.that 1 con exempt from the Contmaors Li law for the
following reawn(Section 7031.5.Busmus and Professions Code:My city memory fEfER OR POLE INST.
which requires a permit to conswct alter,improve,dermlish,m repair any swclme
Wf'rtY prior to its issuance,also require Ne applicantfor such permit to file a signed statement POWER DEVICES
ej �p 9(coin anceng wiuSeanuo M)of siisim3he C°nvan°rs License LsionsC pt
a C 9t that
he is exempt therefrom
and ehadsit,n Jof@eed exemption.
vena Code $WIMMA'G POOL ELECTRIC o¢, )° 1 VALUATION
orthmhcisexby tyappomamd the hermitss for bje is thedenemant to civil
of O ETS-SWITCHES-FIXTURES I�W
,ZQ Section7031.36y Imploolicant for apennitsubjecethe applicmtmacivil penalty of Sal ` V
t mom Nen five hundred dollars(E500). NEW RESIDENTIAL ELECTR S .I7.
� m n❑ 1,nsewnerofth MNny.mmyempl°ymwithwagmuR¢irsolecompe=tm, —SQ.FT. TYPE CONS'fItUCIION
BiL willdo the work,and the structure isnotintendedoroffered forsale(Sec.7044,Business
and Professions Code:The Contractor's License law does not apply at an owner of
property who builds or improves thereon,and who does such work himxlfof through his ,
own employees,provided that such improvements me,not intended or offered f°rmle.If. OCC.GROUP RES.UNI IS
however,the building or improvement is sold within one yam of completion,the owner-
builder will have the burden of proving that he did not build or improve her purpose of OT
e I.uownerofthepmpeny,amexclmsivelycmm tingwiNlice c°nm«tmam QTY. PLUMBING PERM( - �LOOD�ty Eta ApN
_ono the project(Sec(S7044,Business and Pr°ftuions Cod
Code:)The Convectors D N
License Lawdessnmapplym anownerofproperty who bmicismimpr°vuthereon,and PERMIT ISSUANCE
who contrsetsforauch projects with aconwclodid licensed paramount,the Convector's ALTER FAfl
Littnse Law. (- SUMMARY
❑ I am exempt under Sec. ,B St P C for this mmt,n OUTSIDE BACK FLOW PROTECT.DEVICE
A y N
Owner DereGi
DRAINS-FLOOR.ROOF,AREA,COND. E REC.IPTM
WORKMAN COMPENSATION DECLARATION N
❑ IhvcbyN dmtlheveacenifieam ofconxnno xlf-inseam,arettnifcata of RECEIPT#
MIXTURES-PER TRAP
Workers'Compensatien Insurance ma certified copy thereof(Sa.J800,lab CJ which �w PARK FEE Y N
ors ell employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RE EIPTN
Policy It BUILDING UNISIONFEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FE'
❑ Cenifiedmpyisherebyfumishcd.
❑ Certified copy is filed with the city inspection division. GREASB/WDUSTRI.WASTE INTERCEPTOR GRADIN
CERTffI ATEOFEXEMPTIONFROMWORKERS' GREASETRAP
COMPENSATION INSURANCE S 'L
(This section need notbe completed ifthe permit is foronehundred dollars(E100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I certify that in Ne performance of the work for which this Permit is issued,I shall WATER HEATER W/VBNT/ELECTR
not employ any person in any memer so as.to become subject to the Workers PAM
Z Compensation Lawsof Califrmia. Date WATER SYSTEM/IREATING Due, R«ciptN
Applicant
C 0 NOTICETO APPLICANT:If,after making this CeniOcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
to become subject to the Worker's Compensation Provisions ofthe Labor Col you must
a ; forthwith comply with such Provisions or this permit shell b<deemed mocked. BUILDINGFEE co
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby off that them is a construction lending agency for the pulfmmen«of
UO the work for which Nie permit is issued(Sec.3(97.Civ.C.) TAL: ELECTRIC FEE
landau's Name O PLUMBING IEE F Lenders Address QTY. MECHANICAL PERMIT FEE
V 1 certify that I have mad this application and state that the above information is
W cot l agree to comply with all city and county ordinances and spite laws relatingtoPERMIT ISSUANCE a� MECHANICALFF-E
I-" h buildingeonstructi°n,and hereby auNmiaerepresentatives ofthis city reenactment the
CONSTRUCTION TAX
U Z above-mentioned property for inspection purpave. ALTERORADDTOMECH.
to save,indemnify and kap harmless Ne City of Cupertino against
liabilif a,j an evemuendes,. yinanywayaccrueagalnstsald Ciry AIR HANDLING UNIT(TO 10,000 CEM)
in con Wuenc o gran! /
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigaamm of APplicant/Comr o oat EXHAUST HOOD(W/DUCn
PAID
HAZ RDOUSM AIS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Remipt4
Will the applicant or future building occupant store or handle haaardous material
u defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00)B7U) TOTAL:
Coda Section 25532(a)?
11 Yea 11 No VENTILATION FAN(SINGLE RESID)
Will the epplicantm furore huilding«cupummeequipmenwrdeviceswhichentit
BOILER-COMP(311P OR I W,Um BTU) ISSUANCE DATE
eanNoua air conteminants u defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
ismi<R
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. q '
1 have mad the harmdom materials requimments under Chapter 6.95 of the W
California Heald J,Safety Code.Sections 25505,25573 and 25534.1 understand that ^�V
if the building does nolcurremly have etenans
nq thin it is my responsibility m A
notify the s� e
occupant of the requirements which must be met prim to issuance of a Certificate of
Occupancy. r
Owner or authorized agent Dote T r ISSUED BY:
OFFICE