25301 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION '"I'll. PERMITNO. O
APPLICATION/PERMIT PING PRNO CIMECHANICAL[DEN]
DENFIL
BUILDING DIVISION 11UILIIINC PN(I,IF.(TI'IDF.N']'IPICA'1'I(IN
BUILDING ADDRESS:�y,�, ��•�� r.�i.. l�{�� SANITARY NO. APPLICAATIIOON�SUBMITTAL DATE
;�� `!1 C�a���-1� —�-cuxt IINITA..-' `ax--�P LOT#
•' OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
Cisme _7 6 NC CONIROLN
•ARCIII'I ECT/HNGINEL'R: LIC NO: ADDRESS ❑
CONTACT: PHONE: S e 'dr,4:- '+` DUILDINC PP.RMIT INFO
QTY. TFLE7,,RIC PERMIT' ' FF.Ii
` ISSU BL ELF.Cy LUM MECII
PERMIT ISSUANCE �— rY`��A`�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RE D JOB CRIPI'ION
ZMz I hereby affirm that l am licensed underprovisions ofaripter!)Bommencing with
400 Seelion7")of Division 3 of the Business and Professions Code,and my license is in PANELS
CWF full force and effect,
FN8O�2QW License Class M
U O
AkW
Ny ate Con20 -10
ARCHITECTSDFCLARATION A
It V I AMPS BQ.FT.FLOOR AREA $/SQ.FT.
z0 � I understandmy plans shall be used as public recnNs. I LE AN
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCU C.
0.xOd. I hereby M.that 1 an exempt methods,Contracurs License Law for the
u1311-¢ following rem.n.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.MEIERO FO ST.
P4 J which segoircs a permit to connrvct,alter,improve,demolish,or repair any machine
>-7 priomo its issuance,also requires the applicant forsuch Permit o rile a signed statement POWER DEVIto
CES
TC,e,0 that he is licensed pursuant to the provisions of the Contractors License Lew(Chapter
2 9(commencin with Section T�X)11 of Division 3 ofthe Business and Professions Code SWIMMING OL ELECTRIC
W=,, (commencing ) ) VALUATION
yI,-,y or that 7031. by mpt
therefrom and the barisfor the
cts the exemantTo civiny l Penalty
of ETS-SWITCHES-FIXTURES ��
ZQ Section than v a hundred dollars
npermit subjects the applicant acivil penalty of V ��
yy not more than five hundred Dollars($500). NEW RMIDENTIALELECIR —SQ.Pf.
rk m ❑do the
wrk,and theanungormycmpended withwagesastheirsol,7BPI.BsinessSTORIES TYPE CONSTRUCTION
y will dmhe atoms C d e The Contclum a tors License
or ow ads n t apply to an Business
and Professions Cale:The C.nhroem,License Law does not apply m an owner of
Emptarowneywyces,pddened mvathemomand whedoessuctanded inform through Ns OCC.GROUP RES.UNITS
mer,theesri improvement
is vemeatsarene ouofd.roffean,ed!forownef,
Ac huwever,ill have
teb rden o(pmenl ie soldhe didn one year of nempl®iom N purpose
o-
m1c.).rwill hove @c burden of proving that he did not build or improve for purynu of
4
s❑)1,as owner oftbepropeny,amexdmivelyconvecting with licensed contiamorst. QTLY,.`„� PLUMBING PI?RM11, :FEC FLOOD ZONE APN
convect the project(Sec.0044,Business and Professions Code:)The Contractor's
License Lawdoes not apply to mtownerofprolxny who builds or improves thereon,and PERMIT ISSUANCE
who conuamsfor such projects with acontooaor(s)licensed pursuant to Bar Convectors ALTER (G)
License Law. FEE SUMMARY
❑ 1 am exempt under Bea B&P C for this rcns.n SIDLE
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Data DRAINS-FLOOR,ROOF,AREA,CON D. RECEIPT#
WORKMAN COMPENSATION DHCLARKI'[ON SCIIWLTAX Y_N
c❑clhertby affirm lhetlheveattnificau ofc.nunimuif-Insure.orattnifice¢of FIXTURES-PER TRAPRECHUTp
Workers'Ccurromotion lmuranor
er a certified copythere.I(So,.3800,Lob C.)which �� PARK PEE Y N
rs all employee's undenhis pennil' GAS-EA.SYSTEM-I INCA OUTLETS RECHIPT 10
Policy of BUILDING DIVISION FEES
Co any GAS-EA.SYS TEM-OVER4(EA) PLANCI IECK PEE
nifiW copy is hereby furnishral.
❑ Certified copy is filed with the city inspmtion division. GREASRANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP I OEE
COMPENSATION INSURANCE
(71i section neW not be completed ifthe permit is board hundred dollars($100) SEWER-SANITARY-STORM EA.2kFT.0ih ,Y MA I Vl
or less.)
I certify that in the Performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELE
not employ any person in any manner so as to become subject to the Workers' e,1
Compemmionlawsof Caifomia. Date WATER SYSTEM/IREATING ate Recoipta
C) z Applicant
Z 0 NOT ICE'1'0 APPLICANT:If,arm,making this Cerificateof lSmmption,you should NEW RESIDENTIAL PLMB. TOTAL:
I-- U) become subject o The Worker's Compensation previsions ofthe Labor Code,you must
Fes-` ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FHh _�
FitQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby of urn that hem is a construction lending agency for the Performance of
O the work for which this permit is issued(Sec.3099,Civ.CJ 2 ELECTRIC THE
Lenders Name - M
H Lender's Addmxa QTY? ;_ MECHANICAL PERMIT. FEE PLUtlING
U 1 certify that I have real this application and slate that the above information is r
coned.l agra to comply with all city and county arairreces and sure laws teletingm PERMIT ISSUANCE MGCHANICARIE
I.IEE
n
building construction,and hereby amouriu representatives of this city toenterupon the Al CONSTRUCTION TAX
U ,z above-memione Xt)Nayfofinspectionpurpous. LTERORADUTOMECH.
(We)agree t s ,indemnify and keep harmless We City of Cartoons.again
budhlities,judg s.casuund fix yr a whicharayisanyway.orme...mstsuid City AIR HANDLING UNIT(TO 10,000CFM)
in ennseq c of the gmntin fthie permit.
AIR HANDLING UNII'(OVER TO.”CFM)
nemrc of A111ifirrViumnact., Dau EXHAUST HWD(W/DUCT)
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Recat,,
Will the applicant or future building occupant state or handle harardons matenal HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
GWc,Section 25532ha)?
❑Yes 13 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP CHP OR 100,(100 BTU) nISSUA;bDATE
Will.air co ieanlnrfts as defined
by the
Ands sent ualiur Management
P PPw'"kkk V
hezalloos air comvninanu u define)by the Bey Arca Air Quality Management BOILER-COMP(OVER 100,0(X1 BTU) P
District?
1:1 Yes ❑No NEW RESIDENTIAL MECH, gQ.PI'. 'JUL vl I Q v `I��a�4
I have read the humadous materials requirements under Chapter 6.95 of the 1 V
California I lealth&Safety Code,Sections 25505,23533 and 25534.1 understand That
if the building does not curemly have a to nam,Jut it is my usponsibility,to notify the '��17 tar our
occupant of the requirements which must be met poor to issuance of a Certificate of
Occupancy.
Owner or authorized agent Data 'O ISSUED BY: