28147 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOT)ILVING-R1'.,.0 CAI' PERMITNO. 5^
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECUIDEN'IIFICA'1'DON
• BUILDINGADDRESS: SANITARY NO. AP LICATIONNSSUUUBBMITTAL DATE
Z0sv3 5�Nw3 UNIT# LOTH f —2- w i
OWNERS NAME: PHONE: CON RACTOR'S NAME: LIC NO:
Ca,s 4, ar I� ( NIC COMIROL0 ARCHI'I'I:CT/FNGINIEIIR: LIC NO: ADDRE S: •7 �l
tM U."Vivivar Los adC�
CONTACT: PHONE: BU :DING PERMIT INFO
Q'fY ,s >,ELECTRICiPERMIT FEE
Yi :kn t T? BL x iklifr PLUMB MECH
PERMIT ISSUANCE El El
LICENSED CONIRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL 70BDESCRIPI'ION
OCZ IhercbyuffirmthutlamlicenttdunderMovisionsofaVta9(commemingwiE ��J�S
IYCC Section7(IOB)of Division 3 ofthe Business and Professions Code,and my license is in PANE"
fall force it effect.
<ZVz,� License Class Lic.# UP TO 2(10 AMPS
y 6 y [)ate Comracmr 201-1000 AMPS
ZOyz ARCHITECTS DECLARATION OVER IgIOAMPS
SQ.PT.FLOOR AREA $ISQ.1T.
CZ-0 I understood my plansshall IN used aspublicrecords.
rryp g ® IN kW SIGNS ELECTRICAL — IL�\Vol
,
Qy E.4 Licensed Professional
�am'6 OWNER-BUILDER nDECLARATION SPECIAL CIRCUR/MISC. 'D (I P Oliz
C
XOyU 1 hereby effnm that 1 um exempt form the Cmntmcmrs License Isw for the J I I� G
W'3Wy following mason(Section 703 1.5,Business and Profession Code:Any city or county TEMP.M ROR
IWA
tpJ�� which requires u Permit m wnstmcl aha,improve,demolish,or repair any structure ATE � '
prion.its issuance,als.requires menpplicant forauch permit m flea signed statement POWER DP.VICPS
no that he is licensed pon,arm to the provisions of the Contmum's License Lmv(Chapter
o•ka�' 9(rommencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POO 'CMC ��-yy�� VALSJ[NTiQN
Wim or that he is exunp themfmmandthe basis for meulleged eaem ipso.Any vaumum., OUTLETS-SWI 1 S FI `uA�/1 g'(�
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ..7 1�`Y✓
5
not marc than five hundred Aollars(ESfq).
m ❑ I,usownemfth<pmpeny.urmyempinyees with wugnastheirsolemmpensaoian, NEW REST E AL 1. Q. J STORIES TYPE GON$TRGLTIGN
a3— will do the work,and the structure is not intended or offered for sale(Sm.70LL Business
and Professions Code.The Contractor's License Law does not apply to an owner of
property who builds or impmvm memao,and who does such work himselfor tluaugh his
own employees,pmvidedthat such improvememsare not intended confRmd(oracle.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcnmpletion,theownez- T.
builder will have the burden of proving that he did not build or improve for p mpman of
solo.).
❑ I,mownerofthepmpeny.umexclusivelyconir tingwithlicenwdcontructorsto QTY:}f'., PLUMBING-PERMIT FEE FLOOD ZGNP APN
mnstrutu the project(Sm.70FL Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Low does om upply li)m owncrofproNny whobuilds m impmves theccon,and
whomnttacav for such projects with acontecmr(s)licensed pursuanuo the Contractor's
Liccnm Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C far mis reason BACK FLOW PROTECT.DEVICE OI'I'.IDL E
SANITARY Y N_
Owns Dam RECIi1PI'#
DNAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN_
❑ IMreby nlfrn lhnlhuvuecmifcmc nfttmscnun ad6insure,nremnifwte of
FIXTURES-PFRTRAPRECEIPT#
Wmkeri Cotnpensetion h¢urance oracenifcdmpy mcremf(Sec.Jg00,lsbCJwhich PARK FEE YN
covers all employee's underthis permit. GAS-G.SYSTF.M-I INCA OUTLETS RECHI #
Policy# BUI(.DING DIV( 10 IT!,ES
C GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ��
eniOed copy is hereby furnished.
❑ M11fifiedl copy is fled with the city inspection division GREASHRNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplehed ifthe permit is tarmac hundred dollar,(SIVE) SEWER-SANITARY-STORM EA.200IT. ENERGY PER
or less)
Icertify that in the peffarmance of the work for which mis permit is issued,Ishall WATER I(EATER W/VENT/ELE.CTR
t employ any person in any mumer so as an become subjmm
t to e Wmirms' PAID
A
Z ltompemsation Lawsof Califomia. Date WATER SYSTEM/1'RFATING at RtteiptM
Applicant
� 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
V1 bmamcsubjecun the Workers Campensmian provisions of the Labor Code,you most
a H forthwith comply with such provisions or this permit shed he chemical mvokM. BUIL IN 'rE If till
I
nal. Q CONSTRUCTION LENDING AGENCY IAC FEE
Vz I hereby affirm that there is a c.nslrueti.n lending agency for the performance of
O the work for which this permit is issued(Sm.3097,Civ.C.) 'TOTAL: PLC CTMCFEE
L4 lenders Name PLUMBING FEE
lender's Address QTY, MECHANICAL PERMIT FF13
V I verify that I have read misap,fc unit and sham that the above infomnuion is
correct. I agree m comply with all city and county ordinances and sum laws miming to PERMIT ISSUANCE MECHANICALD i
Vf•' to building construction,and hereby submiu representatives ofthiscity teener upon the CONSTRUCT, TAX
7 above-mentioned property for inspection puryosea. ALTER OR ADD TO MF.CIL
.^� (We)agree m save,interim and keep harmless the City of Cupertino against
liabilitiesjudgments,coa endsea which meym any way.m.eagamstsmid City AIR HANDLINGUNT11(TO 10,0 )CFM)
e the d of this peon'.
AIR HANDLING UNIT(OVER IB,(IBB CFM)
Simati fAp int/Comr. (/ pam EXHAUST HOOD(W/DUCq
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) D a Receipt It
Will the applicant or home building occupant some or handle hazardous material
as defined by the Cupenim Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER Hk 000 BTU) TOTAL:
Cede,Bantam 25532(u)?
El Yes 11 No VENTILATION FAN(SINGLE RESID)
Will theepplicerat azfummi
rebuildingoccuprm use equipment ardevices which et BOILER-COMPCIHPOR 100,000 BTU)
ISSUAN •DATE
hazardous air commitments as defined by the Bay Area Air Quality ManagementtP BOILER-COMP(OVER 100,810 BTU) PAID D
District? N
❑Yea ❑No NEW RESIDENTIAL MECH. SQ,IT.
1 have mad the hazardous materials eqummoods under Chapter 6.95 of the JUM—)
N /I 1
California Health At Safety Cork,S<ctions 25505.25533 and 253]4. I undersand ohm x,99 1/
if the building does not currently have a tenant•mthat is my responsibility to runty the ^+,
occupant of the tequircents which mush IN met ter to issuance of a Certificate of VI
Occupancy.
Owner a amthim.il agent Date TOTAL: ISSUED BY:
L