25252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OECUPERTINO P IIIAJJNG-hi,KUIRICAI. PFRMI'PNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n C g]C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION G J G J
2.
BUILDING ADDRP_SS: /��/\� SANITARY NO. APPLICATION SUBMIT]AL DATE
L s • o UNIT If LOT,
OWNERS NAME: PI N :� I CONIRAC R'S NAME: LIC NO:
G NIC CONTROLIf
_ AR 1 tiff I E LIC NO: �OR S. ❑ �30P
-
ONT PHONE', Y
////llfl Ql'Y. _ ELECf IC PERMIT FEL? BUILDING PERMIT INFO
S�QPERMIT 1
ECI
9511
CC) 16—
LICENSED CONTRACTOR'S DECLARATION APPLIANC RESIDENTIAL JOB DcfS�CIp'IPI'ION�.
�pyZ Iherchy affirm lhaG am licenudundcrprovisinns of Chepmr9(commencingwish 6 a l�V D \� �\`�1 —
c100 Sectiarmici)1af Division3 oRhe Husinas end Rofessiom Code,nnA mylioense is in pANEI.
f -'E fim. celas effect. 1 O
Fy W license Class LI[.# ` U fO AMPS I
ma� Da,. Carton., 2B -1000 AMPS
ZoNz ARCHITECTS DECLARATION OV-R 1000AM S SQ.FL.FI.00R AREA $/SQ.FT.
O z—O 1 understand my plans shall be used M public rtcords.
SIGNSEI.H R
Qy�,a Licensed Professional
a'•EOWNER-BUILDER DECLARATION S .CI 1 U ISC.
aFI hereby offnn that I am exempt front the Contractor's License w r he
q following reason.Section 7031.5,Business and Professions Code:Any cit are ly TE OR POLE INST.
fJO� which mptlmsapermit,.rnnstmm,alter,improvq demolish,or repair any, ct
Yn prior to its issuance.also requires the applicant for such permit a signed stamen P E EVICCS
�L 00z that he is licensed pursuant to the provisions of the Comrutors Licenu Law(Chapter
LgeLL 9(commencing with Section 7")of Division 3 of the Business and Ritessione Cod e) SWI ING POOL ELECTRIC VALUATI
XXW_y orthat he is exempt therefrom and the basisforthe alleged exemption.Any violation of OUTLE -SWITCHES-FLCILRES O MjI
Y Section 9031.5 bym,applicant fora pemit su
sbjects theapplicamns.eivil penalty of LJi.n(J
G mol more than five hundred dollars(SSW).
O NEWRESIDENTIALCLECTR _SQ.IT.
yc4 ❑ Lazowrk,anheestructuermyemploy«swishwed forilt,(Se. 0,14,Bsinesson, S'fOR1ES 'TYPE CONS'IRUCI'ION
;°_ will dmhework,ande:The antre ra not is ended Limase lat.
an Business
and Professions Crede:The Contractors License law does not apply lf an owner of
prop enywM1nbuildsmimprvvesthereon,undwhod«such work himulforthrougM1 his
OCO GROUP RLS.ON]
tun employees.prvvided Ihnt such impmvcmenmurenot intended oroffemd fnrsale.If,
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
salts.).
❑ I,as owneroftheprvperty.amexclusively contracting with licensed contractors,. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cmnsr.ct the project(S«.0044,Business and Professions Cade:)The ContractorspCRMIT ISSUANCE
Liccme Law does not apply to an ownerof property who builds or improves thereon,and
whocommcts for such projects with a contnemr(s)licensed pursuaouo the Co mic or's
License L.W. ALTER-DRAIN&VENT-WATER(KA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OOT. 11 FI:I;S
SANITARY Y N
Owner —Dr.— DRAWS-FLOOR,ROOF.ARCA. ND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
t❑ I herehy affirm that l have a certificate ofconsenrto self-insure,or a cerificam of IIXTURFS-P[:R TRAP RECENT7N
Wrnkurs'Compe...Fort lnsummmo,acid Led,.,thereof(Sec.3800,Wb C.)whlcM1 PARK ME Y N
ars all employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTL RECEIPT'it
'Policy# BUILDING DIVISION FEES
Com GAS-EA.SYSTEM-OVER 4(IIA) PLANCHECK FEE
Certified copy is hereby famished.
❑ Cenifed copy is fled with the city ins,«tion division. GREASHANDUSTRLWASTEINTERC. O GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP SollS FEE
COMPENSATION INSURANCE
(Fes section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM fA. 1• ENERGY FEE
or less)
I certify that in the perfannnncc of Otc work for whichlhispernitisissucd,lshull WATERHEATERWNENT/ELECPR
not employ any person in any m as to become subject m the Workers' PAID
Cianumiumil.awsof Culifomia. Date so WATER SYSTEM(MRATING Date Receipt,
z Applicant
z�zO NOTICE1'0 APPLICANT:IL after making this Cimificme of Exemption,y.u,h..Id NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
beannesubj«u.the Worker's Citummmoinprovisions of the Labor Cole,you most
FFFa'" > forthwith comply with such provisions or this permit shall be,thermal revoked. BUILDING FEE `
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z 1 hereby effantbanhere iso commutation leadingagency for the perform mof O R iE
V O the work for which this permit is issued(Sat.3110.Civ.C.)
LI. 1-mahmsName
0 U Lenders Address QTY. MECHANICAL PERMIT FEF. PI.UmbffiGFCE
1 certify that 1 have rend this.,plication and stem,hut the alowe imfurmatim is
�^ W cromm.l.gree to comply with all city and comity nrdinences and eWte laws relating,. PERMIT ISSUANCE MECHANICAL FEE
ybuilding conswction,and hereby mahoriac representatives ofthiscity incineration the CONSTRUCTION T'A%
V Z aMwo-mem'mned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cutpcnino against
liabilities judgments,costs andexpenses who may in any way ammeagaimt mid City AIR HANDLING UNIT T 010,000 CFM)
al the gra ting thispermi
AIR HANDLING UNIT(OVER 10,000 CFM)
Signe d DaEXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITGO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hmsrdom material HEATING UNI'I'(OVCR 100,!100 BTU)
w defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
PA
Credo,S«lino 25532(a)7
1:1 Yes El No VIiNTILA'I'ION FAN(SINGLE RBSID) Uno
Will the applicant or future building o«upont use equipment o,devices which unit
BOILER-COMP(3118 OR Igl,f(I(1 BTU)Will
DATE
"Fal ix air conmmin arm as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,(1(0 BTU)
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.PT.
PAID
I have read the humr he,mwco.1s requirements under Chopmr 6.95 of the AUG
Califomia I IealN&Safety Code,Sections 25505,25533 and 25534. I understand then
if the building dace not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy. I-s r ,
Ownerar uulhodnW a gent Date T ISSUED BY: ®�
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OECUPERTINO P IIIAJJNG-hi,KUIRICAI. PFRMI'PNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n C g]C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION G J G J
2.
BUILDING ADDRP_SS: /��/\� SANITARY NO. APPLICATION SUBMIT]AL DATE
L s • o UNIT If LOT,
OWNERS NAME: PI N :� I CONIRAC R'S NAME: LIC NO:
G NIC CONTROLIf
_ AR 1 tiff I E LIC NO: �OR S. ❑ �30P
-
ONT PHONE', Y
////llfl Ql'Y. _ ELECf IC PERMIT FEL? BUILDING PERMIT INFO
S�QPERMIT 1
ECI
9511
CC) 16—
LICENSED CONTRACTOR'S DECLARATION APPLIANC RESIDENTIAL JOB DcfS�CIp'IPI'ION�.
�pyZ Iherchy affirm lhaG am licenudundcrprovisinns of Chepmr9(commencingwish 6 a l�V D \� �\`�1 —
c100 Sectiarmici)1af Division3 oRhe Husinas end Rofessiom Code,nnA mylioense is in pANEI.
f -'E fim. celas effect. 1 O
Fy W license Class LI[.# ` U fO AMPS I
ma� Da,. Carton., 2B -1000 AMPS
ZoNz ARCHITECTS DECLARATION OV-R 1000AM S SQ.FL.FI.00R AREA $/SQ.FT.
O z—O 1 understand my plans shall be used M public rtcords.
SIGNSEI.H R
Qy�,a Licensed Professional
a'•EOWNER-BUILDER DECLARATION S .CI 1 U ISC.
aFI hereby offnn that I am exempt front the Contractor's License w r he
q following reason.Section 7031.5,Business and Professions Code:Any cit are ly TE OR POLE INST.
fJO� which mptlmsapermit,.rnnstmm,alter,improvq demolish,or repair any, ct
Yn prior to its issuance.also requires the applicant for such permit a signed stamen P E EVICCS
�L 00z that he is licensed pursuant to the provisions of the Comrutors Licenu Law(Chapter
LgeLL 9(commencing with Section 7")of Division 3 of the Business and Ritessione Cod e) SWI ING POOL ELECTRIC VALUATI
XXW_y orthat he is exempt therefrom and the basisforthe alleged exemption.Any violation of OUTLE -SWITCHES-FLCILRES O MjI
Y Section 9031.5 bym,applicant fora pemit su
sbjects theapplicamns.eivil penalty of LJi.n(J
G mol more than five hundred dollars(SSW).
O NEWRESIDENTIALCLECTR _SQ.IT.
yc4 ❑ Lazowrk,anheestructuermyemploy«swishwed forilt,(Se. 0,14,Bsinesson, S'fOR1ES 'TYPE CONS'IRUCI'ION
;°_ will dmhework,ande:The antre ra not is ended Limase lat.
an Business
and Professions Crede:The Contractors License law does not apply lf an owner of
prop enywM1nbuildsmimprvvesthereon,undwhod«such work himulforthrougM1 his
OCO GROUP RLS.ON]
tun employees.prvvided Ihnt such impmvcmenmurenot intended oroffemd fnrsale.If,
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
salts.).
❑ I,as owneroftheprvperty.amexclusively contracting with licensed contractors,. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cmnsr.ct the project(S«.0044,Business and Professions Cade:)The ContractorspCRMIT ISSUANCE
Liccme Law does not apply to an ownerof property who builds or improves thereon,and
whocommcts for such projects with a contnemr(s)licensed pursuaouo the Co mic or's
License L.W. ALTER-DRAIN&VENT-WATER(KA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OOT. 11 FI:I;S
SANITARY Y N
Owner —Dr.— DRAWS-FLOOR,ROOF.ARCA. ND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
t❑ I herehy affirm that l have a certificate ofconsenrto self-insure,or a cerificam of IIXTURFS-P[:R TRAP RECENT7N
Wrnkurs'Compe...Fort lnsummmo,acid Led,.,thereof(Sec.3800,Wb C.)whlcM1 PARK ME Y N
ars all employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTL RECEIPT'it
'Policy# BUILDING DIVISION FEES
Com GAS-EA.SYSTEM-OVER 4(IIA) PLANCHECK FEE
Certified copy is hereby famished.
❑ Cenifed copy is fled with the city ins,«tion division. GREASHANDUSTRLWASTEINTERC. O GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP SollS FEE
COMPENSATION INSURANCE
(Fes section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM fA. 1• ENERGY FEE
or less)
I certify that in the perfannnncc of Otc work for whichlhispernitisissucd,lshull WATERHEATERWNENT/ELECPR
not employ any person in any m as to become subject m the Workers' PAID
Cianumiumil.awsof Culifomia. Date so WATER SYSTEM(MRATING Date Receipt,
z Applicant
z�zO NOTICE1'0 APPLICANT:IL after making this Cimificme of Exemption,y.u,h..Id NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
beannesubj«u.the Worker's Citummmoinprovisions of the Labor Cole,you most
FFFa'" > forthwith comply with such provisions or this permit shall be,thermal revoked. BUILDING FEE `
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z 1 hereby effantbanhere iso commutation leadingagency for the perform mof O R iE
V O the work for which this permit is issued(Sat.3110.Civ.C.)
LI. 1-mahmsName
0 U Lenders Address QTY. MECHANICAL PERMIT FEF. PI.UmbffiGFCE
1 certify that 1 have rend this.,plication and stem,hut the alowe imfurmatim is
�^ W cromm.l.gree to comply with all city and comity nrdinences and eWte laws relating,. PERMIT ISSUANCE MECHANICAL FEE
ybuilding conswction,and hereby mahoriac representatives ofthiscity incineration the CONSTRUCTION T'A%
V Z aMwo-mem'mned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cutpcnino against
liabilities judgments,costs andexpenses who may in any way ammeagaimt mid City AIR HANDLING UNIT T 010,000 CFM)
al the gra ting thispermi
AIR HANDLING UNIT(OVER 10,000 CFM)
Signe d DaEXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITGO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hmsrdom material HEATING UNI'I'(OVCR 100,!100 BTU)
w defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
PA
Credo,S«lino 25532(a)7
1:1 Yes El No VIiNTILA'I'ION FAN(SINGLE RBSID) Uno
Will the applicant or future building o«upont use equipment o,devices which unit
BOILER-COMP(3118 OR Igl,f(I(1 BTU)Will
DATE
"Fal ix air conmmin arm as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,(1(0 BTU)
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.PT.
PAID
I have read the humr he,mwco.1s requirements under Chopmr 6.95 of the AUG
Califomia I IealN&Safety Code,Sections 25505,25533 and 25534. I understand then
if the building dace not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy. I-s r ,
Ownerar uulhodnW a gent Date T ISSUED BY: ®�