25340 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BIIB,DIn U-LLFCTNI AI- PERMITNO.
APPLICATION/PERMIT PLUMBING-MECDANICAL G f� [ a] �1 OI
BUILDING DIVISION BUILDING PROJECT IUENI IFICATION J J LI
BUILDING
ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
UNIT# LOT# 1-10-03
OW fi/R�S F��I'II N@ ?y 0f CONTRACTOR'S NAME: LIC NO: TRh p
25 L� 1� AG(r,
C.R.IEst^' CON NIC CONO
RCf1IT1?CTIIiNG INNER: 1. 'NO: ADDRESS: - ElL/ x490 $RE'ME2-fL 'D 5 ra wee sIA e.E.
'ONTACI': - PHONE:
AOI!L,I1I1 ht'�J �s{��V J� 1 ,11 QTY. ELECT IC E MIT •PI3G BUILDING PERMIT INFO
JD1 ✓F 5105AL_ TIS I�O���/ / PERMIT ISSl1A li �� BLDG PLUMB A11:CH
LICENSED CONTRACTOR'S DECLARATION ppPl. CE ENTIAI.
Meet Thereby offimthae l an licensed underprovisinnsnf Chaporri Fommencing with JOB DESCRIPTION
�QOO Section 7000)of Division 3afthe Readmission Profcasions Cade,and my license is in
p
Fefull force and cl'I'cet.
w Iormucl.x 8 Lic.# ,,616416/ u �Q o PS
w<y Date Q3 Comm 'ACIs�f 'r 201 MPS
1-nz ARCHITECTS DECLARATION .
SQ.Ff.MOOR AREA S/SQ.FT
CZ-0 O ER )ANRS
O t_Q 1 understand ray plans shall be used as public moors. OA
F_F"uI SIGNS ELE 00 �R
4W�J Licensed Professional
P tYa< OWNER-BUILDER DECLARATION SPECIALCIR UI1'
Axx'OyF I hereby affirm that 1 in exempt from the Contractors License Lew for the
t+134w following mason.(Sectinn703LA Business and Professions Code:Any city arcounty TEMP.METT;R Nut INST.
lttl ONa which requires it penins to consumer.alter,improve,demolish,or repair tiny almentre
� prior toils iomnace,aborcquims theepplicant forsucbpetmit mfileasignedstatement POWER DEVICES
WOp that he is licensed purnauum the poesicurimme Cnntmaars license Law(Chapter
aaoP4 9(onmmoocing with Section 7")of Division 3 of the Business and Pmt'essians Code) SW I M MING POOL ELECTRIC I .� yyaaVwwALUATIOeAY'i
Wim or thin he is exempt herefrom and the basis for the alleged exemption.Any violation of
SOUTLETS-SWITCHES-FI%TURES
adion 70315 by any nimlicum rare pctmi t ubjects the p,lic
saCol niecivil penahy of
�2p
not mom than five hundred dollars($500). NEW RESIDENTIAL PLC= _SQ.IT.
IKFm ❑ Lusowrk,and the
formic
or tic(ec.c0mpenastram STORIES TYPE CONST'RUCT'ION
a3— will Jo lesions Code;'The cmreisnats License ed
Lo a dosnota(Sec.7(an Business
and Professions ldsori pr Contruors ndwho Law docs not apply m an owner of
proown enywyees,ideaiimprovcsch unFroanJtimare such work hlmseRrn through
mle.I. OCC OROUI' RES.UNITS
employees,Prov dMthatsve improvemenisarenae immadMmoffemA for sale.If,
hweer ,will have
burden of
proving
nghat he diino«year ofmprove on,thepose of
builder will hive the Furden of proving that he did nue buil)or improve for purpose of
e).
❑ I,annwneronhe nropeny,am exclusively convening wire licensed nmtmmoram QTY. PLUMBING PERMIT FEE Iq,00D ZONE pPN
consmict the project(Sec.7044,Empress and Professions CMa:)The Contactors PERMIT ISSUANCELicense l.aw d«s not apply o an owner of progeny who builds or improves thereon,and
whocontrachorsuch projechavith acommcrorls)licensed pumuanumhe Cmtmcl.ls pLT1iR-DNAIN&VENT-W ;A
License Law. J FF,E SUMMARY
❑ I nm exempt under Sec. ,D&P C fir this mason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITANY YN
Owner Data RF.CEIP1T#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP,AREA,CON SCHOOLTAX Y N
❑ Ihcreby affirm that lhaveacenificate of<onum oulf-insure,0rac<nif¢me of FIXTURES-PEk'fRAP RIiCF.II'1'p
or was Compensation has aranmoraanifiedcapythercof(Sec.3S00,Lnb C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INCA 0 RECEff`T#
Iblicy# - BUILDING DIVISIO FEIiS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCUECK FISP.
❑ Certified copy is hereby fumiahed.
❑ Certified copy is fled with the city inspection division. GNIIASE/INDUSTRL WASTE INTERCEPT GRADING FEE
CERTIEICAT'1;OF EXEMPTION FROM WORKERS' GRIiASF.TRAP SOILS FEE
INSURANCE,
(Thin section medal be completed Hine per mit is fotonehundredd011m;(5100) SEWER-SANITARY-STORMEd 300FT. IiNBRGY FEE /�
0r las.)
I certify that in the performance ofthe work for which this permit is issued,i shall WATER HEATER W/VENT/F.LECIR
mat employ any person In any manner In as to hgc �up�e m the Workers' PAID C
Z
Compensation I.uwlj)j >���7 /Y3 WATER SYSTEM/TREATING —Dale Rc tp a D
Z0 NONCE TO APPLICANT:ll,after making this Certificate of Exemption.you should NEW RESIDENTIAL.PLMEL SQ.FT IpTAL: .
Fto becumesubjeat to the Worker's Compensation provisionsofhe Labor Cest must
> fanhwuh comply withsue,provisions in this permit shall be damM revoked. BUIL ING FEB taaaaaalli
t]#i
Q CONSTRUCTION LENDING AGENCY SETS IC FREOL
Z I hereby affirm that There is a construction lending agency formeperformanceof TO'T'AL: EI CTNIC FI?E
L) O the work for which this permit is issued(Sa.3097,Civ.C.)
Lender,,Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING IgiE
1 cmify that 1 have read his application and aorta rent 0e above information is
A. tvmcv PERMIT ISSUANCE MECHANICAL FEE
�-•' ,,0 building construction,and hereby authorize representatives ofthis city marterupan the CONSTRUCTION TAX
L) Z above-mentioned property In,inspection purposes ALT ER OR ADD TO MECH.
(We)agree to save,indemnify and keep ha ss the City of Cupertino against
liabilieica,jungmenb,rests adexpenc reagainat avid City AIR HANDLING UNIT(TO 10,000 CFM)
vcme
gaa of tin
tAIR I IANDLING UNIT(OVER 10.0(10 CFM)
Signamm of Appli UCon nor Date EXIIAUS'f HOOD(W4)UCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA'T'ING UNIT LTO 100,000 BTU) Date Receipt#
Will the mpplicant m future building reeupant sore of handle harardmis materia)
as defined by lie Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety HFATING UNIT(OVER 100,100 BTU) TOTAI
Coda,Section 25532nd? JNO _ VENTILATION PAN(SINGLE RESID)
11LC Yes R
BOILER-COMP ULIP OR 100,000 BTU) ISSU NC�)AT,(y
Will eheupplicum«fmere building«cupanmuequipmentnrdevices whichemit #aa Y L�JJ
hazardous air contaminant,,as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) SEP)istda? // r11''
❑Yes rNn NEW RESIDENTIAL M[CH. SQ.FT. � 19 93
1 have read the hard
zaous materials requirements under Chapter 6.95 of the - //! Vl'
Culirnrnia Heehh&Safety Cade.Sections 25505,25533 and 25534. I understand that �Urt
if the building J«s not currently have a mnnnL that in is my responsibility to notify he 0
occupant of the irmepwn hie an he met prior to issuance me Cc ideate of
Owner nr an hot agent 'f ISSUCD BY:
OFFICE