25198 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OFCUPERTINO
HUH, I .-h.LC'1'RI AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT 1CHANICAL 25198
IIIIIhIJING PROJECT IUkN'I'INICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNITp LOTp
OW ' NAMIi: PHONE: CO ACTOR'S NAM- LIC NO:
NIC CONTROLp
• ARCIIIT[Cl'/ENGINE& LIC NO: ADDRESS: s ❑
CONTACT: PHONE: \
QTY. ELECTRIC PP.R FEE BUILDING PERMIT INFO
PERMIT ISSUANCEBLDG PLU P MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES 1,R ENTIAL JOB DESCRIPTION
QWz Iherebyaffinn Nm l am licensed under provisiorsof Chapher9(commencing with
a�IZO fall Bn]IKMB of Division3of the Business and Professions Code,and my licertu is in r IR f �� {�
y sC�pUpO full face and elf `
Lic,my Class Lica U 'O MPS
F=y Date lu^\NContact., s 2 AMPS A I,,z ARCHITECTS DECLARATION SQ.PT.BOOR AREA 5/SQ.FT.
ZOOVERT M
O Z pp 1 understand my plans shall be used n public records.
JE ,LicensedProfessional OWNER-BUILDER DECLARATION SC.
°Opw,U 1 hereby affirm that 1 um exempt from the Contrctors License Law forthe
h- following reason(Section 7031.5,Business and Professions Code:Any city or county OLE INST.which requites a permit to conmtua,alter,improve,demolish,or repair any sttuchim
prior.Is issuance,also requires the applicant for such penNno file a signed statement Cthat he is licensed pursuant to the provisions of the Connector's License Low(ChapterLLYcommencin LECI'RIC
xc (commencing Section 7000)mf Division the Business end Professions Code) VALUA
WMos or that he is exempt therefrom and the basis for alleged exemption.Any violation ofUTLETS-SWITCHFB-FIXTURES
It
Fa Section 7031.5 by any applicant fora shomit,clayets the applicant no a civil penalty of
I `
SS not mom than five hundred dollars($500). _
y+Fo C] 1,mownerofthepoMny.ormyemploymwiNwagesv NeirwlecompensadNEW RFSIDENTIALCLECfR on, SQ.IT. STORIES TYPECONSTRUCDON
willdothework,nnd themnitcone is no,mendedoroffcreA fo...le(Sec.7044.13miness
and Professions Code:The Contactor.License law does nm not to an own,of
property who builds or improves thereon,and who does such work himsel for through his
owaemploym,providedthat such improvements marot intendedoroffered formic.If, G UP IRS. NITS
however,the building or improvement is sold within one yearofcnmpletion,the owner. TOT
builder will have the burden of proving that he did not build or improve for purpose of -OV,
sale).
❑ 1,nowneroDhe propmy,amexdusively contectmg wiN licensed conwcmrsm QTY, PLUMBING PERMIT FEE 1 DANEN
menet the project(Sec.70,14,Business and Professions Cale)Ove CommitppRMIT ISSUANCE J'
License Lawdoesnot apply loan ownerofproperty who builds comment thereon,and ATE / 7
who contracts forsuch projects with a contracter(s)deemed purmanuarhe Contactors
LicAI T13R-DRAIN&VONT-WA'IiR(PA)
FEE SUMMAR
Ce
Law.I am exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICEO f"
SANITARY Y_N
. Owner Date RECEIPT g
DRAINS-FLOOR.ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ 1hereby affirm that l have a ceniftcmo cleanser,to sel6insute,or a cenificme of FIXTURES-PER TRAP RECF:IPTM
Workers'Compenactime Insurance ora cmifiedcopy therem(See.3800.Lab C.)which PARK IEE Y N
covers all employee'a under this Permit. GAS-FA.SYSTEM-I INC.4 OUTLETS RECHIPT g
Policy at BUILDING DIVISION FEES
pony GAS-EA.SYSTEM-OVER 4 RA) PLANCHECK FEE aossass
n Cfnlfiest copy is hereby furnished. Q
❑ Certified copy is filed with theciny inspe.iondomoa. GREASRANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS HE
COMPENSATION INSURANCE
(This sectionneed not be completed ifthe permit I.for one hundred do[]..($100) SEWER.SANITARY-STORM P.A.200FT. ENERGY HE
or less.)
I certify that in the arfom.nce.f Ne work for which this permit is issued.Isbell WATER HEATER W/VENTp3LECTR
not employ any person in any manner so as to become subject no the Workers' PAID
Z Compenwinn Lawsof C.lifomla. Data WATERSYSTEM/IREATING Dam ReceiptM
Applicant
Z 2 NOTECE'TOAPPLICANT:lf,af.,.ding N,Cmifcateof E.e.Nion,youshould NEWRESIDENTTALPI.MB. SQ.FT. 'TOTAL:
> forthwith
comply the Worh pre Compensation ermisionsofthe Lnbm Codeyou must BUILDING ITE
a ; forthwith comply with such provision or Permit stall Its,returned mvokW.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE ♦✓
V Ihereby affirm that them is a construction lending agency for the performance of
ELECTRIC FEE
O the work for which this permit i.issued(Sec.30197,Civ.C.)
4. .-t Lenders Nam.
Q [Cr, Lenders Address QTY. MP-CIIANICAL PERMIT FEB PLUMBING FEE
1 certify that 1 have read this application and state that the above information is
RWi cmmct.lugaemcomply wiN ell city end cotmty ominenm and state levee mledng to PERMIT ISSUANCE MECHANICAL FEE
building construction,and herebyauthonze representatives alibis city it)enter opium the
V 2 a d property fm inspection purposes. ALTER OR, TO MECH. CONSTRUCTION TAX
r-t I We)agree ave,indemnify end keep harmless the City of C.Pertlm.agmen
ImbilRie..)udgmems,c s dexpenws whichmryinmy way wcmeagainst said City AIR HANDLING UNIT ITO 10,0110 CFM)
in eon yuenoe of the gin 'ng of this pe it. AIR HANDLING UNIT(OVER 10,000 CFM)
netua actor Dane EXI IAUST HOOD(W/DUCG
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date ReceiptM
Will the applicant or fuarc building rccupual st.re or handle hazardous material HEATING UNIT(OVER 100,(X10 BTU)
as defined by the Cupertino Municipal CodClaude,ude,9.12,and the Health and Safety
Cale,Section O 11532(a)?
E3 ❑No VENTILATION PAN(SINGLE RESID)
Will doeapplicant or lucre huilAing mcupam uu equipment urdevices which emit
BOILER-COMP GHP OR 100,000 BTU) ISSUANCE DATE
hazantous air contaminants as defined by the Bay Ares Air Quality Management BOILER-COMP(OVER 100,1X10 BTU)
Dislnn7 P a
❑Ya 11 No NEW RE.SIDF.NTIA1.MECH. SQ.IT. aW
1 have read the hare dous m.eriNs requirements under Chapter 6.95 of the ���
Califomia Health&Safety Code,Sections 25505.25537 and 25534 1 undersand that n
if the building does not currently have o tenant.that it is my responsibility to notify the Q�
occupant of the requirements which must he met prim to issuance of a Certificate of
Occupancy, V
f
Owner or authorities].gem Data ISSUEDB .