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25221 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPESION '- ' PERM NO. /) APPLICATION/PERMIT PLUMBING-MECHANIFICA (.� BUILDING DIVISION BUIIAING I'R(4,IF•.CT'111F.N'1'IN'ICA'1'ION 25221 BUILDING ADDRESS: SANITARY NO. APPIJCAT'ION SUBMITTAL DATE UNIT N LOT# O S A E: I'll 1?: CON'RACTO 'SAN ME' r LIC O' NIC CChGJdOL# • ARCHITI: VENGINEER: LIC N : A1f7qSS: sed ❑ CONTACT: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE BLDG E�ECTr PLUMB M ff PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION py.Z I hereby affirm that l am licensed underprovislonsof Chapter9 m (comencing with t 00❑ Section700lpof Division 3ofthe Business and Professions Code,and my lice..is in PANE �ZU full force and effect's - 4 tmD Lice I.1 V Lic.Is UPTO200AMPS o,6 N Cute Contractor 201-1000 AMPS F'yZ ARCHITECTS DECLA RA E SISQ.FT. ZOsn— OVER 1000 AMPS 1 � ' I understand my pians shell be used.public records. Fyt� Licensed{hofeuional II— 1'.1f SIGNS ELEMICAL 1 11 ri p p T E fr'd y�d y OWNER-BUILDER mom,CRATION r SPECIAL CIRCUIT/MISC. ip0.�ee,,,OaF 1 hereby nfrom.(Se that I ore ,Business usin from the Contractors License Law for the 124 Yl3 pm followinguieson.archon consu .Busines sand Professions Code:Any city orcountyTEMP.METER OR POLE INST. DATE �!• 7 f•4s y g which requires a permit to construct,elmq improve,demNiah,or repair my ewaum ',�✓+}� prior to its Issuance,also RyulRa the applicant for such permit to file a signed summent POWER DEVICES WO p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 4yx p fl 9(conunencing with Seen..]")of Division 3ofthe Basin.and Prefevin.Code) SWIMMING POOL ELECTRIC VALUATION W_rn cur that he is exempt therefromand the basis for the alleged exemption.Any violation of I� OIITLBfS-SWITCHES-FIXIIIREg�FG Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I not mom than true hundred dollars(5500). CCCo ❑ 1,asownerofthepnpKrty,mmycmployeeswithwagesastheirsn]ecompensation, NEW RESIDENTIALELECTR _SQ.FI'. STORIES T'YPECONSTRUCTION y300 will do the work,and the swaure is not intended or offered for We IS..9044,Business and Professions Code:The Contrucror's License Law does not apply to an owner of property who builds or improves thereon,and who dee.ouch work himself.,through his ownemployces,pmvidedtbatsuchimpmvementsv nwintendedoroffemdforsaie.If, OCC.GROUP RES.ON[IS however,the building or improvement is sold within oneyearofeempleim.themener- builder will have the burden of proving that he did not build or improve for purpose of ' sale.). ❑ 1,.ownerofthepmp.ry,amexcl.ivelycontnctingwithlicensedmnwct. ,. QTY. PLUMBING PERMT FEE FLOOD'ZONE APN consomet the project(Sec.7N4,Business and Professions Code:)The Convector's PERMIT ISSUANCE Lice se Law does not apply toanownerofpropeny,whobuilds or improvesthereon,and who contracts forsuch projects withaconVeclor(e)licenfed persuant to the Connacm/s License Law. ALTER (EA) FEL SUMMARY ❑ I am exempt under Sec. ,B&P C for this reason HACK FLOW PROTECT.DEVICE O IDs .E SANITARY Y N Owner Date RECEIPT p GRAINS-FLOOR.ROOF,AREA,COND. WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N ❑ Iherehy affirm that lhave acertificme ofemunua selGinsurc,orecertificate of RECEIPT# Workcri Com FIXTURES-PER TRAP 101pensasion lnsurence0raunifiedcupy thereof(See.3800,1ab C.)which PARK FEE Y_N coven elleAW er hie Resit RECEIPT# ST7] :1.AN GAS-FA.SYSTEM-I INC.40U'I'LFTS BUILDING DIVISION PEES Policy N� �^ 0 Cert l a GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ CcnifieJ copy is herchy famished. Certified copy is filed with the dry inspection division. GREASUNDUSTRI.WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASCTRAP SOILS FEE COMPENSATION INSURANCE (This section nerd not he completed ifthe Permit is foronehundred dollars($1013) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or lay.) I certify that in the performance of the work far which this permit is issued,l shut] WATER HEA'I'HE W/VENT/ELECIR not employ an person in any maseter a.u to became subject to the Workers' PAID 7mac;nmi. of CaHm.. Date WATER SYSI HNIVRPATINO Date Receipt# O Z Applicant z 0 NOTICE APPLICANT:If,after making this Cer6f¢are of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL: fA become subject to the Workers Compensation provisions of the labor Code,you must Lam^ ; forthwith comply with such provisions,or this Permit shill be deemed revoked. BUILDING FEE W z L' CONSTRUCTION LENDING AGENCY SEISMIC FE C� Ihereby of cat that there is a denstmcticn lending agency far the perfomwnes of TOTAL: ELECTRIC ITB UC) the work for which this permit is ismed(See 3097.Civ.CJ LLi Lender'.Nance - O Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING IEE 0. 1 certify that I have rend this application and sate that the above inftmmatlon is flat correct.Io tocom 1 with all cit send count rdinances and stem laws missing to PERMIT ISSUANCE MECHANICALFEE gree comply Y Yo B �. huilJingconsuudion,end hereby amhorize rcpmsenmtives of thio city toemerupnn the CONSTRUCTION TAX O Z above-mentionedm pperry for inspection purposes. ALTER OR ADD TO MFCH. (We)agree Intense,indemnify and keep harmless the City of Cupertino against .-m liabillon 'udgmenta.costsun n neaswhich may in any way scheme against said City AIR HANDLING UNIT'(TO 10.00)CFM) I n co ! cope a(Ni of Thi it. 7_(9_yy AIR HANDLING UNIT(OVER IO.OW CFM7 . gnammof ApplicmVCmhr rot Date EXIIAUSTHOOD(W/DUC t PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 110,000 BIT) Date Receipt# Will the applicant or future building occupant store or handle harvrdom material HEATING UNIT(OVER 1011,000 BTU) TO as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Cade,Sermon 25532(0)7 ❑Yes 11 No VENTILATION PAN(SINGLE RESID) �— BOILER.COMP 0HP OR Uroda Xl RTU) ISSUANCE DATE. Will the 0cmdurmmfmum building by the ay Are.Air ualityttswhicM1ema pT - p DSsudet?lachourchmit cornami.nts.Jefimd by the Bay Artu Air Quality Menegement BOILER-COMP(OVER IW,WO BTU) 1� P Dis a7 � ❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. RJ(O 349 ga �� 1 have read the hazardous mmenals requirements under Chapter 6.95 of the 3 49 /�„ Califomia Ifcahh&Safety Code,S.tions 25505,25533 and 25534. 1 understand Net `Y'd4l if The bt'Iding does nm curets he tenant,that it is my responsibility mmoify the /��u of 1pe"air m s hi Y st be met prim m romance of.Cenificam ofV�Vf'"C(/T j�fjPv c u /'Fly wrier or authorized agent Dom L: ISSUED BY: