25084 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
RTINO BING N 31' FERMI"1NO.CITY OF CUPPLUMBIN -MECHANICU
BUILDING DIVISIONAPPLICATION/PERMIT BO25084
F
BUILDING ADDRESS �j may, SANITARY NO. APPLICA')ION SUBMITTAL DAIT
/O" Z 3 W Ot /J UNIS( 7-0iW I.T. 5��� 3
OWERS NAME: PHONE: CON JACTOR .
S NAME: i LIC NO: N/C CONTROL
Gv?Srr�,nn Slt� (L tSn�uP D2�7 (�t�1 . Gd.> 3 yizs3
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CONTACT: PHONE:
�/,� �� � /�� /(�/ ply QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
CI
CH-ui—IL Fok�GL /y�,b�� �Z /O PERMITISSUANCE B CT U
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENIAL JOB DES( IITION
na•Z I herebyaffinn that l am licensed under pmvisionsof Cbapter9(commencingwith
yO� fulltNm(n JOeffewision3of the Business vnd Pres'S33anJ my Eeewae is in PANE(.SN M /yam '''(/'�'
FZW License frx/ 13 Lic.It 1 , any F
y6a Die ��/�_/ Convenor +�/� 2 I MPS
I—,z ARCHITECTS DECLARATIONSQ.FT.FLUOR AREA $/SQ.FT.
ZOy— RIt01UA S
oz-0
1 understand my plans shall be used as public records.
F,rn F•W SIGN F.E I ` 1 D� YP
2� D0
QY�,,, Licensed Pfolcssumal Y\
�I a'6 OWNER-BUILDER DECLARATION SPECIA I T/MISC.
XOyU1 hereby actions that 1 am exempt from the Contmetors License law for the
W 3 LL y following reason.(Section 7071.5,Business and Professions Code:Any city or county TEMP. R OR POLE INST.
l-4,0 which requires a permit to constmct.alter,improve,demolish,or repair any structure
$yu1}5 prior to its isimian ,also requires the applicant for.such permit to flea signed.statement POWER DEVICES
WKOO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
eaMT 9(commencing with Section 700(d of Division J critic Business and Professions Code) VALUATION/
WM, onM1at he isexcmpt tticrtfromand the bmis(or Ne alleged exemption.Any violaion of UTLETS-SWITCHES-FIXTURES ��y a ��
HZQ Section 703 L5 by any applicant for apvar it subjects the applicant to a civil penalty of l
s Q not me than rofthevc property.
dollars($500), NEW RESIDENTIALELEC1'R _SQ.IT. STORI.S I'YPE CONS'I'RUCI'ION
o ❑ othe wrk,adheestrucy.nrmyempindees d!withwad forsale(Sec.compensation,
will Professions
work,and the structure Cont actor intendrd or ave ed dos not apply
t an Business
and Professions Code:improves
ves da eon,License law docs not apply to an owner of
property who buildsormpfat suchemon,andwhod«ssachworkM1om1fedthrough his
employers.provided then such imprnv<menfsarc not inlendeJoraffertdfunalc.If, OCC.GROUP RES.UNITS
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving dist be did not build or improve for purpose of
sale.).
❑ I,mowncrofthepmpny,amexclmivelyconv tingwiNliaesed ..n t.l. Q1 Y. PLUMBING PERMIT FEE FLOOD ZONE MIN
convect the project(Sec.7034,Business and Professions Cade:)The Convenor's
License Low Joesnot apply to an ownerofpropeny whobuildsorimproves thereon,and PERMIT ISSUANCE
who vonvncls for suchpmjccts withaammrunogs)licensed pannamovdic Cnmrucmr's gLTER-DRAIN&VFN'f-WATER FA
LicroveLaw. (. ) FEE SUMMARY
❑ 1 an exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSI FTPS
SANITARY YN
OwnerDRAINS-FLOOR.ROOF,AREA,COND.
Date RECEIPT"
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
F Is,Co penrm thatInsurance
oraccateof consent sure,nrnccrlificade of FIXTURES-PER TRAP RFCIEIPI'M
'ohM Compensation lnsumnce oreanifeJ copy thereof(Sec.Jg00,Lub CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPTp
Policy. BUILDING DIVISION REFS
Cum yB AS EA. TF VER I ) PLANCHECK FEE 3
Ccrtif ivd copy is hereby famished.
C3CcnilieJ copy is OlcJ wiN the city lnspcnion division. `; GREASE/1 DUSTRU`WASTEI f CEPTOR GRADING FEC
CERTIFICATE OF EXEMPTION FROM WORKERS' ( GR 5. AP, ` SOILS FEE
COMPENSATION INSURANCE �.J
(This section need not be completed ifthe permit is fursme hundred dollars(5000) SFWE A 1 Y .2WFT. IWERGY FEE S-6-6
art Iesa.)
I cenify that in the performance of the work for which this permit idy ed,Is R � b .S 7 ylg
not employ any person in any m at, to become subject tolTe•Workers' PAID lb" /}
Compersmmnlawsuf Cdifom0a.manner
so WATER SYSTEIATREAIING Dae Receipt.
zz Applicant
0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDF.NTIALPLNUL SQ.FT. '1'0 L:
FDO become luhject m the Worker's Compensation provisions of the Labor Cada you must
> forthwith comply with such provisions Or this permit shall le deemed revoked. BUILDING FE' 3 36 .12
IX
CQ CONSTRUCTION LENDING AGENCY STISMIC 8
U Z Ihereby affirm that is a construction lending agency for the performance of 'IU ♦ CI CCI, C �rC
O the wsln [S
ork far which thinnit is issued m.3090.Civ.CJ
Lender's Name
D" F Lenders Address QTY. MECHANICAL PERMITFEE PLIJING FEE
V 1 certify that I have mad this application and smote that the above information is M 'HA CAI.FF.
correct. l agree to comply withal)city and county ordinances and state laws relating to PERMIT ISSUANCE
V Z building construction,and hereby amhoriu<representatives ofthis city to enter upon the CONSIRUCfIf TAX
ub.,u inmuioted property lir inspection purpose, ALTER OR ADD TO MSCI I. 'r
(We)agree to save,indemnify and keep ham)rax the City of Cupertino glowed
r livaebimlityiees,judgments, penuswhu, mayinsnywayaceruea,dreasaid City AIR HANDLING UNIT(TO 10.000 CFM)
remyey s cangrting ox his pctmiL S'—/ _Aqz AIR HANDLING UNIT(OVER IO."CFM)
Signature of ApplicanUContracdor Date EXHAUST HOOD(Wd)UCI'1 PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO 1100,000 BTU) Daa, Receipt.
Will the appCa,rirfmurt buiml Core.Camnorcot handleha�oand Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by Oc Cupcnino Mun1 'pal Csde.Chapter 9.12,and the Health and Safety
Code,Samoan 25532(a)'l VENTILATION FAN(SINGLH RESID)
❑Yes 6d No ISSUA CE DATE
Willtheapplicant orfuwmbuidingoccupant usccgoipmentordeviceswhichemit BOILER�COMP OHP OR 100,00)BTU)
"oBOILER or contaminants as def d by the Bay Area Air Quality Management BOILER-COMP(OVER IW,000 BTU) D
yrictl
❑Yes n< NEW RESIDEMIAL MSCI I. SQ.Fr.
I have tad the Safe,,
materials requirements 3 under Chapter understand
of Jaid 'JUL
1 1O 1
California haalth ve ons!
Safety Code,Sections 25505,eme t vndder Ch I ter 6.9 an f then d L J
if the huilding docs nut cmmntly have a tanam,that it is my responsibility to notify die
I'm e reyuamt• which muss he met prior to Lommce of aa/Ccnifccmmu of Cfl Y Ur ver •.r I
Own am rued ager Date 'AL ISSUED BY VVY\ 1 \/