25200 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECINIAL PERMIT NO,
APPLICATION/PERMIT
PLUMBING-MECHANICAL
BUILDING25200
BUILDING DIVISION BUILDINGPROJECT IDERI'IFICA'I'IUN
BUILDING ADDRESS: SANIARYNOPPPPLICA'HON MURMMMH•'AL DATE
(U'T# �LT!
OW
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C RAMORSNAME: LI N
li-�/\`�J[ � N/C CONTROL p1
'.�ARCIIII CI'/IiNGINEIiR: LIC NO: Ii55: ❑ {�V
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CONTACT: PHONE IBUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BL r ' [ PLUMB MEC
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDE IDB DESCRIPTION
QKZ Iherebyafr..that l am lieetsedunde,ecobionsof0m,ser 9(commend.,with
4100 Scam.7BWlor Division 3of1he Business and Pubessiore Code.and my hernse is in PANELS
y,ts� full fercread effev" `
wZcu License I Lic.M UP 2
QO• Dam ConlruClnr 2 1 I NS
I—M oo - ARCHI'TELTSDECLARATION O AMPS SV.FT.II.00R AREA $/SQ.In'.
Z O m I un�lc aEgmy plans shall h used as public records.
GNS EL TRIC
CY Licensed 1cmional
�0Q OWNER-BUILDER DECLARATION SPECIALCI . SC
I hereby of ern,M1m 1 am exempt from the Contractor's license law home
Wan-v[—i following must(Section 7031.5.Business and Professions Code:Any city or county TEMP.METE .f:INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
�cnY2 pdonnhaisauance,alao requires,he applicant for.such pewit to Flea signed statement POWER DEVC'
C p Q that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aio 9(commencing with Section]000)of Division 3ofthe Business and Professions Code) IIu(MING L IIILE VALUATION
4
Moo or that he is exempt thercliom and the basis for the alleged exemption.Any ttRES violmmn
I_ZQ
Section 7031.5 by any applicant for a Permit subjects the applicant a civil penalty of mLETS-SWI'r ti XTU
m than five hundred dollen(S500f
$$Sp not mu NE ESIDE A •LEM _SQ.FT.
Ca F_p ❑ I,asnwnemfthe prepenY,tr�,yemployeea withwageamtheireolc con,pcnsmiory STORIES TYPE CONSTRUCTION
i3=e killd.1hewod,andthe someone isnot intended or offered for sake(See J044,Business t
and Professions Code:The Contracmfs Littnse Law does not apply to an owner of
prupony who hui Ids or improves thereon,and who does such work himself or through his
ownemployxs,providedthat such improvemensare not immrdedoroffertdforsale.If. ❑ q g�YCC_GItO P RIiS.UNITS
however,the building or improvement is sold within ora year ofcompletion.the owner- q 1.\/I fa•+ 'I
bui Idcrwlll havctheburdenofProving,hathedid notbuildorimprove forputpossof Yl7 YYY
f LIJif
AIE
sale')' QTY. PLUMBING PERMIT F E APN
❑ I,aowner of the PropcnY.amexclusivdy comrsting with lianscdconunnorsrn
construct the project(See,7044.Business and Professions Cade:)The Contractor's
License law dues ma.pplym an owneroTmpery who builds or improves thereon.and A
PERM IT ISSUANCE _
who Contracts for such pmjCUS with acmntracmgs)licensed pursuant o the Contractors ALTER-DRAIN&VENT-WATER(Fs) FEE SUMMARY
Littnse Law.
❑ 1 um exempt under Sec. ,B&PC for this reason OU'1 SITU:FEES
BACK ROW PROTECT.DEVICE
SANITARY YN
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL LAX Y N
❑ Thereby effirm,M1atl M1aveaanificete of conxmto self-in sure....crnifiw¢ofRLC:17a
Fl%TURES-i'ER TRAY
Workeri Compensation Insurance oreanifird copy thereof(Sec.3g00,Leb CJwhicry PARK FTE YN
covesall employee's undertho,mut. GAS-EA.SYS'IEM-I INC.4OUTLETS RECEIP #
Policyro BUILD GDIV ON FEES
Company GAS-EA.SYSTEM-O V ER 4(EA) PfANCHECK FEF,
❑ Ccmfiedcapyisherebyfumishcd.
❑ Certified copy is fled with the city impretion division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(his section need not be completed lithe permit is for one hundred dollars(3100) SEWER-SANITARY-STORM EA.200FT. I7NERG PEE �+
or less.)
I certify that in the perfomance of the work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR If
not employ any person in any manner so a,to become subject to the Worker: PAID
Compensation i,aws of California. Dam WATER SYSTEMTREATING Date
A)Von
O z Applicant
� NOTICE TO APPLICANT if,after making this Certificate of Exemption,you should NEW RESIDFJPIAL PLM. SQ.FT. TOTAL:
zz
become maretm the Worker's Cumpcnsmion powisionaor,he Lupo Cade.you mus,
C54 7 forthwith comply with such Provisions or this .if sha116e deemed revoked. BUILDING FEE
Q CONS]ROCHON LENDING AGENCY SEISMI
Z I hereby affirm that there is a construction lending agency for the performance of T A ELECTRIC FEL
UO Ne workror whichi
this arem,is isaoed(See.3W],Civ.C.)
Lender's Name PLUMBING PER
F Lender's Address QTY. MECHANICAL PERMIT FEF:
U I certify that I have read this application end sate that the above information is MECHANICAL FEE is
�^ W Core". PERMITISSUANCH
F' Lbuildingematmetion,and hereby nutho err repreaematives ofthis city reenter upon the CONSTRUCTION TAX
Uabove-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
1 (We)agree to save,Indemnify and keep hmmleax,he City of Cupertino against
Iiabilities,judga¢rets,costs and capeases which may in any wayacer against seri ny AIR HANDLING UNIT(TO 10,000 CI-M)
me ace of the goy ting of this permit.
t AIR HANDLING UNIT(OVER IO,IXg)CFMI
ignnwren PPlicant umrect Dat EXHAUST HOOD(W/DUCT) PAID
HAaa
LARDOUSMATERIA OSURL HEATING UNIT IT0100ktgl BTU) Date Remipt#
Will the applicant or future building occupant roe or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by thr Cupcnloo Municipal Calc.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? VLNTIIATION FAN(SINGLE RESID)
❑Yrs ❑No
ISSUANCE DATE (
Will the applicant orfmore building«cupant uuequipmentordevicessehichemit BOILER.COME(HIP OR 111),000 BTU) q
. hessdous air commitments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) W I D
Dinuicfl
❑Yes ❑No NEW RESIDENTIAL MEClI. SQ.FT. J �J'I have read the hazzrdous materials requirements under Chapter 6.95 of the R/(Clifornia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand than
if the building does not currently have a tenant.that it is my responsibility to notify the :UM
Lr
urapam err me regmre:,,ema wbirn,n„w x mer oder to iaamanee ter a Cenifirma ter V V�Ch I/
Occupancy. V
Owner,or amhorimd agent Dam TO ISSUED BY: