25461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO m7H:Dm7reLECTRICAI, PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 25461
BUILDING DIVISION BUILDING PROJEC9'IDENTIF'ICA'TION
NUIL.IING ADOR^E SANITARY NO. APPLICATI�N S_'UHMfITAhQDATE'
IOl [/� LwV s ON[f# LOl'p71...)
OWN#1 N MF CON'1'RALTj)R'S NAME: LIC NO:
_TJ N/C CON]Rol.
• ARCCT/FNGINEER: LIC NO: A FSS:
CONTACT: PHONE: I BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BL G � ECf PLU n ECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION pPPLUWCFS-RESIDFNTIA
004Z I hereby affirm that lam licensed underMvisionsof LTapter9(commeneingwth )OR DESCRIPTION
WOR
S.Ima Sof the Business artd Professigons Cade.and my license is in PANELS
Li Clasit s "� Lic.# ✓� UPT02WAMPS JO
ti Q a at — "` Contact 1 201-1000 AMpS
Fy - ARCHITECTS DECLARATION OVER IOWA S /� SQ.PT.Fl.OREA S/SQ.FT.
Z O y 1 undcmonA my plans shall be used as public records. L�
Pyn- /
twy SI NSE LCAL SIL v�
¢Y f J LicensM Professional
C'=< OWNER-BUILDER DECLARATION 1 DtCUIT
KOwu I hereby Off,.that I,n exempt from Ne Convea,'s License law for the
mans following reason.(Sation 1031"1,Business and Professions Code:Any city or county ST.
F O¢ which requires Ir permit to construct mer,improve,demolish,or repair any swcturt
Io,
prior to it nordec,nlsareynires the applicant breach pcmrit to filen signed suremem WERD
K¢p Nut he is licensed pursuuntm the provisions of the Cransto is License law(Chapter
aaoM 9(commencing with Section 1000)ofDivision J ofthe Business and Professions Code) gWIMMLN LELF.CfRICell VALLUL ON
�
w to or that he is and the basis for the alleged exemption.Any violation of Ol1TLEf5- ITCHES-FIXTURES
t-Z G Section 1031.5 by any applicant for a Permit subjects the applicant too'is il'had"of
FZp not most than five hundred dollars($50(l). NEW RESID AL ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
CF. [) ormyemployeuwithwagexssnc�iraolecomperuadon,
will do the work,and the swcwre is not intended or offered for sale(Sec.TOM,Business
and Pmfessions Code:'I'he Contractors License Law does not apply to an owner of
property who builds,imp rovies there.,and who docs such work himsel for through his /
employees,pmvidcd Nmanch improvemcros arena imendedormffecd for sale.If. OCC,GROUP NIiS.UNITS
however,the building or impmvemem is sold within one year of completion,theowner-
builder will have the burden of proving that he did not build,improve for parpou Of
ale.). QTY. PLUMBING PERMIT FEE FLO ZOZONE APN
❑ I.a woero0hepropeny.amexcimivelycon=tingwithlicensedcom .a to
consumer the project(Sec.1014.Business and Professions Coded The Contractors
License Lawdoes not appy to ovosocrofpropcny who builds or improves thereon,add PERMIT ISSUANCE,
who contracts for such projects wish.cmdmcmr(s)licensedPursmuauo he Conlowlm I ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
Liscnsa Law.
❑ I am exempt under Stt. ,B&P C for this w'on BACK FLOW PROTECT.DEVICE, O TSI DE PLI:5
SANITARY Y N
OwnerDam DRAINS-FLOORROOFAREACoN RBCGIPI'x
WORKMAN COMPENSATION DECLARA . , ,TION SCHOOLTAX Y
• ❑ Thereby affirm that lhave ecertificme of conuntm self-insum,oracertificate of RMCEWTFIXTURES-PER TRAP M
Workers Compensation Insurance ora comfort copy thereof(Sce.3800,Lab C.)which PARK ME Y IN
—
Workers
all employee's mode,his permit. GAS-PA.SYSTEM.]INC DITfLETS E E
covers
Policy Is 1 v FfFS ativ
Company GAS-EA.SYSTyi(d- R4(EA) 9#1D
II KPEE
❑ Certifiedcopy is hereby fumish d.
as a—
❑ Certified copy is fled with the city inspection division. GREASEANDU RASL I C
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEP 4
m
COMPENSATION INSURANCE
(Thoscedon ndombecompleed if Nepeniir isforoachundrWdollars(E100) SEWS SANITARY-STORMEA.200F. JAY'Y FEE
or le"'.)
I certify that in can perlbnnance m the work Por which this permit is issued,Isball W HPATI W/VB E
not employ any person in any manner so as m become subject to the Workers'
Compensationlawsof Califumia. Date— ATER SYSTEM/1'ItEATING Dae Rttpt
ein
Z
Applicant
DO NOTICE TO APPLICANT:If.after making this Ceniftun Of Exemption.you shouldNEW RESIDENTIAL PLM. SQ.FT. TOTAL:
f" r/) become subjecmo the Worker's Compewticn provisi,o of Ne Labor Cade,you mus
� 5: forthwith comply with such provisions or this permiuhall be deemed revoked. BUILDING PER a/_
91-
U
(] CONSTRUCTION LENDING AGENCY SEISMIC FEE It `
I hereby affirm thuuM1crc isaconstruction lending agency for rhe perform, of
`7 '� the work for which this permit is issued(Sec.3091,Civ.Cd TOTAL: ELLCfRIC FF.E
U O I.cock's Name
F tandems Address QTY. MECHANICAL PERMIT FEE PLUMBING FF.F.
U 1 unify that I have read this application and sate dot the above information is MECHANICAL FEE
III ronect.lagreearomplywlrhillciryandcounyordirwcessrNstatelawsmlaingto PERMIT ISSUANCE
F^ building construction,and hereby authorise mprcumativesof Nis city to enter upon the CONSURUCTIONTAX
� IZI
'Z ab,e-mentioneA pro ny for inspection purposes ALTER OR ADD TO MECH.
(Wa)ugrcu m.n indcmni d keep harmless the Cary of Cupertino against
liabilirics,judgmen , sond ex a es which ma yin any way acemeu ins said Ciry AIR HANDLING ONI'I'('1'010000 ChM)
segmc oft ecosaw o[h' pe it
AIR HANDLING UNIT(OVER 10,000 CFM)
oat of Ap Dat EXHAUST FOOD DVMUCTI PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
W III the applicant or future building occupant same or handle haauNoos mamrial TO
asdafined by the Cupertino Municipal Code,Chime,9.12,andthe l lcuhh and Salety LIGATING UNIT(OVER 100,000 BTU)
Cuda.Section 25532(a)? VENTILATION PAN(SINGLE RESID)
❑Ycs ❑No ISSUANCE DATE
. BOLER-COMP(JHP OR IW,B00 BTU)
Will thealtltlicanrorfuturebuildin occu nLuseeqipmcntordevices whichemit
QQ�� pp
A
haranlous air conmmired,as deftncd by the Bay Ams Air Quality Management ,000 BOILER-COMP(OVER 100BTU) p- D
Dis cr?
❑Yea ❑No NEW RESIDENTIAL MfCl1. SQ.14.
1 have mud the hmarduus materials rcymirtmems coder CM1aper 6.95 of the AUG 301993
California Health&Safety Code,Sections 25505,25533 and 25534. I understand Nat
i«the building dons not currently have a tenant that it is my responsibility to notify Ne
cultism of the requirements which must Fe met prior to issuance of a Certificate of CI I't Ur UUr CI L 1 11 1
txrmwncy.
Owner or euthoriacd agent Dae ISSUED BY: