25503 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY¢2&CUPERTINO • --' PERMITNO. O
APPLICATION/PERMIT PLUMBINO-MECHANICAL.
BUILDING DIVISION IIUII,DING PROJECT IDEN'PIF'ICATION
BUILDIN3 ADDRESS SANITARY NO. APPLICATIONSUBMUTTTALDATE
ZJa6 De a r, 04, UNITM LOT saaas`)_�.`
OWN' N ME: "�6PHONE: CONTRA OR'S NA E: LIC NO: V
6 S rt 4 ��1— / 1-1 1 NIC CONTROI.p
0.CHITECTIENGINEE0.: LIC NO: ADDRESS: ❑ � 5�
CONTACT: PHONE: BUILDING PERMIT INFO
as, '/� ((�� // QTY.- ;- r EL C�PERMIT FEE
as, YQ�.V ���O'S) � 1V PERMIT ISS£my'IEEl
�. v"1.: L PLUMB MECH
LICENSED CO cr'R'S DECLARATION APPL -RESIDENIO JOB DESCRIPDON
Matz I herchy affirm that l um licensed underprovisions of Chapter9(commencing with
f�0O Section 7")of Division Softhe Business and Pmfcasions Code,arta If..y liai¢in Is
ff�; full force end effect.
Fz❑ License Class Lic.N AMPS RVO
to 6 y Data Conn.. 1- AMPS
ZO vD ARCHITECTS DECLARATION 0 1000AMP SQ.FT.FLOOR AREA �a $5Q.FT'
OZ-0
I understand my glare shall be used m public rccoma, r1
a g v Licensed Professional SIGNS HLH 1 TVl
5 OWNER-exempt RDEC Combs DN PECI IRU LSC. Lf
XdXOaU 1 nearby affirm thus 1 em exempt from the ConvactWa Liceve Law for the '
sl3LLy following reason.(Section 7031.5,Business and Professions Cade:Any city or county Im RPOL ST.
toWhich requires a Mount to concoct,aha,improve,demolish,or repair any srumure CES
that he is licensed pursuant to the provisions ofthe Comrsctues License Law(ChapmrG.L ' 9(commencing with Section 7000)ofDivision 3 ofNe Business and Professions Code) M GPOOLELECIRIC VALUATION
m ohot he is exempnhercfmmend Ne basis for the alleged exemption.Any violationof TLETS- WITCHES-FlXTURES
< Section 7031.5 by anyapplicat fest maimbjecs theapplicrnt to.dvil perslryof
mmnot mare than five hundred dollars(SSOo). NEW RESIDENTLLL ELECTR _SQ.FT.
❑ I,asowneroftheproperty,mmyemploymswithwagesastheirsolerompens.tion, STORIES 9'YPECONSTRUCTION
willJnthewvrlstmai henrucwre isnot imm�redoroffercJ forsnle(SecA044,Bu¢inas
arm Professions Code:The Comrecrors License Law does not apply to en owner of
proanny whobmidsorimproves thereon,and whodassuch work himselforthrough his OCC.GROUP RES.UNITS
cmployess.pmvidcdthat such impravementimen a iatrndedaaffemd fame..IL
however,the bulldingor impmvamem issold within one yearafcompletioo,theowner- 0
builder,will have the human of proving that he did not build or improve for purpose of
hvuwnerof the property,am exclusively contracting with licensed contractors to QTY'. PLUMBING PERMIT FEE FLOOD ZONE APN
cons et the projem(Sec.7049,Business and Prafeasi ess Code:)The Co...&s PERMIT ISSUANCE
License wdaenot applymwownerofprogeny whobuild+orimprovesthercon,and
whoconrecte forsuchprojecu with aconarmor(s)Iiccnsedpumusmtothe Contractors
License Law. ALTER-DRAIN@VENT-WATER(EAG FEE SUMMARY
❑ I me exempt under Sec. ,B @ P C far this reason BACK FLOW PROTECT.DEVICE OUISIDliphhS
SANITARY Y N
Omer Dau DRAINS-FLOORRDOFAREA. RECEIPT
WORKMAN COMPENSATION . , . .
DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsent 0 sel6itsure,or a cenificam of FlXTURFS-PER TRAP RECEIPT#
,Warkcn'Compensation lusummemiteenified copythereof(Sec.3800,Lm CJ which 1 PARK FEE Y N
coverall employeasunderthispermit. GAS-HA.SYSTEM-I INCA OUTL S RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYS EM-OVERA( PLANCHECK FEE O
❑ Cenified ropy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GREASEANDU INT4C R GRADING FEE xissass,
s CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEj!K %"�j SOILS FEE O
COMPENSATION INSURANCE
(This section need notbe completedBNe permit Is Barone handredrlollere($IN) SEWER�SANIT Y-STORM EA.200FT. ENERGY FEE assassins,
less.)
I cenifyflat in the K...f Rte work for which Nie Permit is issued,l shell WATER HEATER W/VENDELECIR
not employ any person in any manner so as to become subject to the WorkersPAID
Compenmtionlswaof Califamia Due WATER SYSTEM)TREATING Date Raeip ON
O Z Applicant
NOTICE TO APPLICANT.If.after making this Cenificeteof Exemption,you should NEWRESIDENTIAL PLMB. SQ.FT. TOTAL: x
i;n become subject to live Workers Compemmio,provisionsofthe Labor Cade,you must BUILDING FEE
ai , foMwith comply with such provisions or this permit shall be deemed revoked.
149 hh�
C Q CONSTRUCTION LENDING AGENCY SEISMICFEE .05 M
O 60
1 harrhy affirm thus them is.construction lending agency Barbara peKomuta of
TOTAL: ELECTRIC FEE
U O
the work for which this permit is issued(Seca 3097.Civ.C.)
ndrs Nang
Under
u" F Lendeer's Address QTY.:j„' . . MECHANICAL PERMIT FEE PLUMBING FEE ,
O L) 1 emiry Net 1 have marl Bus app0 samin end acme that the above m ommtion is MECHANICAL FEE
>1LkI correct. l agree it)comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE
E” building construction,and hereby aothonx re,msentuiveso(this city to emerupon the CONSTRUCTION TAX
V7 absve-mcmianed property fm inspection purposes. ALTER OR ADD TO MECH.
C. (We)agree to save,indemnify and kap hamdas the City of Cupertino against
Iiabilitics,judgmenu,costs endexpenses which mayin any way scommagainu saidCRY AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the grouting of this Permit.
J, AIR HANDLING UNIT(OVER 10,000 CFM)
St sof Applicam ,e cror are EXHAUST HOLD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN."BTU) Date Receipt#
Will the applicant affable building occupantsmre orhundle hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
m defined by the Cupertino Municipal Cade,Chapmr 9.12,and the Health and Safety
Car,Section 25532(u)? VENTILATION FAN(SINGLE RISID) Car
❑Ya ❑No
ISSUANCE DATE
Will the applicant orfuror.buildingacupmuseequipmentordevices whichemit BOILER-COW(311P OR IN,"BTU) pp
us air con andrunts as defined by the Bay Arta Air Quality Management BOILER-COW(OVER 100,000 BTU) P A O D
Istriu7
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FB.
1 I have mad the hazardous..led.],on,meam on,under Chapter 6.95 of the NOV 19 '993
California Heehh @ Safaty Coda,Sections 25505,25533 and 25534. 1 undo unit that �^
if the building does not currently have a anent,that it is my responsibility to notify the CiNY Vf TNTJ
capam of the requl.emams which must he met prior to issuance of a Cenificam of (aUYLfj f y
Occupancy.
Owner m amhonzcd agent Date TOTAL: ISSUED BY: