25070 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOD• '- • PERMIT NO. C 7O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJKCT IDENTIPLCATION 5 O 1
BUILDING ADDRESS: s.�� 1 SANI'T'ARY NO. APPLICATION SUBMIITTAL DATE
/rl
"^CO PV- —e-ft UNIT# LOTH
WNERS NAME: PHONE: CO RACfOljS NAME I.IG NO: J 7 V
5. rkr6 7*5z— 704i-a /i /ass _/O 11_1 Jpj NAC CONTROL#
Am RCHI'IE BiNGINEER: i''LIC`NO: JJ LL�✓ A AS::V IV F1(o S /•O T
'CONTACT: �jPHONE: QTY, ELECTRIC PE MIT FEE BUILDING PERMIT INFO
BLUG CLECf PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL FJOB DESCRIPTION
Mintz Thereby uffirmmat l sm licensed underpmvieionsofChapar9(commencingwith
000 Section 700B)af Division 3cf the Basin.,add Professions Cadc.and my limn..in PANELS
q U full force and effect.g.
t zz License Class Lie.al UPTO2MAMP5 So
toDate Connote., 201-That AMPS
z OARCHITECT'S DECLARATION OV, 00 S SQ.FT.FLOOR AREA S/SQ.FT.
CZ-0 J I understand my plans shall be used m public records.
r�lzQy Licensed Professional SIG AL
XKc' OWNER-exempt RDLC Contra ON PECI IRCUIT/MISC,
OaF 1 hereby affirm That 1 am exempt from me Conuacmrs License Luw fordo
61'36.rn following rcouon(Section]031,5.Rosiness and Profcssiom Cadc:Any cityorcounty EMP.TvmnRO L
which requires n permit m cnnmmct,omr.improve,demolish,or repair any structure
m>� prior to its issuume,alsonequirea lheapplicent for such pe mit to Hlea signedswtemcnt WERDEVIC
pO Nat he u licensed pursuant to Its,provisions of the Conmctots License Law(Chapter
9(mmmencing with Simon,7OTITBof Division 34 the Business and Professions Cotte) SWIMMING LE CCIR ^ VALUATION
61�y Se Nm nein 1 exempt5bymhertfmm and the buisfor the allegW,flemi to civiny l sawly of OUTLETS-SWI P IXTURES `�
i- Senion]o3 L56y hundred
dollfor$500).tsubjects the epplicanuoaCivil penalty of • v
nm mom Than live hundreJ Jnllws($5fO). NRWRESIDIiNTIALELCCfR S .Pf.
❑ othe work,and epropeny,ormyemplayedoroferegaasthe(See 04,L Business Q STORIES TYPE CONSTRUCTION
will Bothe wons and e:The Conture ractors
License
a w doesed of apply to an Business
send Professions Cale:The Comnctors Liana Lew does not apply to an owner of
property whobuildsorimproves Thereon,endwhodaessuch work hlmalforN ugh his OCC.GROUP RES.UNITS
ownemployees,Provided that such improvements monot imendedoroffered formic,If,
however,the buddingmimprovement is sold within one year ofeempletion,the owner. L
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepmpeny.amexclusivelycontracting with licensed commumars to QTY. PLUMBING PERMIT FEE F1.O0D ZONE APN
comtruss the project(Sec.](144,Business and Professions Cade:)The Contractors PERMIT ISSUANCE I �'
License Lsw doer not apply T o an owner of property who builds m improves Ih ereon,and
whocontracts forsuchprojxn with a contmsetor(s)licensed moment o the Contractors ALTER ATL
License Lew. ) IM PEG SUMMARY
❑ I am exempt under Sec. ,B at P C for This mason BACK FLOW PROTECT.DP. ICE i I11 A 4 T AR ROOP, CO D. IE N
Owner pate L
Y CEIn4
,
WORKMAN COMPFNSATION DECLARATION DRAINS-FLOOR. C N
❑ Iherebyaffmt that l have o ceniGcats ofconsentto self-insure,or a certificaa of PIXTl1RE.5-PER TRAP p F,CEIPT#
Warkcre'CompensusionlnsumnconrecenifW copy Nereof(Sm.JgHU,LabCJ which PARK FYN
coven all employee's under this permit. GAS-EAi.SYSTEM-1 INC.4G ETS RECEIPT#
Policy# BUT GDIVISION FEES
o C�ayiiflW co GAS-PA.SYSTEM-0VER4 TEA) PLA .0
py is hereby fumixhed.
❑ Cenified copy is filed with The city impectton division. GRPASPpNDUSTRL WASTE INTERCEPTOR INC.Mi rte'
CERTIFICATE OF EXEMPTION FROM WORKERS' GRLASH TRAP SOILS -FF,' I d
COMPENSATION INSURANCE
(This section need nos be cumplcted ifine permit is immiehundreddollars(SID(l) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
or less.)
Icenifythatl performance of the work Rewhich Nisperm iss pd,lshell WATER HHATER WNENTAELECfR
na toy any m man er sons Tm become eubje� h PAID
mnsmia r elifoyC/. Ti ars WATER SYSTEM/TREATING Dnte Receipt#
'7" APPlicanT ate////
7O. 0 NOTICE TO APPLICANT:ILaftcr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
y became subject mthe Waded Compensation provisions of the Labor Code,you must
a.
forthwith comply with such provisions in this permit shall be deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FRE
z Q
✓R I hrmbyuffrm that is a canstrvction lendingagency far Performance of TOTAL: ELECTRIC FP.P.
V O The work for which this permit is issued(Sec.3097,Civ.C.)
LL. Lenders theme PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT F'EP.
1 certify that I have rend this application and rdia that an above information is
T,J correct.Iagremocomply
and hembylcnummospromat i,esu and statelawsrdatiag To PERMD'ISSUANCE MECHANICAL FEE
U h building conxauctiomert horebyaothat su amos. fives of did.
citymemer upon the CONSTRUCTION TAX
U above-mrndored.save,yfbionard tiod kesposes. ALTER OR ADD TO MF.CFl.
(We)e o save,indemnify and keep hamslnss the City of Cupertino id Ch,
in
nn.costs andexpense hichmayineny wayeecrvengeinnuid City AIR HANDLING UNIT(TO Io,000 CFM)
in con. this ImiT.
AIR HANDLING UNIT(OVER 10,00)CFM)
ign reof Appbcent/Con(r r Dale EXHAUSTHOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HFA71NO UNIT(TO IOQOOO BTU) Dam Receipt IT
Will The applicant or future building occupant sore or handle henrdom material HEATING UNIT(OVER I W,1O0 BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety
Code,Section 25532(a)?
CI Yu ❑No VENTILATION FAN(SINGLE RFSID)
Will shaapplimnsnr furore buildinga;rnpent uaequipmrntmdevica whichemit
BOILER-COMP(3HP OR 100,00 BTU) ISSUANCE DATE
hu ardous air contaminants as,defined by the Bay Am AG Quality Management HOLLER-COMP(OVER IW,(OO BTU)
D sat m?
11 Yes CI No NEWRESIUFNTIALMECH.—SQ.FT. WD
I have read The hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that FOS/'/ Iq
if the building does not cumently have a amns,that it is my responsibility Ta notify the Q
occupant of the requimmenn which must Ise me prior to issuance of a Cenificam of CI)y U
Occupancy. I
Owner or nmharizW agent Date ISSUED BY: fyf