25570 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOul u.uln -ELCU'I RICA], PERMrrNo.
APPLICATION/PERMIT PLUM NG-MECHANICAL 25570
IIUILDING DIVISION BUILDING PROJECTIDENTIFICATTON
BUILDING ADDDRF'_SS: SANITARY NO, APPLICATION SUBM[TIALDATE
I /� lar ' UNIT'p LOT« -93
OWNHRS MF:: alywAsil
PHONE: CONTRA 'Og'S NAMEI .$
NAC `COMTROLX
RCHI :CT(1dWGINEER: PJC NO: ADD HSS: �"' r ❑
-vivic-di� 11
U . 5.ft Vi
ONI'ACT: PHONE: - BUILDING PERMIT INFO
QTY. EI.ECI'RIC PERMIT FEE
tl BLDG 1' PLUMB • MECH
r , 171 /y/ PERMITISSIIANCE IiLEC' El 0
LICENSED CONIRAC'1'OR:S DECLARATION APPLIANCES-RESIDENTIAL I�1 JOB DESCRIPTION
y,Z I hereby affirm that l not licensed underpoOsio®of Chapmr9(Co.Ce.ing with
yy�
al zo{'' Sectifall on
700dofDivision 3nf the Business are Profeesssi...CCodgand my license la in PANELS /{��.p
QZ� License- Can - -g�ff 201-I"1 AMPS �\{��
y,z Doe GOnnacD 201.Iq)O AMPS 1 YY
FyZ ARCIIITI3CIS UECLARA'f10NSQ.FT.FLUOR AREA $/Sp.FI'.
ZOm— OVER IgYJ AMPS
mQ 1 understood my plans ah:Jl be used as public records. isA L. h Ifs tt 1
u1 SIGNS ELECTRICAL Illi-'
6k�Jj Licensed Pm(essinnnl
qC G OWNER-BUILDER it the Co ATION SPECIAL CIRCUIT/MISC. I. I�� �� l 3
X�O V I hereby a(Saint..
that 1 am exempt frmn the Contractor's License Law for me ° �J fl—
w3u.nFi following reawn.(Section)03L5,13usinasand ProfcasioreC„Je:An,cityorcnunty T'EMP.MC'fERORPOLE INST.
/^ J
���; which requires a permit to construct,alter,improve,demolish,or repair any structure T' I'I G
E' }: prior nits waawardso requires the.,heant to...chpermitmfileesigned smmment I'GWIiR 1]IiVIC13S Al
cat :g
0p that he is licensed persu:rano the provisions of the Contractor's Liceree Luw r--fen
aXce 9(commencing with Section 7000)of Division 3ofthe Business and Professions Cale) SWIMMING POOL ELECTRIC V(sLUA'I'Ifp�N -
ly.,y or that be is exemptherefrom and the bask for the alleged exemption.Any violationof I O OQ 400
F-Za Section]031.5 byunyapplicantforaperrrin subjects me applicant to a civil penalty of OO I'LETS-SWITCI LES-FIXTURES
i ran¢than 11vc hundred dollars($5011). NEW RESID(iNTIAI.
❑ I,asowncrofinepmMny,ormyemployeawiNwagesutheirmlecompcnmtion, ELECfR —SQ FT. STORIES TY11H CONS'I'RUCfION
d will dothe work,and the structure is not intended or iffiend foraale(Sce.O(144,Business
and Professions Code:The Contractors Licernu Law does not apply to an owner of
property who builds or Improves mercon,and who does such work Llmsel f or mmugh his
own employees.pmvidel that such improvements menotinteadedorofferedforsale.If, I OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcomplaion,the owner- 'TOT'AL:
builder will have the burden of proving that he did not build or improve for purpose of V
mlc.).
❑ 1,asowncrofthepmpriy,amexclusivelycontmeiingwitblicenxdc.nt.c.mo Q'I'Y. PLUMBING PERMIT FEE FLOOD ZONE APN
instruct tha
e project(S .994,Earliness and ProfesdeO Th
sinns Cme Contractors
License Lawdoesna apply ounowaerofpopony whobuildsmrimproves thereon,and PERMIT ISSUANCE
wlmeomrams forsuch projeers with acommmor(s)licensed prawaalmdo,Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEL?SUMMARY
❑ 1 um exehnph antler Sec. ,U&P C for this reos,,n BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY YN
Owner Date RFCEIPTa
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ Iherehy affirm lhmlhaveacmificme of ronxnnn selGinsurc,ora certif¢ate of FIXTURESPERTRAP RECEIPT«
nrkeci Cnmpensminn lnsurnnce oracertiEW copy mere,,((Sec.3g00.Lnb CJ which PARK IFE YN
en.ers sllemploy �hr �� RECISION
1rNI m� GAS-G.SYSTEM-1 INC.4 OUTLETS BUILDING F.CEIIONFEES
P„umy a ''aw1
E] Canidied copy is herehy furnished. GAS-EA.SYSTEM OVER 4 IRA) PIANCHECK FEL?
'Ib❑”Certified copy is filed with the city inspection division. GRPASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSTTRANCE
(This section need not be completed ifthe permit is for one hundred dollars 01 IN) SEWER-SANITARY-S'P'ORM EA.200F7. ENERGY FEE
or less.)
I cenifythm inflepcommance OxChe work for which Of.permit is issued,P shall WKUER ItEATHR W/VENT/F.LECfR
not employ any person in tiny m as to becomes subject to the Workers' PAID
z Compensatinn Lawsof Celifand.. Date e,, WATERSYSTFAn REATING Dara Receipt«
Applicant
� � NOTICETO APPLICANT.If,after mekingthis Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ,FT. TOTAL:
p) [famine subject,,the Workers Compeasulart provisions of the Labor Code,you must
7 forthwith comply with such provisions or this Nmi l shall he deemed revokod, BUILDING FEE QO
Ia CONSTRUCTION LENDING AGENCY SBISMICPRE (- 00
I herehy affirm that there is u constructon lending agency for the performance of
U O the work for which this permit is issued(Sec.31197,Civ.C.) TOTAL: ELECTRIC FEE �4b
Leader'a Name PLUMBING PHIL
U ].endm'a Address QTY, MECHANICAL PERMIT FE8
L) I certify that 1 have read this application and state that the above information is
Correct.Is of with all cit and count ordinances and state laws relating o PERMIT ISSUANCE MECHANICAL FEE
grco comply yes county g
F's Z buildingcmrroned proert h<rebyouthndu representatives of this city mercer upon the CONSIRUCTIONTAX
[� 'z above-ment gree propertyfor mnify and proposes. ALTER OR AIID TO MECH.
(We)agree nt save,indemnify and keep oy i.as the City rt Cupertino s id City
liubilitics,judgments,costs and expenses which yin any way accrue against said City AIR HANDLING UNIT('(010,000 ChM)
in conscqueneeof erg tin ofthispnoth.rv� 417
9 AIR HANDLING UNIT(OVER 10,000 CPM) )
namrcof pliC1rx omracmr Du EXI IAUST FIOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Doe Receipt If
Will the applicant or future building occupant amm or handle hazardous material HEATING UNIT(OVER 100,00)B'1'Iq TO
as defined by the Contra..Municipal Code,Chapter 9.12,and the IIcahn end Safery
Code,Sccti yes, a)Y 11 No
El VpNTLATION FAN(SINGLE RESID)
❑Yes
BOILER-COMP(31PPOR 100,000 BTU) ly U(sNQEv E
Will hair contaminants
as building by themae Areequa
Quality Management
whigement I++ �A IfB
•hazardous air Ymmminams as defined by the UoY Arca Air Quality Managemcm BOILER-COMP(OVER 100,000 BTU)
Disrtie) n/ �1 �}
❑Yen ❑No NEW RESIDENTIAL MEC I. SQ.FT. SEP 22 ISSJ
1 have fad the hazardous materials requirements under Chapter 6.95 of the fO
California l lerelth&Safety Code.Sections 25505,25533 and 25534. lunderstandmat C�Iti UC �t�l LhltltlU
If the building docs nm Currently have a tenant,that it Is my responsibility to notify the
cupanl of the requimnents which must be met prior o issuance of a Cmificate of -
Occupuncy. x
Owncr or anmm redri,al Date TOTAL: ISSUED BY:4Q�IU1��)��
OFFICE