25622 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN_OHI IL"U ,-KLMARICAL FERMI fNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� C C /'�/�
BUILDING DIVISION BUILDING PROJECp IDEPE IFICATION G J o L L
BUILDING ADDRESS: S-7- SANH'ARY NO. APPLICAU SUBMITI'ALDATI?
2 C i6bD6 UNI'TN I.OTM ��/
0.00 0— ,J is• ' /S PHONE: CONTRAC9'OR'S NAMP,;�,JI LIC NO: !!!
pfTl Ill'.{1{) /V'M`eY\ �P�I�W/�I�� N/CCONTROLp
RCI1,1'ECT/I'NGINI?fiR: LIC NO: ADDRESS: - ❑
CONTACT': PHONE: QT'Y ELECTRIC PERMIT FI7H BUILDING PERMITINFO
gLDG� EL1?Q' PLUMB MICE
PERMIT ISSUANCE 4/If�A/\ (1.1
LICENSED CONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
GC7 1M1mrehy uffrLI Thall E licensed uACTORvieDE DECLARATION
9(commencing with IfCR
�00 Sectian9d(Ja.fDivison3 arms,Businesaand Professions Codatudd my license is in PANELS �� Mw
C� LbxmpChfall to. nJ,ffecm. UPT02MAMPS �, • ,CI1 _ ul��
Pyy License Class Lic.H UWVr�'i
vFa Qy Dme Compactor 201-ILX)B AMPS
,Z�NZ ARCHITECTS DECLARATION OVER IOW AMPS SQ,FT.FLOOR AREA 5/SQ.IT.
OZ- 0 I understand my plans shall be used as public teams.
SIGNS ELECTRICAL _
9y�j Licensed Professional
q0 OWN13R.BUILDHR DECLARATION SPECIAL CIRCUITIMISC. �-
pxi(,DyU I hereby affirm that 1 am exempt from the Cmaracmr's Licrnse Law for the
Yl'+0y ,allowing rtaasn.(Smion 90JL5.Busineas and Proressions Cafe:Any city or county TEMP.METER OR POLI?INST.
F.i, < which requ m,uproot to mannite ohce improve,demolkh, a repair any stmewle
WYEto its ismance,also, then applicant for such Ito file a signed statement IY)WER DI?VICES
prior ,quits pp Penni g
'ER that he is licensed pumuamb.Ne Provisions f,he Contracme,License I...(Chapter SWIMMING POOL ELECTRIC
ei 9(mommondng with swtlon]BW)of Dlvision9nf theBminess and Rofesslons Cod,) V .DATION
WZw onto 7031. by any
yapplicant f the batt subjects the
to civilpnann of
F Z_Q Section7031.5had by anyapplimalmsd rantfor a us($50mrit subjects the applicant macivil penally of OU'I'LEI'S-SWITCHES-fIXTURPS
s�O n nrasonnbvmhepro,sdmlormyernp.
Cm unwnerefts,progeny,ormyemployeeswiNwages azmheirsolecompensmion, NEW RESII3ENTIAI.F.LCCfR —SQ FT. S'1'ORII?S, 'I'VPE CONSIRIJC310N
a3— 'i11sa the work,and the smocmm is not intended or offered for sale Euse.7144,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his
ownemployees,p ing or imp,such improvements wit an not intended moffered forsalt.If,
OCC.GROUP RIS.UNITS
howeveg(lie
llhave the or den of proem issoldhe id one ycm or improve for the CoPose of
buil.),,will Love the hurdrn of Proving Ihe1 he did not build or improve far plupose of
❑ 1,asowneronhmpropeny,amexdusivmlyoontraming wit licenses mmpamorsm QTY. PLUMBING PERMIT Ff:F. FLOOD ZONE APN
construct the Ami(Seo.7044,Business and Professions Cw1eJ The Contmnor's
License Lawdoes not apply to annwnerufpropeny who huildsor improves theme .and PERMIT ISSUANCE
whomntracts fasueltpmieerswith.eommetor(s)licensedpmsuant to the Commemrs
License law. A,TBR-DRAIN&vENI-WAT?N(EA)) FEE SUMMARY
❑ 1 am exempt under Se<. .B&P C far this reason BACK FLOW PROTECT.DEVICE OUTSIDE r1r.91
SANITARY V N
Owner Dme RI?CF.IPI'N
GOND
AREA
ROOF, , .
WORKMAN COMPENSATION DECLARA'T'ION DRAINS-FLOOR. SCHOOLTAX YN
❑ Iherchy affirm lhullh:rvcucedificme of consent In sdbinsure,nnr certifinnc ofRECEIPT'#
IIXTURIS PER'1'RAP
Workers COmpensamion lrrxumnce oraeenifird copy therwf(Su.38W,lab CJ whits PARK FEC YN
covers all employee's under this permit. GAS-EA.SYSTE M-I INC.4 OUTLETS RECEIPT p
Polity k BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 OA) PLANCHF.CK FEE
❑ Ccrrified copy is hereby famished.
'❑ Cerlilial arpy is filed with the city inspection division. OREASDINDUS,RL WASTE INTERCEPTOR GRADING PEE
CF.RJTyrCATE OF MEMPTION FROM WORKERS' GREASE'FRAP SOILS FEE
COMPENSATION INSURANCE
(This senimmadnotbecompleddif Nepermim is foronehundreddullms(SIM) SHWER-SANITARY-STORM BA.2001111. ENERGY IEE
or less.)
I certify that in the performance of the work for which Ni s permit is issued,l shall WATER I[CATER W/VHNI'/f?LECI'R
not employ any person in any manner so as to become subject to the Workers PAID
z Compensation Laws of California. Dam WATER SYSTF.M/rREATING Dam Receipt#
z� Q
NO TICE TO APPLICANT:If,.7c,making this Certificate of Exemption,you should NEW RESIDENT IAL PLMIL SQ,Ff. TOTAL:
t-I fn become subject to the Workers COmpen nation Previsions of the labor Cale,you Most
FFI--a'rr ; farm with comply wiihauch Previsions Or this permit shall be deemed revoked, BUILOIN(I PEEPut E
rs. CONSTRUCTION LENDING AGENCY SEISMIC FEE
T?
^� I hereby affirm that hem is a construction lending agency for the Performance of
U O rhe wad for which this papassue
,is named(Sec.3097,Civ.CJ TOTAL: ELECTRIC PEE
lender's Name PLUMBING FEE
Lender's Address QTY. MECI IANICAL PERMIT PER
I certify that I have read this application and smote that Ne above information is
0. correct.la me to cot I th all cit and count dinances and state laws matin to PI7RMIT ISSUANCE MIiCNANICAf.FEIi
g PYwi city county g
(/j building Construction,and hereby authmi ze representatives of this city to enter upon the CONSTRUCTION TAX
U z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
(WW.91.to save,indemnify and keep harmless the City of Catarina against
IW"esoudgmenb,emisaod expenses which..'a.?,wayn .itsrydCity AIR HANDLING UNIT-(1'O I0,000CFNH
on quant,of N ranting of Nis pe „„ ///
Ve iti AIR HANDLING UNIT(OVER 10.1)MCFM)
r
nature of Applicanl/Contram i Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOE SATF.RIALS DISCLOSURE I HHA'ENGUNIT(I'OIW,OWBTU) Dme ReceiPIN
Will the applieam arfntum building occopam norm or handle Interaction materiel HEATING UNI'I'(OV[R H10,0011 BTU) T L:
.s defiral by Ibe Cupertino Municipal Code,Ch.p e,9.12,and the Health and Safety
Code,Section25532(u)? VENTIL riON PAN(SINGLE RISID) -__
11 Yes ❑No
Will thea applicant orfuturobulldin fusee ui mem ordeviceswhich emit BOILER-COMP(311P OR 100,IXNt BTU)
ISSUANCE DATE
pp gby he q p
haz.Nous air conmminents m dented by the Bay Arta Air Quality Management BOILER-GGMP(QVER 100,000 B'1'Il) A 1 D
Dinrim?
❑Yd, ❑No NEW RCSID[N'1'IAL MECH. SQ.FT. Q(�
1 have read the hazardous materials reyuiremente once,Chapter 6.95 of the 11 '
California Health&Safety QMc,Sections 25535,25533 and 25534. I undersand that y
ifthe building doer not currently have Ytaaanl.that it is mymsamsibiliryto notify Ne C1I1
Occupant of Ibc requirements which must be met prior m issuance of o Cenifietne of ( V Ut'
LUF j
ccupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE