25203 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B."DausT.-F.I:ECPRICAL PERMITNO. 25203
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION - BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: G/�),�� SANITARY NO. APPLICATION
SUBMITTAL DATE
�/1/ UNITf LOT# Gi 1%r-Et
OWNER A HONE: CON GRAM[;: LIC NO:
�qAY./d� N/C COMI'ROLp
•ARCHITPCf/ENGINEE �LICNO ADDRESS: / v G�
CONTACT: PHONE: ' �w-` -`.' ' - ' > BUILDING PERMIT INFO
.I ,} QTyI' °yg PI;�CTRIC PI RMFPa a � FEEr
Nn/61,0— (.��&�. 0 . . :'ak BL[G E PLUMB M CII
�O (/ PERMIT ISSUANCE }��/1/k` El
LICENSED CO CfOR'S DECLARATION APPLIANCES-REST JOB DESCRIPTION
I Lerebyaffirtn that l um licensed underprovisions of Chapter9(commencing with
Rn Sectinn]000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
<zw full force andrrce anA cffce--� 0 UP T02W AM
t<.yav5 fu CI s Lic.g
r;6 a ate Contractor it./4�.� 2 -I
Fy HITECPSDECLARATIO ✓/ O 1 S � IT.FLORf3A E/SQ.FT.
ZO z�O I understand my plans shall treated es public retards. -`
rLy w SI ICAL U
Licensed Professional
? U
OWNER-BUILDER DECLARATION PE CIRCIBT S / `
O a U I hereby affirm that 1 am exempt from the Contractor's License Law for.t
n13 wyQ following rcsom(Section]031.5,Business and Profeesione Code:Any city or county MP.ME LE INST
1.1 ON J which mquires a Permit to construct,alteq improve,demolish,or repair viy atmcl a t- l )[ 1 -y
K Q7 priormitsissuancgalao requimsthe�pplicant(orsich permiuoflZ signed statement WERDE V ��, {{{
W tY Om That he is licensed pursuant to the Provisions of the Commcters License law(Chapter
a OoLL 9(commencingwith Sectinn](100)of0ivision3ofthe Businessmii Professions Code) SWIMMING PbdL CfRIC VAI. TIO
,,,,y or that he is exempnherefrom and the basis fanhe nllege4 exemption.Any violation ofOUT - W CUES-
ZY
Section 7031.5 by onyupplicant for.permit subjects Marmplicinno a civil penahy of LETSSFIXTU S
^a
tY � retain than Eve hundred Jolles($50% NEW RPSI IALELECIR _SQ.FT, t t
❑ I'mowneroftheproperty,ormyemployeeswithwagesastheirsolecompensation, STORIES TYPE!CONSTRUCTION
EWywillda the work,and the structure is not imendedoroffered forsile(Sm.]B14,Business
and Professions Code:'[he Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work himself or through his
own employees.provided Nat suchimprovemenis.rent lntendedorofferal foreale.If, AN i,iaas OCC.GROUP RES.UNITS
however,Mebuildingor improvement is sold within one year ofcompledan,theowner- TO L
builder will have the burden of proving that he did not build or improve for purpose of
sale.). E
❑ I,as nwnerof dic property,am exclusive) conwetom to QTYy
VS '. 'i ' PLUMBING PERMIT- 171,E FLOOD ZONE APN
exclusively licensed _ ...
construct the project(Sea THq Business and Professions Code:)'The Contracture PERMIT ISSUANCE
License taw does not apply ct an owner of praperry li hu builds rs im t to the therum,and
wicrew,ractsforsucM1 pmjectswith econtracmr(s)licensed pursuant the Conwemr's ALTER-DRAIN&VIII'-WATER(EA7
License Law, FEE SUMMARY
❑ 1 um exempt under Sec. 6&P C for thio reason BACK MOW PROTECT.DEVICE UT.ID: E.S
SANITARY YN_
Owner Data RHCIIPI'N
DRAINS-FLOOR.ROOF,AREA,CONII.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Thereby off nn tM1elhaveecenifcem of commms<If-Insure,oracenifcate of FIXTURES-PER TRAP RHCHIPTM
Workers'Compenwtion Insurance or a ccNBei copy thercof(Seu.3800,Lab CJ which I PARK FEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RfiCEI
policy Y BUILDING DJVISJbN TH..
Co y r i GAS-EA.SYSTEM-OVER 4(2,A) PIANCHECK TRE
enifed ropy is hereby urumed.
Cenified copy is filed with the city inspection division. GRF,ASE/INDUSTRL WAS'TE IT O
NTERCEPR GRADING THE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASF,TRAP SOILS FEE
COMPENSATION INSURANCE
(This seeuon need not Eve completed Effie permit is recent,hundreddollars(gIW) SEWER-SANITARY-STORM EA.20l ENERGY FIR
or less.)
I certify that in the performance ofthe work for which this permit is issued,i shall WATER HEATER W/VENT/ELECTR
not employ any person in any mormer so u m become subject to the Workers' PAID
Compensatmirlawsof Califomia. Date WATER SY91'EM(RUSATING Receipt#
NOTICE TO APPLICANT If,after making this Cmifcate of Exemption,you should NEW RESIDENTIAL PLM I{. SQ.FT. TOTAL:
[a E;,iI become subject to the Workers Compensation provisions of the Labor Cede,you must
FFa'' > fmthwith comply with such provisions or this permit shall he deemed mocked. BUIL/Nd"lti
Z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that inert is a construction lending agency for the performance of q QgAL: IiLECTRIC FEE
C) the work for which this Permit isaamil(Sm.3097,Co.CJ
Len ku'a Name
0 U Landers Address QTY. M1101ANICALPERMIT FEE PLUMBING IRE
U 1 certify that I have read this application and seam then Ne above information is k s
>. a coned I agree m comply with all cityand county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL PEE
building construction,and hereby authorize represenwtivesoftbisciry to emarapon the
U z above-mentioned pmpmy for inspeetlon purposes. ALTER OR ADD TO MECH. CONSTRUCHONTA
(We)agree to save,indemnify ad keep harmless the City of Cuperdim against
liabia ,Jud u,coo expenses whi<hmay in anyway acerveegeinasaid City AIR HANDLING UNIT(TO IB,B00 CFM)
c q sof egrnntin thin unit.
AIR HANDLING UNIT(OVER 10.000 CFM)
al plicamt/C tractor Date/ EXHAUSTHOOD(W/DUCfJ
PAID
HAZARDOUS MATERIALS DISCLOSURE I[HATING UNIT(TO IW,001)BTU) Dam R7mm,
dl the applicam or future building occupam store or handle bazardaus material IIPATING UNIT(OVER I(I(I,IMVJ BTU)
as defined by the Cupcnino Municipal Cale,Chapter 9.12,and the Ilealth and Safety
Code,Section 25532(u)
0Yes VENTILATION FAN(SING LE RESID)
o
Will theapplicum nrfuturehuilAingoccopum use equipte
nnmrJevices which emit
BOILER-COMP(3111?OR 100,000 BI'U) ISSUANCE ATE
hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Di.metz ��` ///���
❑Yes `�No NEW RESIDENTIAL MECH.—SQ.FT. B�g
4ifthebuildin
the azardous materials requirements under Chapter 6.95 of the r A t Ih
California &Safety Cade,Sections 25505,2553]and 25534. 1 understand that 6/
s not currently have a oment.that it is my ruponsibipity to notify the
quire hien use be met for eojssuance of a Cenif , of 1993
ug Date 'I L: ISSUED BY: