25672 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUIf'"IN'i—hLhU IICn. PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 25672
BUILDING PRojEC'1'IDENTIFICATION
BUILDING ADDRESS: TTSANITARY NO. APPLICATIONSUBMITJAL�DAIU
WQ 15'C& V( U n/^w V 10 UNIT# LOT#
OWNERS NAME: PHONE: CONTRACc}� 'S NAME: LIC NO:
4AIE15 AtiT a-,r;I f 1// s 0- to9730 (o NIC CONTROL#
RCHITECLEGINEER: LIC NO: AD) ESS:
q-r- I^—
CONTACT: PHONE: QT '
Y. ELECTRIC PARMIT FEE BUILDING 1PEItM1T INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0 0
LIC PSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. LOB DISCRIPnON
Metz Ihereby afircutha l am licensed underprovisinns of Chaper9(commencing with
Pr100 Satidn l00B)of DivisionJnf the Business and Professions Co9c,end my licrnse is in pNO9
az �
w ulUfxe, errs_ Lm.# 297 30 (o UP'rosooAMPs
V,6 .Ito 201-I"AMPS
E-,z `�ARCHITGCTS DECLARATION SQ.M.FLOOR AREA - S/SQ.IT,
ZOm Idndcrsmnd my plans#hall ha use.)as public records. OVER IOOO AMPS
OZ'-'Q
FykkJSIGNS HLEC'1'RICAL
QC)Su Licensed Professional OWNER-BUILDER DECLARA DON SPECIAL CIRCUIT'/MISC. pfp��'
iCOdU I hereby effort chat 1 um exempt firms the Commcbr.License Law far the 6w
n13 R-m following reason.(Seetion 7031.5,Booressand Professions Cade:Any city memory TI?MP.METER OR POLL INST. V
which requires a permit to consumer,alter,improve,demolish,or repair any structure
}� prion.its issaadire
ce,01m.qus the applicant for...hpetmit to file.aimed statement POWER DEVICES _
GO that In,mis licensed pursuant lathe provisions Mthe Contractor's license Law(Chapter
dao 9(comencingwith Scvino70001of Division 3ofthc Business and l'fnfessians Cude) SWIMMING POOL F.LECI'RIC _ VALUATION
,-, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTIIRF.S
Fz_a Section 7131.5 by any applicant for a pemtit subjects the applicantto u civil penalty of
,T nm co—had five hundred do11ars(5500).
Cm C1I.usnwneroftheproperly.ormyemployeeswithwagesastheirsolccompensmNCW R�SIDENTIALELECfR _SQ.fT.ion, STORIES TYPECONSTRULTION
willdothe work,add the structure is notmordWorofferW formle(Sec.7144,Business
and Professions Cade:The Comrereon, ddwhe oes Aces or apply to an owner of
property loyms,dsor rovidmpmvesth improvements
aressuctende or offered
his
own employees,prnvidedthat such improvements me not intended orofferedforsale.If, OCC.GROUP R
ES, ITS
however,the building or improvement is sold within one year of completion.the owner TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lbawner anne vrorertr,am excmamdyaommeung whbBamee aamramors to QTY, PLUMBING PERMIT, FEE ILooD ZONE
concord the project(Sec.7044,Business and Professions Code:)The Contractors PERMIT ISSUANCE
Luccselaw doesnot apply loan ownerofpropeny who buildsmarproves lhereom and
who contracts farsuch projects withacanuanor(s)licensed Pursuannothe Conuaarors
License low. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE TSIDI FEES
SANITARY Y N
Owner Dam RF.CI?IPI'p
DRAINS-FLUOR.ROOF,AMA,COND.
WORKMAN COMPI NSATION DECLARATION SCHOOL TAX YN
❑ Ihemhy affirm thannhaveacertificamofcodsembof(Secure,or Loh C.)which
FIXTURES-PER TRAP RECIi1P1'a
Wnrkers'Compensminn Insurance oracertified copy thereof(Sec.3900,Loh CJwhich PARK PER Y
vwv1.all emploee'sund RF,CI?IPI'#
yy r�1h,�pe®t, I� GAS-I?A.SYSTL'M-I INC. OUTLETS
Polley# /d 27SY'So > Z BUILDING DIVISION FEES
Company $ — �a� T GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ CertifeJ copy is hereby famished.
J&Cenifted cagy is filed with the city irepecdon division. GREASUINDUSTRL WASTE INTERCEPTOR GRADING FEL?
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectiormad not be completed ifthe .it is nature hundred dollars(SIW) SEWER-SANITARY-STORM EA.20o1T. ENERGY FEE
or less.)
I certify that in the performance of the work for which this vermis is issued,I shall WATER HEATER W/VENT/EECTR
not employ any person in any m as to become subject to the Workem PAID
z Compensarion latwsof Colifomiu. Date so WATER SYSTENUTREATING Dare Receipt#
Applicant
NOTICE TO APPLICANT:If,atter makingthis Certificate of Exemption.you should NEW RL'SIDEN TIAL PLMB. SQ.IT.
r Y TOTAL.:
N
become hwithc reply the WorkersCompensation Fervor
Is,eLabor Code,you must
forthwith comply with such provisions or this permit#boll 6e dcemcJ revnkrd. BUILDING THE
6Wi CONSTRUCTION LENDING AGENCY - SEISMIC FEC
z I hereby affirm that there is a construction lending agency for the Performance of
UO the work for which this pe.air isissuW(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Leader's Name
QF Lenders Address Q'rY, MECI IANICAL PERMIT FEE PLUMBING FEE
U 1 certify that 1 have read this application and scam that the above information is
carrect.Iagree to comply with all city and county ordinances and state laws relating toPERMIT ISSUANCE MECHANICAL FEF
LO building construction,and hereby aarhorim representatives ofthischy beater oracular, CONSTRUCTION TAX
U Z above-mentioned prapery for inspection purposes. ALTER OR ADD TO MECI I.
.. (We)agree to save,indemnify and keep harmless the City of Cbpertino against
liabilitiesjudgmems,coskvand expenses which may in any way accrue againstsaid City AIR HANDLING UNITTf010,000 CFM)
in conscquescre of the granting of this permit.
AIR HANDLING UNIT(OVER Ill,(IW CFM)
Signature of Applicum/Comonat Date EXHAUST HOOD(W/DUCr) PAID
HAZARDOUS MATERIALS DISCLOSURE
METING UNIT(TO 100.000)BTU) Dae Rme
Will bymo orrorNbmbuildingme.Chmalaeor handle hHealth vmarednl
as defined by the Cupertino Municipal Calc,Chapter 9.12,add the Health wd Safety HEATING UNIT(OVER IIXI,lN10 BTU)
Code,Station 25512(#)?
❑Yes ❑No VENI'11ATION FAN(SINGLE RESID)
do
W ill theuppllCam art Tulare hullding accupan use cyuipmrntordevicea whlehemit
BOILER-COMP(3HP OR I(0,W)BTU) ISSUANCE DATE
aaarus air,cantnmimunts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
caret,
❑Ycs ❑No NEW RESIDENTIAL MECH. SQ.IT. P A + D
I have read the hwardom materizls mquiremems under Chapter 6.95 of the ®�
if the mia Heal does
not currently
have
a to 25505,25533.d25534.titis responsibility
1 icy to notify
shut r 2 5199
if shah ilding does no¢umently haveamnant.that it is my responsibility to notify the
oecup t of the requireme s h moa he met prior b issuance of u Cerilicum of
1 Y
Ow e . -.26-P CUED Y t "
rf
authof dagem Dem O ISSUED BY:
OFFICE