25923 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO �. ;r% 1" PERMrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL � 5
BUILDING DIVISION BUILDING PRO7F.C'I'IDENTIFICATION J
923
BUILDING ADDRESS: SANITARY NO. APPLICATION 0 CURNITITlyy'ALDATII UNIT# LOT# /� 7
OW . NAME: �/ x PHONE_ -.J CONTRACTOR'S NAM^ LIC NO:
WC CONTROL
S V
a a ,
�ARCHITF.CT/ENGINHRR: LICNO: ADDRESS
r
CONTACT: PHONE:
W $ # -t. :
AE4 ELECWRICRPER T, t, FRE ^ 'BUIIiDING PERMIT INFO
s ISSUANCE
# y BLDG FLPCT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANC - SI AL
cmz I hereby official that l am licensed underpmvisions ofalipter9(commencingwith JOB DESCRIPTION
�OO Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
,dU fall foommul effect.
F6yW License Class Lia.# UP 2 PS g
y6y Dam Conrctor MPS
201 1 A
Z 8r Ey ' ARCHITECTS DECLARATION ERIOWAWSIM I SQ.FT.FI.QON AREA $ISQ.ET.
O`-0 Inndersmad mypinns shell beusW as public records. SIGN VO `'�T1f.'1a
N S C
6 ; Licensed Professional
C� 6 OWNER-BUILDER DECLARATION SPEC UrDMISC.
FM5�'OaU 1 hereby affirm that 1 am exempt from the Contractors License Law f th
, fallowing reason.(Section 7031.5,Business and Professions Code:Any city orc y TEMP TERORPOLEINST.
IaJ'�; which canniness permit m construct,alter,improve,demolish,or repair,any structure
Y7 prior,,it,issuuvcc,niso acquires thcapplicant forsuch perrrvt to file a signed stammmt POWH DEVICES
m_ Om Nat he is licensed pursuant to the previsions of the Contrsemrs License Law(Chapmr
p-X�LL 9(commencing with Section 7")of Division 3 of the Business and Pmfessimv Code) SWIMMING POOL ELECTRIC VALUATIO
Wim or that he is exempt therefrom and the basis for the alleged exemption.Any violation of �s w _
d
Section 7031.5 by any applicant for a permit subjects the applicant m v civil penally of OUTLETS-SWITCHES-FIXTURES I a� goo
not n five more hall hundred dollars($5(10). Il •J D
ElI.a.sowneroflheprnperty,ormyemplo mswithwa$c witheirsolecomp oration, NEW RFSIDENTIALELECfR _SQ. STORI IYPECONSIRUCiION
is, will do the work,and the structure is not intended or offered for We(Sm.704 ,Basilicas
and Proac
Professions Code:The Contractors License Law does not apply to an owner of
n IN
property whobuildsorimproves thersi nand whodoes such work himselfor thmughhis t�
own employees,provided that such improvements aenor lntendedoroffered forsale.If, ULCG..IJ)' RES.UNETS
however,the building orimprovement is sold within one years(completion,the owner- r p '-tl�
builder will have the burden mf that he did not build or improve for se of TOTA"
proving prov pampa
PR
sale.). QTY.+ S PLUMBINGPERMIT FEE F O APN
❑ Ince oe pocceth(Sol.any.amexdasia and PrradingwiNlicessedmmtmemrsro ebt'y ' ,I
icanseconstruct the project(Sec.otalo Business end ywholioms Cod prove Como,,or'sand PERMIT ISSUANCE _
License Luw forsuc,applymanownernmeWr(sywhehuildsnui ttoihethereon,and
whocomraw.forsuch projects withamnlmcNr(s)licensed pursuauothe Con,mc,ors
License Law. ALTER-DRAIN&VENT-WATT:R(LA) FEE SUMMARY
❑ 1 nm exempt under Sec. ,B At P C for this reason BACK FLAW PROTECT.DEVICE UTSID:FLES
SANITARY YN_
Owner DateRECIJPT#
DRAINS-FLOOR,ROOF,AREA, D.
WORKMAN COMPfsNSAT10N DECLARATION SCHOOLTA% N
❑ Ihaeby affirm Nnhl hnveacenificvm Dfmaxm,o self-insum,macertificam of FIXTURES-PER TRAP AT.
Workers'Compensation insurance oramnified copy thereof(SmJg00,Lab C.)which PARK FEF. Y N
covets all employee's under this permit. GAS-EA.SYSTEM-1 IN .4 OUTLETS 'CCHT,
Policy# BUILDING 1VISION FEES
Company GAS-PA.SYSTEM ER 4 GIA) PLANCHP.CK FEE
❑ Cenifiedcopy ishembyfumished.
❑ Certified copy is filed with rhe city inspection division. GREASFANDU.' L WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION 17ROM WORKERS' GREASE SOILS PER
COMPENSATION INSURANCE
phis sectilmoralnot be completed ifthe peril is torose hundred dollars($IN) SFWER UNITARY-STORM F.A.200FT. ENERGY HU7,
or peas.)
I smify that in the performance ofine work for which this peril is issued.Is hall WAln HEATER W/VHNT/CLECTR
not employ any person in any manner so as to become subject to the Workers' PAID
ZClon,caatiom Lawsof Cvlifal Dam TER SYSTF.M(UEATING D Receipt
Applicant
ZO NOTICE'to APPLICANT:If,after making this Cenifieam of Exemption,you should NEW RESIDENTIAL PIIHB. SQ.FT. TOTAL:
t^ V] become subject o Ne Workers Compensation provisions of Ne Labor Code,you must
a. . forthwith comply with such provisions or,hia peri,shall be deemed revoked.
0. Q CONSTRUCTION LHNDp4S AGENCY SFJMTC PER
z 1 hereby affix that then is a musico on pending agency for the Performance of
V O the work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: FLECIHC HIL
V. Lenders Name "p aa, VLUMBING EH
Lenders Address QPY. �. �MECIIANICAL- PLRMI7; * •-I Lh
G 1 certify that 1 have read this applicafnon and state that Ne above information n :. 2 . ' .
Tt correct.I agree in comply withal)city end county onivaares and shale lows slating to PERMIT ISSUANCE MFCIIANIC LHE
building conswcton,and hereby amhemire representativesofthisciry,omair upon the
7 CONSTRUC ON TAX
V C above-mentioned property for inspection purposes. ALTER OR ADD I'O MECH.
(We)agree to saw,indemnify and keep hinicals the City.1 Cupertino against
liabipitiw,judgmen,s,cns,s dezlenses which may in any wayaccrue agains,said City AIR HANDLING UNIT Go 10,000 CPM)
in co inalocnreo r got ispeamit.
AIR HANDLING UNIT(OVER 10,030,CFM)
Signature at Appmcanl artacmr ate I EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BT —WT-
,P.RlPl#
Will the apppicamor future building resonant otos or handle hcoadousmatedal HEATING UNIT(OVERI Kill BTU)
T T
as defined by the Cupertino Municipal Code,Chapter 9.12,and,he Health and Safety
Code,Section 25532(u)'t VENTILATION FAN NGI,E RESID)
❑Yes ❑No
BOILER-COMP HP OR IOOpW BTU) ISSUANCE DATE
Will theapplicantorfutusbuildingmcupant usecquipmemordevices whichemit I
hazardous air con,aninsnrs as defined by the Bay Area Air Quality Management BOILER-C P(OVER 100,000 BTU)
Dismict7
❑Yes ❑No NEW RHS HNl'IAL MECH. SQ.19'. PAID
' pA ' D
1 have read the initiations materials mryimme,ns under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand Nat ���
19
if the building does not currently have a tenant.that it is my responsibility to notify the 9
octhe squu,nian i which mast he met vi,a m Issaance ora CenlOcas of 9
en,am lir p
mupaney. CITY of
Owner or authorized agent Data TOTAL: ISSUEor
D BY: (,U
OFFICE