25306 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL '-MAAA MECHANICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM ROJECTEDEN11CAL 25306
IIIIILISING PR(1.IE1;'I'IUFNI'IFTCA'1'ION
BUILDIN7G AD\DyRESS: SANITARY NO. APPLICAnONSUBMITALDATE
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PHONE: I l t BUILDING PERMIT INFO
;� QTY. ELECTRIC PERMIT FEF.
f}vI�Up205 253-P33z HL G LCT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION pppLIANCCS-RFSIDENTIAI. JOB DESCRIPTION
p00 Ihereby affimm Nan31,f0h Bmiod nderrallso e,xi...Code. (comylicemgwith
=W tiff finlsencie D'v ion lofthe Business and Rv(essions Code.and myliunseisin ppNl)L$
<zwb full force and ef(e
f Zu1 License s Lic.# UP T02fp AMPS
y< morman 201-Exist)AMPS
20"i ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
OVER I(1W AMPS
I OZ�O understood my plans shall be used as public rccnrda, l
ra W SIGNS I?LF,CfRICAI. I
Licensed Proficnd...I I`
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. C
ipS.OaU 1 hereby affirm that 1 am exempt from Ne Contractors License Law for the C .K{
to3B-vF¢i following....ISeelmn]011.5.Business and IRofeaions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve.demolish,or repsir any structurei�
prior mits issuance,aim myuims Ne applicant(onuch pemmitmmonsignor!ammmentPOWER DEVICES
<p that he is licensed pursuant to the provisions of the Coronaries License Law(Chapter
a
0111 9(commencing with Section 7030)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC yAID
or Ilia,he is exempt hercliom and the basis for the alleged exemption.Any violation of OUTI LETS-
QSection 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of SWITCHES FIXTURES #� ^
t more then Eve hundred dollars($500). NEW HPSIDBNTIAL ELGCB _SQ.FT. (xJ
n❑ I,asowrerofthepropm'.mmyen'k.ymswlihweg,,.thei..alecompermsomi. STORIFS TYPF.CONSTRUCTION
will dothework.and the strucmre isnm infendW oroffered forsale(Sec.004q Business
and professions Code:The Committers License Isw does not apply an an comer of
property,whobuildli mimpmves Nereon,and wind.such werkhimsel(orthroughhis
own employees,provided that such improvements are notimendedore(fend fortune.If, OCC.GROUP RES,UNITS
however,the building or improvement is sold within one yearof completion,theowner- TOTAL:
builder will have the harden of proving that he did not build or improve for purpose of
sale.).
1,as ownernl Nepmpeny,amexclusively contracting with licensed contactors to QTY. PLUMBING PERMIT' F1,113 FLOOD ZONE APN
construct the project(Sm.7044,Business and Professions Code:)The Common's \ PERMIT ISSUANCE
Li cense law does om.ppl y 1.an owner of property who luil ds m imptnves thereon,end
whaconmcu fortieth pmjeetswith a concurs)licensed pursuant mthe Convacmb ALTER-DRAIN&VENT-WATER LA
Lim.law. (' ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far this mention BACK PLOW PROTECT.DEVICE OUTSIDE RM,
SANITARY YN
Owner Dare- DRAINS-FLOORROOFARCACOND. RECEIPI'p
, , , .
S WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Thereby affirmNmlhaveacenifcare of consemmself inmre,or ecenificam of RECEII'I'p
Wmkers'Compenum Immurce ora eunifted copy thereof(Sec.3900,Lab C.)which FIXTURES-PER TRAP PARK FET? Y_N
covers all employee's mderthis perenit. GAS-PA.SYSTEM-I INC.4 OU'll.FTS RECEIPT p
gIb'y# BUILDING DIVISION PEES
mpeetrtified copy is hereby famished. GAS.EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GRI?ASF/]NDUSTRL WASTE INTERCEPTOR GRADING FEE
CER1'IIICATH OF EXEMPTION FROM WORKERS' GRFASHIRAP SOILS THE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundred dollars(5100) SEWER-SANITARY-STORM P.A.20(fiFT. ENERGY FEE
mlesn)
I unify tom in the performance ofthe work for which this Permit is issued.l shall WATER HEATER W/VRbfTA'.I.P.CIR
n employ permn in an er as I.become subject m the Worker' PAID
nmpensa on (Calif i m e so WATER SYSTEM/fRPATING Dare R tip If
Q APPlicam 6���_/��/
z � NOTICE T6 PPLICANT:If,after mkingthis CenificateofExemption.you should NEW RESIDENTIALPLMB SQ.PT. TOTAL:
p+ (q become subject to the Workers Cnmpcnsmian provisions of the Labor Code,you mus
ai frilwithcomply with such pmvisionsm Nispermit shall hedeemedrevoked. BUILDING HiRa1 �P
G (] CONSTRUCTION LENDING AGENCY SEISMIC
Pr: /
7 z I hereby affirm that there is o construction lending agency for the'ff..of
V O the work for which this permit is issued(Sm.3099,Civ.C.) a, ELE CFT
Lenders Nome
Lendm's Address QTY. MECHANICAL PERMIT FRE PLD B FEE
{0 1 certify-bat 1 have read this application and state that the above information is :CI ICAL iE
a correct. l agree to comply with all city and county oNinancee and stoic laws relmingm PERMIT ISSUANCE.
,Z, building construction,and hereby amhonim representatives ofthiscity to enter upon the
U 7 above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCII NTAX
C7 (We)agree to save,indemnify and keep harmless the City of Cupertino against
hiflaitiesjvdgmenm.cazbrand penuxwhich mayin any wayammeagamst said City AIR HANDLINGUNIT(TO IgWOCFM)
'tit con .(,he loosen fN" ;mraL.
to AIR HANDLING UNIT(OVER FLOOD(TIM)
Signmre of ApdicmusC.1bmcm, Date It FAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT LTO IOg000 BTU) Dat Receipt#
Will the applicant nrfuture building occupant more or handle Imenno.s material HPATINO UNIT LOVER IOO,IXNI BTU) AL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25312FU? VENTILATION FAN(SINGLE RES]Of
❑Yea ❑No
BDILER-COMP(JHPOR IW,g10 BTU) I UANCE DATE
/I Will Neapplicant orfmure buildingoempant use equipmentmdeviceswhich emit II�T�
hoaardous air cnamini n i ss defined by the Bay Am.Air Quality Management P A
�I Dis net? mBOILER.COMP(OVER 10(1,(X10 BTU) Q
❑Yen ❑No NEW HESIDENDAL MECII. SQ.FT.
1 have read the notorious mmensls rrquinamems under Chapter 6.95 of the UJJgtlhl L993
California Health&Safety Code,Sections 255(15.2551]and 25534. I understand that C/y
i(the building does not enormity have.turner,,that it is my responsibility tonality Ne
occupant of Ne requiremems which mus,he met prim to issuance of a Cer iften,e of /Y1.4
Occupancy.
Owner or amharized agent Doo TOTAL: ISSUED BY:
OFFICE