25401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
*BUILDINGADDRESS
ERTINO BU�I:131h'irELECTRTCA. PERMITNO.
APPLICATION/PERMIT PLUMBING—MECHANICAL5 /1 O1
IVISION BUILDING PROJECT]DEN]IFICATION J 4F .L
'. SANITARY NO. APPLICATION SUBMITTAL DATEUNIT. 1.0'1'# �PHONE: CONTRACTOR'S NAME: LIC NO:a •1 / NC CONTROL4
.F.R: OC LIC NO: ADDRESS:PHONE: BUILDING PERMIT INhO
QTY. ELECTRIC PER IT FEE
l�P es Hukh f,"&M 7a7-ayz�
fmPERMIT ISSUANCE BL , ELECT PIU MF: H
LICENSED CONTRACTOR'S DECLARATION gpPLIANCES- 1 IAL
ZWz I hereby nfn that l am licensed underprovisions ofCbapmr9(commencing with 10B DESCRIPTION
WOWp❑ Section]IMIII)of Divisimn3ofthe Buxiness and Profusions Cade,cad mylicense is in p .LS
F�UU
it forc_and /L UP 2 PS
F7ty Licenx Class- �C Lic.a -U�M±
s Doo Dae ConTS D L 01- AMPS
Fyj RCNITECTS DEC RAT a' V IODO SQ,FT.FLOOR AREA S/SQ,FT.
OCG c,O I understand my plans shall be used as public rewrds. /f� /S 11 aZ
F,mt; SIGNS ELE 1 A �l(aJ( fV_ /✓`
k Licensed Professional
45
C
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOav I hereby affirm that 1 am exempt from the Contractors Cc License Ism for the CDC ��
¢ir following reason.(Section 70H.5,Business and Rofeasionz Code:Mycity or county TEMP.METER OR POLE INST.
I-�O J which rectums o permit to construct,alter,impmve,demolish,or repair any somemre
EtaS prmami¢iis ance.also requires the applicant for such pemduo fileesigned sNtement POWER DEVICES
W M 0 p That he is licensed pursuan to the provisions ofthe Contractor's License Law(Chapter
ISWIMMING POOL ELECTRIC
aoF' 9(c.mmencing with Section](KKDof Division Sof the Business and Professions Code) ^ VALUATION —�
m_w nrthm he is exempnhercfromnnd the basis onthenll,ndexemption.Any violation. IITLETS-SWITCHES-
FZQ S«tion]O3L5byanyapplicantforapermitsubjecmtheapplicant toacivil penalty of FIXTURES
f.=0 not more than rise hundred dollars(ISW). NEW RESIDENTIALELECIR _SQ.FT. STORI TYPF:CONSfRUCTION
W~m ❑ Lssuwrk,roahepropeny.ormyemtendeeswithwaguasthei(See.c0mpBusiness
a3— will dancewons and then ructureoContratot's Liceseoffiereal ssdueoraide ot apply
Business I ppfd p
and Profusions Code:The Contractor's License Isw Ares not apply to an owner ofour
propertywyces,dxarimprovesthereon,andwho Aressuchwdocion slf.r tM.ughhis
employees,provided that such improvements are not imcndedmroffered loreale.If, /S^\O/C/❑,\` UI/' /�1 _ Qµ{�� UNI '
huweve,ftinildingorimpowemem dssold withinoneyeaofcompletion,he ownef- .p o u • -0 /�
builder will have the burden ofproving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE ATE FLOOD ZO APN
❑ I.asownerofthepmp ny,amexclusivelycontmetingwiNlimnsedcontractonm
construct the project(Sec.7044,Business and Professions Code:)The Contractors
License Law dreanor apply man ownerefpropcny who builds or improvesthemon,and PERMIT ISSUANCE
whoc.ntruna for such propos with a wntractor(a)licensed pursu.nt m the Comructor's
U.nsc law. ALTER-DRAIN&VENT-WATER(IiA) a— FEESUMMARY
❑ I am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE r• OU T IDE FEES
SANITARY Y N
Owner Dam pRA1NS-FLOOR.ROOF,AREA.GOND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX - YN
I hereby affirm that I have a cenilicamofconsem mself-insure,...cerificateof pIXTURES-PER TRAP RECEIPTN
eri Cmnpenation Insurance or it cenified copy thereof(Sec.3800.Lech C.)which PARK ITE Y N
m all employees under this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS RDIVISI a
Policy p BUILDING DIVISION FIiE
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE O
Certified entry is hereby famished.'
Cenifed copy is riled with the city inspection division. GREASERNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE `
COMPENSATION INSURANCE
(This section need not becmnpleed ifthe permit is for one hundrddolless(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or luso)
I tend,that in dte perfomw«af the work for which this permit is issued.l shell WATER HEATER WNENT/ELECTR
not employ any pmmis in any manner an as to become subject in the Workers' PAID
CompereaioulswxoTCalifomia. Date WATER SYST'EM/IREATING Date Receipts
U z Applicant
z 0 NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
FV] become subject to the Worker's Compensation pmvificru of Ne labor Code,you must
a ? forthwith comply with such provisions or this Permit shall h damned invoked. BUILDING IEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7- z I hereby affirm that hem is a construction lending agency for the performance of L
U O the work for which this permit is issued(Sec.3097,Civ.C.) �CCONS�U�ON
bender's Name
W F headers Address QTY. MECHANICALPERMIT �-
U I certify that 1 have reed this application and ntnm tha the above information is
>_ W corrM:lagree m comply with all city and county ordinance and state laws relating to PERMIT ISSUANCE
h" N buildingconstmnion.and hereby auNoria<mpre atircsofthis city toenmr upon the X
aMwc-mcmioncJ prnpcny far inspcmi.n para.. ALTER OR ADD'fO MECH.
(We)ngmu i.save,indemnify and k« rmlexs the City of Cupertino nguinst
liabilities.judgmena,cosrs.n extremeswh' mayinanyw.y.ceme agiomiaddCity AIR HANDLING UNITTO 10,00t
im conseyuenceyf+R of alis pe r AIR HANDLING UNIT(OVER 10,000 CPM)
C 7- U
Sigwwm of pbc, on0aaor Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"BTU) Dam Receipt If
Will the npplic.m ter future had ldlng occupant sore of handle h.m.dous material TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER I W,WU B1 U)
Code,Section 25532(.)? VENTILATION FAN(SINGLE RFSIU)
❑Yes ❑N. ISSUANCE.DATE
Will theapplicturno furore budlding«cupant uxegifnamtordevices which emit BOILER-COMP DHP OR IM,M0 BTU)
dons air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 10),"BTU) p�
�t. ❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT. p B D
I have read the havardous materials requdremcnrs under Chapter 6.95 of the Fp
California Health&Safety Cede.Sections 2505,25533 and 25534. 1 undm
cand that aS
if the building does tcurently ten that it is my responsibility to nmify the
xcupum of q <h must met prior In issuance of o Certificate of C�� (f t
�\rf£/� s y
oecaranmy. 7 Jm /_ � 14 f�"�'q� _ 1 YCh JIVU
Owner urimahmixN.gent a7 O TOTAL: ISSUED BY: