25193 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT NO. 25193
CITY OF CUPERTIAPPLICATION/PERMIT PLUMBING-MECIIANFCAh'
BUILDING DIVISION NO
PROJECT IDEN'TIPICATION
BUILDING ADDRESS: IJ`` 1� (��� SANITARY NO. APPLICATION SUBBMMOTAL DATE
/i`'L[/ �{I DGI Ci ./ UNIT# LOT#
OWNER NAMF.:� �j��/w PRONE: WTi ere
R'S N27: G .//- LIC NO: N/C CON[/f�,g/�O\JL(p
A HI WW/ENGINn ^Tl_\swi'�i+ - M SLIC NO: N'!9/. J/ 1, a � —n
CONTACT: AF�V PHONE:
11 i/'r� 1I �/. QTY, , HLFCTRtC PARMIT j', FEE, i BUILDING PERMIT INFO
V� PERMITISSUANCE - BLDG EW PI�IMB
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JInJ(�'
I heart ffirmthat l am limmedondn nsnfChetnr9(commeara with JOB DESCRIPTION
OmZ Ya pad Podfi P 8
u100 Section 7000)of Division 3of the Business and Pmf<uions Cale.and mylimveis in ppryPyg i 1 ��
full force unJ eHeac '1s11L(yYll t
znUj I,i Lic.# UP T0200 AMPS V (�
sn Q dto Carom 201-1000 AMPS
F
�G~Orn a ARCHITECTS DECLARATION OVER 1000 SQ.FT.pi. BHA E/SQ.FT.
O R"D I understood my plans shift te used republic nomads.
aF-an ; SIGNS ELECLNCIVa
J Licensed Professional
�yoo6 OWNER-BUILDER DECLARATION SPF.CIALCI5 �/ 'I's 1I• 3J,
OaF 1 hereby affirm that 1 wo exempt farm the Contractors License Law for the 1 s�7 fY `r
3pcefollowing masm.(Section 7031.S,Business and Professions Code:Any city or county TEMP.AFTER ORPOL ST.
F' which reyuira a permit m construct,alter,improve,demolish,or.,an any nrncmm U O a 0
f N primmre
ibis...am,ulsoquires theappliam mrsach Permit file alignstatementestatementPOWER DEVICPS Ivo
Goof O thm he is licensed puts
uam tote hproviumuofthe Contractor's Limme Law(Chapter
')(commencing with Section]001)uf Division Sof Ne Business and Profasi...Code) SWIMMINOP—LELECTRIC VALUATION
yl_m or that he is exempthemfrom and the basis for the alleged exemption.Any violation of ,,,•••
GSection]031.5 by any applicant for a permit subjects the applicant to a civil penalty of OIJTI.ETS-SWITCHES-FIXTURES /V s
nor more than five hundred dollars($500). ( C
tYm ❑ I,aownerohepmpny,ormyemplaeuwiNwugesotheiralecNEW RESIDENTIAL ELECTR _SQ,FT.ompcnseton.
STORIES TYPE CONSTRUCTION
Wa'3- willdo the work.a.d thesommrcis not imenalWoroffered for We(See 7BG4,Business
and Professions Code:Ile Contractor's License Law does not apply to an owner of
propeny who buildsorimproves thereon,andwhodoessuch work himselfo through Ns
howemployoosilding ri improvement
sold within
intendedmpletio ,foovancL OCG GROUP RES.UNITS
howeer will building or impro#mein is hath within one veto or improve
t purpose
r-
M1flr.). will have the harden of proving that he did not build or improve for puryase of
h❑)1muwnerofthepropeny,amexclusivelyconhacting Mi licensedconwcm t QTY..e" 3,PhUMAING'PERMPI' - 'HEA? FLOOD ZONE AI'N
construct the project(Sec.7144,Boniness and Professions Code:)The Contractor's -,I—
License
ontractor'sPERMIT ISSUANCE
License Lawdoesnot apply man.wnerofproperty who builds or improves thereon,and
who contacts for such projects with a contractors)licensed pursuant(the Contractor's AL'rl?R-DRAIN&VENT-WATER PA FEE SUMMARY
LicenseLaw. O - - '
❑ l am exempt undo Sec. ,B&PC for this reason BACK FLOW PROTECT,DEVICEOUTSIDE FEES
SANTI'ARY Y N
Owner Date RECEIPT p
DRAINS-FLOOR,RIX)P,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I Compffirniat mamm cenificateaf comm�rtrmf(Sreure,ur Lab C.)which
FIXTURES-PER TRAP RI:CL•IPTp
40 Worker%Cnmoymm arm,
emit. nified copy thereof(Ser.3800,Lab CJ which PARK FEE Y N
ern all cmpinyee's under this pertnif GAS-EA.SYSTEM-1 INC.4 OU1'LI?1'S RFCEIPT#
Policy It BUILDING DIVISION FEES
C an CertifiW copy is hereby famished, GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEL?
nilied copy is fled with the city inspection division. GREASEINDUSTRL WASTE IN ? CEPTOR GRADING ITE G7®�
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP GG r
COMPENSATION INSURANCE SOILS FIiF, o 1 _o
(This section need not he completed iffle Permit is for ane hundred dollars($100) SEWER-SANITARY-STORM .200 ENERGY 17EE
�eY1.QIJO
or less.) O V
I certify that in the PaRmarenceofthe work far which this permit is issued,Ishalf WATER HEATER WNPNf/ELECTR
not empty any perm. m any manner so as to Jerome subject to the Workers' - pAlp4:q) :(.j
z Compeosationlawsof Calif tau. Date WATER SYS9'EMTRPATING Date Rec,'ilit#
Applicant
zO � NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PL MH. TOTAL III C1 Z,4510
L V) become subject to the Workers Compensation provisions of the Labor Cale,you most
4X 5:
forthwith comply will,such provisions or this permit shall be doomed revoked. BUILDINGFEI?
Wo
(.5 CONSTRUCTION LENDING AGENCY SEISMIC FEE �
5 z I hereby affirm that there is a consuaction lending agency for the performance of
U O the work for which this permit is issued(Sm.3097,Cie C.) ELECTRIC FEE `
Lender's Name
O" U Lender's Address QTY, -„ ' MECHANICAL PERMIT', PLUMBING FEE
U I certify that 1 hove read This application county
seem that an aMwe information is .ub9 * v"'
>" S corer. ema, co. any with all city and county ordinances and vmelaws rrelatingum PERMIT ISSUANCE MECHANICAL II?E �a
.' adxr an cmiaw io and thanpitop a mtiva of this toemttupon the CONSTRUCTIONTAX
U .have-mentlune ape 'in'
'inn pit
s ALTER OR ADD TO MT:CH.
(We7a i.denard and kc hs Tess the City.1 Cupenin.against
habilitiea,ju costs and es eM1 ay in any way amrm.gainst said City AIR HANDLING UNIT T010,000 CFM)
,a can
qt o t igranr of ispew
I AIR HANDLING UNIT(OVER 10,000 CFM)
w of APPlica Dem EXIIAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
ml theapplicant or futon building cacupantsmre or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1W,t1001ITU) TOTAL:
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Will theepPlicaotorfuturc boildingoccupnntnueyuipmem ordevices whichemit
BOILER-COMP QHP OR IMBED BTU) ISSUANCE DATE
b'a'ud°us air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Rps
District?
P P A V
Yee ❑No NEW RF.SIDFiNT1AL MECH. SQ.FT.
1 have read the hazardous materiels requiremems under Chapter 6.95 of the AVG 19
ant
California I lealth&Safey Code,Sections 25505,25533 and 25534. I understand that rur
if the building does oat ren0ty,m y have a tenum,that it is my responsibilinotify the
occupof the requirements which must be met prior to issuance of u Cenificate of
Occupancy, d•' (
Owner or authorized agent Dam A ISSUED BY: L♦