25934 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-bLht; RICA PI7RMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBIN G-MECHANICAL /� [' �/� A
-` TI
BUILDING PROJECT IDENFICATL
ION J 34
BUILDING ADDRESS: ) 1 SANITARY NO. AAP'Ik'LICA'1'ION SUBMITTAL DATE
UNIT'# LOT#
O ERS NAME: PHONE a/C� C CTOR'S NAME: x LIC NO: � T R
N/C CONOLN
m+k o C(Illch.maZ �✓/ _ -fed �1M K 15Si� 6a A5
RCIII'f[CT/fiNGINEER: LIC NO: A
CONTACT: PHONE: QTY. ELECTRIC PERfi 7 FEE BUILDING PERMIT INFO
B E CI' PLUMB MECEI
P[RMI'1'ISSUANCE -a��'✓ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-R 1 - AL
0CZ I hereby affirmsthat l am licensed under provisions of Chapter 9(commencing with LOBI SCRIPI'ION
X0p0[] Sec' 000)of Division 3 of the Baslnessand Professions Code,and my license is in PANELS
QObmmemd effe.
E.ZW Licemi Class soLic.N��k,�� UP 2110
y<y Data Contractor ol-
V0nK. ARCNITECTR DIiCLARA'I'ION 0 ER MPS SQ.('(;FLOOR AREA S/SQ,IT.
0 Z.. I understand my plans shall be used as public records.
SI. (�)
Licensed Professional INS EII±C'IRICA
K�C'< OWNER-BUILDER DECLARATION CIAL CIRC T
g4x Oa V I hereby affirm that I am exempt from the Contractor's License Law fur the
W3liy following censor,(Scction]031.5,Business and Professions Code:Any city.,county TEMP.MF, L:INST
which rvapams a Tomtit to crr.mct,.ba,,improve.demolish,or repair any structure,
W YE prionoitsissu..aa,also requires the applicant for such permitto file.signed statement POWER DEVI '
O0 that he is licensed pursuant to tate provisions of the Contractors License Law(Chapter
9(mmmenong with Section 70(0)of Gis stun 3 m due Rmmc,omd Professions Code) SWIMMING fb ELECTRIC y VALUATION
W_m or that he is exempnherefnuu nd the basia for the alleged exemption.Any viola nor OUTLETS-SWITCH IS-FI%TURES I I • L
Fye Section 9031.5 by any applicant fora pemtit subjects the nplumana to.civil penalty of ` �/r
$ 0 mom than five hundreddollormyem). NEWRFSIDENTIALELECIR _SQ.FT. STORIES l TYPECONSTRUCTION
pL m ❑ I,esownendlhe Property,ormycmployccswith wagcsasthcirsolecompersnour,
y3. will dothework,endo h.Contractor License La c dolor.,apply in ancm
and Professions Cnde:The Contractor.License Lew does not apply I.an owner of
ptnemployeb,p vi&drovestherenmandenaamasuch workoroffforsugh his
employees,p building
or i provchimpmvcmentsnrene earoedopletin,fur ovine, OCG GROUP RFS.UNITS
however,the building orimprovementissold e withinoneyearofmproveforthe owner-
b.]a.). will have the burden of Troving that he did not build or improve for purpose of
sole.). . . e.
❑ L as owner ofthe property,am exclusivelycontruning with licensed contractors to QTY, _ PLUMBINGPERMIT 'FEF- FWOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractors pGRMTI'ISSUANCE
License Low ducsnot apply town ownemfpropery whobuildsor improves thereon,and
who contracts fursach projects with a comrumm(s)licensed pursuant nthe Contractor's FLYER-DRAIN&VENT- lift E
Liavc Law. FEE SUMMARY
❑ l son exempt under Sec. ,B&P C for Nis reason HACK FLOW PROTECT.DEV QIP Y DF FF N
s it
Owner Date RECEIPT#
nvc WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.AR � 1. A Y N
❑ Thereby affirm thmlhave anificem ofconsem to sdf-insure,oracertifiome of RECEIPT#
FIXTURES-PER TRAP
Workers'Compyce'sundermncerracertificd copy thecae((Sec.JgOo,IsbCJ which A Y N
roc ell em to cc's undcnhis L RECEIPTp
p Y parrot GAS-GA.SYSTEM-II OUTLIiTS
I'alicyq - CITING DIV ION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PER
❑ Certified copy is hereby famished.
❑ CertiBW copy is fled with the city in.pcction Division. GREASEIINDUSTRL WASTE INTER R GRADING FEE 4AKS
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP S(111.S FEF.
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is furune hundred dollars(1100) SEWER-SANITARY-STORM EA.200FT. ENERGY
less.)
I cceifyffim inthe perbouratceofda,work for which thispermit is issued,[shall WATER HEATER W/VEN'1'/ELECfR
not employ any person in any manner so as to become subject to the Workers' PAID
C.mpcmalion Lawanf California. Data WATER SYSTEM,`ptGTING Dum Receipt#
O z Applicant
O NOTICE.TO APPLICANT:If,after making this Ccrifc.m of Exemption,you should NEW RESIDINTIAL PLMB. SQ.Fr. TOTAL:
V1 bennnesubject mihe WorkasCompansmion provisionsoflhe)Labor Code,you must
7 forthwith comply with such provisions or this permit shall ba deemed revoked. RI LD FEE -
ITZ
CONS'I'RUCfION LENDING AGENCY S CIS ME
I hereby uffirm Jim Them iso construction lendingagency for the performunce of TO]'AT,: ELECTRICfi
uO the work for which this permit is issued IS..309'1,Civ.CJ
Landers Name I'LUMBIN FEE
O L) Landers Address QTY. MECHANICAL PERMIT FEE
U I certify that I have rest[this application and state that the shove information is
r?' Wcorrect.I agree us comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE, MECfIA CAL FEE -
F-' buildingeonstruction,and hereby authonce representatives ofthis city to enter upon the CONS Cf10N TAX
U Z above-mentionW property for inspection purposes. ALTERORADDTOMECH.
(Wa)a nee to save,Indemnify and keep harmless the City of Cupertino against
Ii.tudif ,luJgments,corns and expenses which may in nnyw crue against said City AIR HANDLING UNIT(TO 10,000 CFM)
an seque!n fthe granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
arum olA,lirmo(otnrramr •� Dat 1 EXHAUST IIOOD(W/DUCT) PAID
HAG US MAT A CLOSURE HEATING UNIT(TO IW,000BTU) Dat Receipt#
Willtheopplestat or fwure building mcupam store ac handle hmardous rodcnel HEATING UNIT(OVER 1(q,000 BTU) T
us defined by the Cupenioo Municipal Calc.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)P
11Yes CINo VENTILATION FAN(SINGLE RISID) �.
Will theepTlicantorfmum buildingmcupanluseequipmem ordevices whichemit
BOILER-COMP(3HPOR I0Qt300 BTU) IS NCE DATE
arajo n,air comuminatas nh defined by the Bay Are.Air Qualify Management BOILER-COME(OVER 100.0010 BTO)
District?
Cl Y. ❑No NEW RESIDENTIAL MECH.-SQ.IT.
1 have card the hazardous materials requitement,ander Chapter 6.95 of the
California llmhh B Sale,,Code.Senders 25505,25533 and 25534. I understand that ■
if the building does not vuremly have a tenant,that it is my responsibility to notify the P
occupant of the requirements which must be met poor to issuance of a Certificate of
Occup
Owner or amhoriud.gem Data TOTAL: ISSUED BY: " 199
OFFICE Clr I' QUI-Eh IINU