25522 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO BUILD INU-S1.5C'I RICAL PERMIT NO,
PLUMBING MECHANICAL BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJEC'I IDENTIFICATION 25522
BUADDR` �� SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
1L UNIT LOTH
f11sgSJAME� PHONE: C.0 RACfORT NAMR: LIC NO: ` VV
'IJ1� V• (�}��� / /�y N!C CONTROLMW00CJ t�0 27 7 RFS G i Cj�/ cox
CON I AUI: PHONE Q1 Y. ELECTRIC PERMIT FEE BUILDING PERMITINFO
er%L►5011 11 Q-0710aO BLDG [CECT' PLEl MF:CH
a+ PF-RMITISSUANCEPK
LICENSED CONTRACT 'S DECT.AkATION APPLIANCES-RESIDENTIAL- JOB DESCRIPTION
Maty I hereby affirm that l am licensed underprovisiomof Ch.pter9(commencing with
woo Section 7")of Division 3 of the Business and Professions Cale,and my license is in PANELS /(•��1
FCWC full forward effect.
FZW LicenClasx Lic.g
I1PT0200AMPS if
rn=y Date Contractor 201-10(10 AMT'S S TI MOOR AREA B/SQ,FT.
ZOm� ARCHITECTS DIiCLARATION VERIOOO PB Q
OZ—'Q I understand my plans shall be,used m public records. ��
n W E 1
Cleansed Professional Dot
yaQ OWNL'R-BUILDER DECLARATION A, IRCUIT/MISC. ir
XM 1 hereby affirm that I ora exempt from the Comment, License law far the
W3O. fallowing rcusna(Scdion]031.5.Buxiness trod Profexxions Code:Any city or county .METER RP
�� which minims apermittoconumar.alter.improve,demolish.ormpairany nmctum
>7 isdortoiPissuanu,alto reyuircsthe applicant for such permit to Bleasigned swmment POWER [ 5
u ¢p O thm he rs licensed pursmm m the prmisinns of the Cnmmctor's License Law(Chapter
o.yoE 9E,...cing with Bedion]nW)of DivisimnJof the Nusincss end Professiom Code) SWIMM BLECfR VALUATION
�_y or he is exempt themman and the basis for the alleged exemption.Any violation of OUI'LL -SWITCH' -PIXTUREB ��' lat
tz} Sectlom]031.5 by say.,iciamI.,.permit subjects the applicant to a civil penalty of LLL D v
Wto not name than rofive heprodnollars(5500). NEWR 'IDE ALELECfR _SQ.Fr. STORIES TYPE CONSTRUCTION
�F� ❑ .thownerofthepropeny,armyemployeawithwugesasrheirsolecompeveaion,
63-J will duthewurk,ande:ehe Comiane la License
ofwdofmn,apply
wo,rarof
end Profusions Cad<:The COntmctnr's Licenu Law does not epPIY m an owner of
propertywyees,pdsorimphat such improvements
de,not ahwmk himselfor through his OCC.GROUT' EA
own employees,provided that such improvements are not intended moffered forsole.If,
however.the building orden ofimemissold within one year ofc provefortheawner-
bale.). will have me burden nfproving that he did not build or improve for puryose of
cele].
❑ I,sownerof the property.amcxclusively contracting with licensed conrtacmmto QTY. PLUMBINGPERMIT FEE FLOOD 20NL:
consumer the project(Sec.9014,Business and Professions Cale:)The Contractors
License Lawdoccom apply to an ownerofproperty who buildsor improvesthereon,and PERMIT ISSUANCE
whocontrdesforsuchpmjwswithaconuactorfs)licene punuaaumhe Conmccoes gLTF:R-DRAIN&VENT-WATER
License Law. HIA) I FEE SUMMARY
❑ I am exempt under Sec. ,B MPC I'or this reason BACK II,OW PROTECT.DEVICE DI SLE
SANITARY YN
Owner Dam DRAINS FLOOR,ROOF,AREA.COND. RECF.IPfp
WORKMAN COMPFNSATIONDLCLARATION SCHOOLTAX Y N
❑ lherehyaffirmion that Insurance
ns mance ortificamofconsemerrof(to er.38oracen.)whichmamof FIXTURES-PER TRAP RECF.IPI'M
g Wvera al C employee's nler this Permit. riled copy lhemaf(Se..38IX1,Lab CJ which PARK FIiP, Y N
covers all employee's under this permit. GAS-EA.SYSTGM-1 INC.4 OUTLETS RDIVISION
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ITH
❑ Certified copy is hereby famished.
❑ Certified copy is filed with Nc ciry inspection division. GREABEANIIUBTRL WASTE INTERCEPTOR GRADING FRE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FSE
COMPENSATION INSURANCE
('Phis section need not be completed if the permit is for one hurniml dollars(S1 WE SEWER-SANITARY-STORM EA.200FT. ENERGYFEH •►��
or Ic..)
Icenifyth.t in the performance of the wmkfor which this permit is issued,l shall WATER HEATER W/VEdT/ELECTR
not employ any person in any m.nner s,as to become subject to the Workers' PAID
Compensationlawsof Califomia. Date WATER SYSTEM/fRFATING Dam R it
O Z Applicant
Z 0 NICE ICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,F1'. TOTAL:
� Vl become subject to the Workers Compensarins provisions mfthe Labor Cade,you must
; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
u^ (] CONSTRUCTION LENDING AGENCY SEISMIC IEE e � y�
P, z I hereby affirm that them is a construction lending agency for the Performance of
U O the work for which this Permit is I...ed(Site 3097,Civ.C.) TO'T'AL: IiLF:CTNIC FEE
Lenders Name
0U Lenders Address a QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U 1 cmify that 1 have mad Nis application and state that the above information is
correct.l agree m comply with ell city and county ordinances and state laws relating to PERMIT ISSUANCE. / MECHANICAL.PEE
bmidingconsvuninn,..binumby amhorim reproarmawes of this citym carer upon the CONSTRUCTION TAX
U Z above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to indemnify trod keep ass Ne ry of Cupertino against
li.bil'm,e.' re coats trod xpcnacaw nay into ynccme ng.instimit City AIR HANDLING UNIT(TO RI,OWCIM)
inc he ri of his
/ �Arj AIR HANDLING UNIT(OVER 10,000C p)
Signawreof Applicant/Commctor Date EXHAUST HOOD(W/DUC)
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Late Receptp
Will the applicant or future building reception store or handle innuendoes material
as defined by the Cupertino Youirijud Cale,Chapter 9.12,andthe Health and Safe,, HEATING UNIT(OVER IW,fh10 BTU)
Code,Sectio 25532(a)P
❑Yes Yi No VENTILATION PAN SINGLE RESID)
ISSUANCE DATE
WillthcepplicenmrfuwrebuilJingoccupamuse cquipmentordeviceswhich emit BOILIiR-COMP(JHPOR IW.000 BTU)
hazardous air conwminams gAdefincd by the Bay Area Air Quality Management BOILER-COMP(OVER Hit BTU)
Di.arim^ �.I('ts� P A I D
❑Yes NEW RESIDENTIAL MECH, SQ,FT.
1 have read the hazardous materials ox,macmems under Chapter 6.95 of the SEP 101
Califomia Health afety Code,Sttaions 25505,2553] d 23534. I understand Net
Hit, buil ' •d mainline lyhave t I.t iai y ortiamiddlityl.indify Ne
occu n t reyuircme idt be met pr rasa u Cenifume of i �r
p a D. V V
Owner Or uuthorizW agate
Out ISSUEU BY:y
OFFICE
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e DATE,DONE ,.TYPrI OFANSPECTUIN An= ecto; Code RA SIFAIL COMMENT •
,.. n.. � _ ____ ________ ____________________________
to IN-_.ECTION CET`.my 'n4 _
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