25426 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT LY
CITY OFhDIVISION
O B ILUI G-ELF. RI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n C /I n C
BUILDINBUILDING PROJECT IUENTIFICATIDN L J 4 G V I
BUILDING ADSANITARY NO. APPLICATION SUBMITTTAAL DATE
UNIT# LOT#OWNIi PII CO 'S NAME: LIC NO: N/C CONTROLN
ro ARCI I : LIC NO: ADD
• ❑
CONTA PHONE:
jkla I]I� 0102'e /�aF'��F�J QTY. ELECTRIC PERMIT PEE BUILDING PCRMIT INFO
1�/ (/ WGIZ. PERMIT ISSUANCE B ELECT PLUMB ME❑CIi
LICENSED CONT ACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Metz I hereby affirm that l am licensed undupmvisionsofC aptor9(commencingwith
BOO Section e and of Division Jof the Business and l'rofessiom Cole,and my license is in PANELS 1
)1 UUpp fullprince rle Class eRca. UPTO200AMPS •1.. lig
FZu1 License Cl ass Camm
ti=y Date rFcranar 201-1tX10 AMPS S PT.FLOOR AREA VSQ.FT.
ZFO ti's ARCHITECTS DECLARATION OVER 1000 AMPS Q
O Z—G I understand try plans shall be used as public records.
F,y W SIGNS ELECTRICAL
„"Ij Licensed Prafeuionel
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�xF�'OdF 1 hereby affirm that I an exempt from the Caron s License Law fur the
1+130 following meson.(Section 7031.5,Business and Profeseioms Code:Any city or county TEMP.METER OR POLE INST.
C��S which requiresuPermit to conswet,elms improve.tlemolish.or repair my structuref;!(P7 prior to its issuance,also octaves the applicant for such permit m file a signed statement POWER DEVICES
ca DO that he is licensed pursuant to the provisions idihe Conmacmr's License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
dKe� 9(commencing with Section Division J ofine Business and Professions Code) CSV
W,may onM1at be is exempt therefrom and the basis fonbe alleged exemption.Any violation of OVI'LEI'S-SWITCHPS-FIXTURES L1�p1
F Z Q Section 7031.5 by any applicant for a Permit subjects the applicant to a civil pemmty of (�.rJ
t mom than Five hundred dollars(SSW). S NEW RESIDENTIAL ELECTR
El employeeswith wugesasiheirsolecompenserion, Q'FT. STORIES TYPE CONSTRUCTION
a3—aJ willdothe work,and the srrvcwmis not imendedoroffemd for see(Sec.7044.Business
and Professions Code:The Commoner License Law does not apply to an owner of
property whobuildsor improves thereon,and whodoes suchwork himselfor lhmughhis / OUP RES.UNITS
own employees,provided thinsuch i mprovementaue not intended or offered for see.I f.
however,the building or improvement is sold within one yen of completion,the owner-
builder will have the burden of that he did not build or int far f L'
proving prove puryoseo
sale.). QTY. PLUMBING PER IT t ONE APN
❑ Tact owneroetu(See.7W,I xclusivelyconmassion,C licensed Cistinorxm
Liceemeanse the project(Sec. ono Business and Professions Code:)The Corr hand PERMIT ISSUANCE
Cleanse Lawdocsnotapply manownerofproperty whnhuilda or improves thereon,und
wboc'cLaw. ser suchprojemswithaconvacror(s)Iicensed putsusnlmthe Comrecmra ALTER-DRAM&VENT. ATFR(EA) -SUMMARY
ATr
License Lew.
❑ 1 nm exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date RECEIFF#
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPFJgSAT10NDECLARATION SCIIWLTAX YN
❑ IherebY affirm that lhave acertificam ofcanum mulGinsom,ora certificate of RECE1PTp
Workers'Cnmpensmiorder this
par ucenifleJ ropy therwf(Sec.Jg00,Lab CJ which DXTURES-PER TRAP PARK FRE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'p
Policy N BUILDING DIVISION FE
Company GAS-EA.SYSTEM-OV FR 4(FA) PLANCHECK FEE
❑ Comficd copy m hereby fumishod.
[I Certified copy is riled with the city inspection division. GREASPJINDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' UREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not be completed iflhe permit is for one hundred di lan(4100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WfVRNT/ELECTR
not employ any person in any manner so as to became subject to the Workers' PAID
z Compensmion Lawsof Cmifomia. Dam WATER SYSTEM/TREATING Date eeeiplI
Applicant
O2 NOTICE 10 APPLICANT,If,after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ.FT. TOTAL:
CI) recentsubject to the Workers Compensation provisions ofthe Labor Code,you most
7 forthwith comply with such provisions or this Fourth shall his eem
deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for whichthis pomtit is issued(Sec,3097.Civ.CJ
Lenders Name O PLUMBING FET:H Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 certify that 1 have read this application and state that the above information is
W correct.lagrtc mcomply with ell city etM county ordinencn and nmelews mletingm PERMITISSUANCE MECHANICALF
building construction,and hereby mahouts,representatives ofthis city to color upon the GON$TRGCTIO TAX
U z above-mentioned properly for inspection purposes. ALTERORADDTOMECII.
(We)agree to nave,indemnify and keep hatmless the City of Cupertino against
Iiabilitiex,jidgnmms,cusm and expenses whichmay in any way accrue againxtsaid City AIR HANDLING UNIT(TO 10,000 CFM)
uyuen sof the morin (this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si i' VCu w �• Dom EXHAUST HOW(W/DUCD PAID
e
R X1U$MATERIAL DISCLOSURE HEATING UNIT TO 100.0011 PTU) Date Rcceip
Will the applicant or future building occupant store or handle hamrdous the rim HEATING UNIT(OVER 100.000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cade,Section 25532(e)P
❑Yea ❑No NTVEILATION FAN(SINGLE RESID)
Will the epplicamor fuwmbuildingoccupantuaeequipmcnmr devices whi<hemit
BOILER-COMP(JHP OR 100,000 BTU) ISSLrANCE TTATE
harmadom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) CEP as 9 19
�DinricA H .
❑Ya ❑No NEW RESIDENTIAL MECH.—SQ.FT.
93
Y
1 have red he fezWous Section 5505,2 533 under 34, 1pe pedimental
of the G11Y Ur wrtN111VU
California Health&Safety Cute,Sections 25505,t it
and 25534. 1 undemmnd mm
if the building does not currentlyhaveatenant,Natit is myrespnce of ty ernotify the
O c spam of the mquircmems which must be met prim m issuance of a Certificate of
Occopanay.
Owner or arborized agent Date TOTAL: ISSUED BY " VVI
OFFICE