25181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMH No. 2 5181
CITY OFCUPERTINO APPIICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION ItI11LDING PRIId N.CT II)ENTIN'ICAT'ION
BUILDDI^IN,G,�ADDRESS: SANITARY NO. APPI.ICATIIIOO/�N SUBMITTAL DATE
��L 1' UNIT# LOT If �AA
OWNERS NAME PHONE C CTOR'g ME: LIC NO:
�- r rrs l)'�' N)C CONTROLM
ARCHITECUENGINEER: LIC NO: ESS:
ON )S f SSa'T
CONTACT: PHONE: TY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MFCH
C P ''��t •9.53 PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1 BDESCRIITION
Metz I hereby affmmther lam licensed under pmvisionsofChspler9(commencingwith
Is10y10❑ S11Oon](1(lo)of Division of@eBwiness and Profeseiov Code.and my license is in PANELS /�
tIy V u Poll force end if t I
IQ.Zu1 Li<rn Clans Li<.N 3 UP T0200 AMPS
to Q y Date Convector G-�CSh 201-1000 AMPS
Z~O r=tr'n Zs. - ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA LSQ.FT.
O y— I undersand my plans shall he used m public awards.
�Ny w SIGNS aidelc RICAL
K Licensed PrnfensionW
XOa' OWNER-exempt RDEC Contra ON SPECIAL CIRCIJIT/MISC.
don 1 hereby n.(Se Net 1 am exempt from the Cantrmroh License Lew for the
W 31r-N following reason.(Section 7031.5,Bulinus and Professions Cade:Any city or county TEMP.METER OR POIP INST.
o,5 which requires a permit to comment,eller,improve.demolish,or repair my structure
9p N'7 prior o its issuance.also nomat lheaMlicant bersuch permit to file a signed statement POWER DEVICES ^
lyy q Othat he is licensed pursuant to the Provisions of the Comrecbls License Lew(ChapterSWIMMING POOL ELECTRIC
p-X.q W 9(mannencing with Section 9000)of Division 3orfthe Business and Professions Code) VALUATION
Mmoo or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Z G Section]031.5 by any applicant for a Permit subjects the applicant m e civil penalty of OUTLETS-SWITCHES-FIXTURES
� G not more than five hundred dollars($500). NEW RESIDENTIAL EI-ECfR .
o ❑ Luan
sownerofthe propy.orman
yemployess with wagesheiuolecomprea
etion, 5Q FT. STORIES TTPECONSTRUCION
will do the work,and the strucums is not intended or offered forsale(Sm.]044,Business
end Profesrimn Code:The Contractor's License Law docs not apply In an owner of
properly who builds or improve.,thereon,and who dues such words hi msel f m through his
employees,pmviddthatsuchimpmvetoentsamnmintttW mof(erdfo We.If,
OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yemafeompletion,theuwner-
TOl
builder will have the burden of proving that he did not build or improve for purpose of
ale).
❑ I,mowner ofthe property,ma exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Profusions Code:)The Connector's
License Lawdoesnoupply mo an ownerofpropenywhobuildsmimpmvuthermn,ted PERMITISSUANCE
whoconwetsfar such pmjmts withocobradoods)licensed pursumuothe Contractors se Law. ER
License
ALT -DRAIN&VENT-WATER(EA) FEE SUMMARY
Ell em exempt under Sec. ,B&P C for this remora BACK FLOW PROTECT.DEVICE OUTBID s
SANITARY Y N
Owner DateRF.CRIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, P, I= ff L AX V—N-
1 hereby
NThereby affirmation l have ocerificxmofconxnno self-insure,ore marifmcme ofRECEIPT#
FI%TUR[S-PER
WoheriCmmpcnsation lnsuanceoracenifidwpy Nerwf(Sec.3800,Lab CJ which KFE YN
rsallemplayseaunderthispermlL GAS-FA.SYSTEM- C. RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.S STEM-O" ) LANCI1 iCK FEE
❑ Certified copy isheneby furnished.
❑ Certified copy is Bled wish the city inspection division. GREAS[/INO WASTL'INTERC' GMDIk FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(I'his section need not IS,completed ifthe permit is forone hundred dollars(8100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I certify that in the efmorance of the work for which this permit is issued,l shell WATER HEATER WfVENT/F.LECTR
not employ my person in my mmntt an as or become subject to the Workers PAID
,Z Compauationlawsaf CWifomia. Date WATER SYSTEMfMEATING Date Neceip,N
Applicant
� Q NOTICE TO APPLICANT:If,after making this Cenificateaf Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL-:
. 4 become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such Provisions or this permit shall be deemed revoked. - BUILDING Iq:E
Z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby effort that there is a consvucdon lending agency for the performance of
the work for which this permit is issued(S .309),Civ.C.) TOTAL: ELECTRIC FEE
" rE der's ec
LenName
C) S^ Lender's Address QTY. MECHANICAL,PERMIT F13E PLUMBING FEE
CCCCJJJJ I madly that 1 have and this application and state that the above information is
comm'.I.'reem comply with all wiry and county mcim wee and state laws redial to PERMIT ISSUANCE M[CHANICAL FEE
y baildingcnmwctimm,and heabyemhoria mpresenuivesofthiacity to enta nNe CONSTRUCTION TAX
V Z above-mentiond properly for inspection purpose. ALTERORADDTOMECH.
(We)ague to save,indemnify and keep harmless the City of Caperton agamet
liabilities,judgmenu,ecsts andexpenxs which may many way mcmeagainstsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si a reof Applic trumr Da¢ EXHAUST HOOD(WIDUCP)
PAID
HAZARDOUS MATERIALS DISCLOSURErhandl
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will theme Cupertinot or Municipal Code.ng puntstore or hurdle M1HZalth and material HEATING UNIT(OVER 100.0(0 BTU) TOTAL-:
as defined by the Cupertino Municipal Cde,Chapter 9.12,and the IfeWlh and Safety
Code.Scion 255J2(e)7 � VENTILATION FAN(SINGLE NFSID)
❑Yu B-No
ISSUANCE DATE
Willtheappliwntorfuture huildingoccupantuuequipmenmrdeviceswhichemii BOILER-COMP(3HPGR IIXI,000 BTU)
aemdoux air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(OVER 100,(1(111 BTU)
8 Distract'!
11 Yea No NEW RESIDENTIAL MECH. gQ.FT. P A 6 D
I have read the havrdous materials requirements under Chapter 6.95 of the f��� O
Califotaie IteW &Bafely Code.Sections 25505,25533 and 25534.I understand dot
if the building docs not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
Owner or authodxd agent Dam TOTAL: ISSUED BY: