25898 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO r aDI G- a
,LF, 'RICA L PERMIT NO,
APPLICATION/PERMIT PING PRNJECTID MECHANICAL 25898 8 9 8
BUILDING DIVISION BUILDING PROJF.C'1'IDEN'1'IF'IC,A'I'ION L J o 0
BUILDING ADDRESS: ����/�}� SANITARY NO. APPLICATION SUBMITTAL DATE
OVTCV)"�/C/�J UNIT# LOT 0
OWNER NA E: PHONE: CON TOR'g ME: LIC NO: NIC CONTROL#
Y �STA.ft 90 .1sZ 1� rrrraci 5 i
�ARCI II'1 ECI/ENGINEER: LIC NO: ADDRESSS3:
/ 0
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT 'FEE
BVI.W ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEM'IAL
Metz I herehyxifrm that l am liccianduralm,mvisionsofCht,am!)cnmmenciag with TOB DESCRIPTION
nQCC Section700fpnf Division 3 of me Busineastud Professions Code.and my license is in PANELS
lull farceand effcin
Qz license Class Like# J 7J gi U UPT0200AMPS —b 1
y a y hale C,xa ae�K.T/Ora 201-10(a)AMPS t
Z O:Ni.2, ARCHITECTS DECLARATION 10110 AMPS 1 fA S�Q'�'
)Z-0 I understand my plans shall be used as public records.
f rn�ul SIGNS EL[LTRICAL T I✓�
LIC[aeed Professional u_'-
E:H< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xiOyF 1 hereby affirm m m that I aexempt frothe Contractors License law for the
1113�m following reason.(Section 7031.5,Businessfu
and Profusions Codrummy Any city m y TEMP.METER OR POLE INST.
[—V,CS which requires.permirto cvnstraa,alter,improve,demolish,or mixture,strunure ATE _lt
Ni 2 prions its issuance,also the applicant forsuch uo file a signedstatement POWER DEVICES --
requires pp panni
W C
too beis li.aled pursuant mthe provisions ofthe Contractor.license Law(Chap¢.
a �y 4(commoneingwlm Salton lg0)of Division 3af the Buainess.nA 11 lassie, Code) SWIMMING POOL BLECfRIC
VAI UIZ05
o
'p�'_o, mnbxt he is exempuM1ercrrnm and the h....far the al legelexempfion.Any violation of OUTLETS-SWITCHES-FIXTURES \/\/`,�O
Z,Q Section 7031.5 by any applicant for a permit subjects the applicant n a civil penalty of
SD sat morcthan five hundreddol l...(.5510). NEW RFSIOENTIAI.ELECTS _SQIT
Wl—o ❑ I,asownemftheproperty,ormyemployuswiNwage ntheiraolecompensminn, . . STORIES TYPECONSTRUCTION
y3o0 will do the work,and the structure is not intended or offered for sale(Sm7044,Business
and Professions Code:The Contractor's License law does not apply m an owner of
prapery who builds or improves thereon,and who does such work himselfor through his OCC.GROUP BES.UNITS
employees,providedthnsuch improvementsare not intendedmoffend Tamale.owner-
however,the ave t e bur improvement is hat within one yca.ofcomplaion,t orposc TOTAL:
builJer will have the harden of proving that he did not build or improve for purpose of
❑ l�sownera0hepmperty,unexats velycontracungwuhl cemalumtrunbusto QTY..,'. PLUMBING PERMIT t FEE FLOOD ZONE APN
.mm
act the project(Sec.1044,Business end Professions Code;)'I re Contractor's
Licence Law does not apply loan ownerofpropcnan
y whobuildsor improves thermer. J PERMIT ISSUANCE
Lima,Lots for tach pmjed.withacnnvanorts)Ii¢need pursunnumhe Conwaors ALTER-DRAIN&VENT-WATER EA
License Law. 1 ) FEE SUMMARY '
❑ 1 sm exempt under Su. ,B&P C for this reason BACK FLOW PROTECT.DEVICE DT
SANITARY Y N
Owner Date RECEIPT M
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I herebyaffrm that[have acer-ificale ofcoment toself-insure,oracenificae of RF.CI1IPI'#
FIXTURES PER TRAP
Wnrkcrs'Compensation Insurance nrxcertified copy thereof(Sea 38(O,IaM1 CJ which PARK FEE Y N
covers all employee's arthritis pamrit. GAS-EA.SYS'T'EM-1 INC. O VI'LHTS RIiCIIII9'#
Policy# BUILDING DIVISION FEES
Company GAS-F.A.SYSTT.M-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished,
❑ Certified copy is filed with the city inspection division. GREASPI1NDUSTR1.WASTE INTERCH17OR GRADING ME
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP SOUS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is fibrose hundreddvllard(SI00) SEWER-SANITARY-STORM EA.20014. ENERGY FEE
or lcssJ
I certify that in the performance of the work for which this permit is issued,l shall WATER I[RATER W/VENT/ELECTR
Colemploy
mpen,ation�jfGyp`t CCumi.ny person in any m:unner so a}m m m the Workers' WATER SYSTEMo R1i TING PAID Data Receipt It
Q z Appfcam Pt
O NOTICE,TO APPLICANT':I1',after making this Certificate of fl.captim, .a should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
LI) become subject to the Worker's Compensation provisions of the Labor Code,you must
!�^ > forthwith comply with mi
such provisions or this pert shallMdeclined revoked. BUILDING ME f
0. [� CONSTRUCTION LENDING AGENCY SHISMIC FEE
Z. I hereby affirm that them is a construction lending agency for the performance of
U O the work fm which this permit is issued(Sec.3097.Civ,C.) TOTAL: ELECTRIC PER
Lmulm,Name v PLUMBING FEE
O F Lander',Address ' QTY.- MECHANICAL PERMIT' - IT, -
U 1 verify that I have read this application and state that the above information is
cnreot. l agree to comply with all cityund county milmance,mal state lawsrclming to PERM1'f ISSUANCE MSCI IANICAL FEE
F" building construction,and hereby mabod a,representatives ofthis city owner upon the
V 7
.hove-mentioned men,for inspection purpCONSTRUCTION TAX
oses.
�7 (We)agree to save,indemnify and keep harmless the City of Cupertino against ALTER OR ADD TO MECH.
liabiliticajudgments,costs and expenses which may in any way secrue against said City AIR HANDLING UNIT TO I(LOod CPM)
in consequence of the Standing of this permit. '
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicant/Commcmr Data EXHAUST I IOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN),"BTU) Date Receipt#
Will the applicant or future building occupant store or handle horsiest material
as do final by the Cupertino M uniei pal Colo,Chapter 9.12,and the l lralth and Safety I]HATING UNIT(OVER 100,000 BTU) 'TOTAL:
Code.Section 25532(u)7
El Vee ❑No VENTIIATIONFAN(SINGLERESID)
Will the applicant or fmure building occupant use eq.ipmem or devices which emit
BOILER-COMP(31(P OR 1(0,0(10 BTU) ISSUANCE DATE
Imemeh us oI,contaminants as defined by the Bay Area Air Quality Management
District? 11
-COMP(OVER 100,000 RTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. A ID
1 have read the norma s materials requirements under Chapter 6.95 of the FEBCalifornia Health&Safety Code,Sections 25505,25533 and 25534. lundemeadNat F �9g
if the hnlldino dao not cuncn0y have amnant,that it is sy espnnsibility to notify the �)y
occupant of the tirements which n n he p' y attr ce of x Cvrlifcam of C/
Occupancy. 8 q �[G�
Owner cruse oriaed agar _ Date TOTAL: ISSUED BY
OFFICE