25444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x 1bTS,-h. EL'RI AI. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25444
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
HUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT p LOT a
0 "RS E: PHONE: CO A O 'S NAME: LIC NO:
`� \ �S JSS 9i NIC CONI'EOL
• ARCHFIECI'IiNGINEER: NO' AQDHj{SS: I �]b ❑ �
`[1S a,,, ICI. �J
CONTACT: PHONE: BUILDING PERMI
F, T'INFO
QTY. ELEC'I'I21C PERMIT FE
`�Lq�� , 1 DC LEC' PLUMI F;CH
VPERMII'ISSUANCIi
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I M1crcb IEmllh,tllumlicenacJunder ICbat )(commencingwith JOBDESrRIMION
WMetz
OO Ytt pnrvrinnso pert
PANELS
WOO Senion)oL`0)nf Division3 of the Pusiness and Profession..Code,end my liceroe is in
t��_
ufll force and cff
FTITZw License Cho Lic.p UPT02MAMP$
way Dam Cmnracdor 201-10X0 AMPS
ARCHITECTS DECLARATIONSQ.FI'.FLOOR AREA $ISQ.FT.
V OU,Oz—�
I understand my plana shall be used as public records. OVER I(IW AMPS
PMLJ J SI NS ELECTRICAL �6
Q U,emod Prnl'e,ionul
OWNER-BUILDER DECLARATION SPECIAL CIRCUIIyMISC.
KOw, I hereby affirm that 1 sm exempt from the Contractor's License Law for the
to3ah followingrecon.(Section]031.5,Business and Professions Code:Anycitymemony TEMP.METER OR POLE[NST.
t(,
O; which requires a permit to Construct.alter,improve,demolish,or repair any swcmre
prior,dm its issuance,alsuri,mues thcapplicam fmaoch penniuo file.signed smdemem POWER DEVICES
t <0 thin he is licensed pursuant to the provisions of the Continences License Law(Clmpmr SWIMMING POOL ELECTRIC
ae,o= 9(commencing with Section 7")of Division 3 of the Business and Professiore,Code) VALUATION
¢i='vi unhat he iscncmpdthercfmm and the basis fonhc alleged exemption.Anyvi.1 tiono �� r'/
f—ZQ Section 703).5 by any applicant for a permit subjects the applicant to a civil pennhy of UTLETS-SWITCHES-FI%I'UftES q to C
FSO nm me ilia. rofthefive rodny.lormycmars ). NEW RFSIDENTIALELECTR _SQ.UL STORI 'TYPE CONSTRUCTION
�f-22 ❑ .thew rand the npccy,or myempendeexwithwed forsale(Sec.c0a4,B motes,
G'3— will dothewons Code:
he Contracnot tor's
License Law
not
9014,Business
and Professions ewe:TM1e emmmnora License Law amen not anplr to an owner or
progeny who bui Ids or i mprov es themon,artd who docs such work hi mac If or dhmugh hi a
IS
employees,provided that such improvements anot intendedoffcredfmaile.IL C. ROU R .UNITS
however.the handing or lmprou
vcnnd is sold within one year ofcompletion.the owner- O77 ID 9 N
builder will have the burden of proving that he did not build m improve for porpose r, V
le.).
l,mowneroftheproparty,amexclusivelycontmetingwithlicenxdcoamactorsto QTY. PLUMBING PERMIT FE
OU NH PN
Elm.muct the projecd(Sr,9044,13ustiv ss and Rof swim,Code:)The Contractor's '^0
License Lawdoss not apply toanovnerofpropcmy whobuildsorimproves thereon.end PERM IT ISSUANCE ry
whoccalmeta for such projects with aconructods)licensed porsuanu.the Contractors ALTER-DRAIN&VENT-WATER(EA) �lTCB9NMMMiif�
License Law.
❑ [,in,exempt ander Sec. ,B&P C for this reasonPACK FLOW PEOI'IiCf.DEVICE TSIDL e
SANITARY YN
Owner Dote DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT'#
• cove WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I berebyaffrm that l have a etrtificatenfeonaenuo self-insum,cru eWireme of XTURBS-PER TRAP RECF.IYI'#
WorAers'Cnmpensmion Insurance or.certified copy thercol($c,38M,Lab C.)which PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIVE,#
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER4(EA7 PLANCHECK FEE Z '�
[:ICrodl,J copy is hereby fumishw.
❑ Cenifw copy is fled with the city inspection division. GREASIONDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE t� '1
('lntissection need not becomplcted ifthe permit is for one hundrdO
dollan(SIM) SEWER-SANITARY-STORM EA.2(OfT. ENERGY FEE �rO0
less.)
I ceraly that in thepeffomtuncc ofthe work for which this permit is issued,Ishan WATER HEATER W/VFNT/ELECTR �_lp 1'�-7 x— 11
not employ any#anon,n any manner n as to become subject to the Workers' PAID 19 , 7,
Compenenion Lawsof Califomi.. Dale s WATER SY$TEM,TREATING Date Receipt#
Z
Applicant qq
NOTICE 10 APPLICANT:If.after making this Cenilicam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: �#oo�f
become subject to the Workers Compensation provisions of the Lahr Code,You must BUILDING ITE
a > forthwith comply with such provisions or this permit shall be deemd mvakd.
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE ♦
z I hereby affirm that there is u construction lending agency for the performance of L
V O the work for which this permit is issued(Sec.300.Civ.C.) ELECTRIC FEBELAM
1<wds Name PLUMBING ME
u-' F Kotler',Address QTY. MECHANICAL PERMIT FEE
V I cerify that 1 have read this application and sm a 0mt the move information is MECHANICAL FEF. pr'
correct.l agree mcomply with all city and county Unbalances and state laws relating to PERMI'I'ISSUANCE
f^ building construction.and hereby authorize representatives ofthiscity toemer upon the CONSTRUCI'IONTAX
U Z flaw,rmaioncd property for inspection purposes. LTHR OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabi ities,judgmenm.cmHan pcnus wh[chmay in any way zccmc against said City AIR HANDLING UNIT(TO 50.000 CFM)
neon ce of thea ting dx tlli permit a
\rte AIR HANDLING UNIT(OVF,R I0,000 CFM)
,gnaturt of ApplicenhConvanor 3jI Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dara Receipt#
Will the applicam orfuwre huilding meupum stare or handle hazardous materiel HEATING UNIT(OVER 100,000 BTU) 101A k1a
res defined by the Cupertino Municipal Code,Chapter 9.12,and the Healthand Safety
Code,Section 25532om? VL+MILATION FAN(SINGLE BESIDE El Yes C3 No
ISSUANCE DATE
Willthcayplicantmfutumbuilding«cupanmseequipmentordevi.whichemit BOILER-COMP(311P OR IMIOM BTU)
• hazardous air contaminants as defined by the Bay Arca Air Quality Man dlemem BOILER-COMP(OVER 100.000 BTU)
DistricR
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FI'. nn pp
1 have and the h narohms materials mquiremems und
er Chapter 6.95 of thr e A i
Califanda I leulth&Safety Cwe,Sections 25505,25533 and 25534. I understand that
if the b dfilm,docs nut currently has.a mnao,that itis my responaibllity to notify the
curent of the requimments which must INC met prim m issuance of a Certificate of AUS 1
txcapancy.
Owner or.nhorizzed a gent Dude TO L. ISSIII�DIIY:
OFFICE