25158 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES< USE BALL POINT PEN ONLY
CITY OF CUPERTINO ml,lou •L A PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25158
tlUILDIN(:PROJECTIDENTIFICATION
BUILDINGADDRESS: o SANITARY NO. APPLICATIIOONSUBMITTALDATE
3 UNIT# LOT
ERS NAMER'S NAME: LIC NO:
IIkP L ,•C � NIC CONTROL#
RCHITE /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELE PLUMB MECH
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Metz I herebyaffirmlhet l am licensed underprovisions of Chapter9(commencing with
❑OO Section]000)of Division 3 of the Business and Professions Coda and my license is in PANELS
;yfWE full force and effect.
FZw License Class Lic.# UPT02WAMPS
ee<a Dam Contractor 201-1000 AMPS
ZFyZ ARCHITECTS DECLARATION SQ.IT.FLOOR AREA $/SQ.FT.
OO OVER 1000AMPS
O Z—A I undersand my plans shill be used us public records.
CY� SIGNS ELECTRICAL
Ca ..1 Licensed Professional
Was< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
Xis U I hereby off.that l am aman,t from the Contractors License Taw for the
to3R.ti¢ following reaam.(Section 7031.5.Business end Professions Cade:Anyciry.county TEMP.METER OR POLE INST.
t O J which requires a permit to consumer.alter,improve,demolish,or repair my structure
Sst't^s�Y� prior to its issuunce,imrequire,theipplicmt famch permit to rile aligned statement POWER DEVICES
pJ C<OK than he is licensed pursuant to the provisio.of the Contractor's License law,(Chapter
Li�LL 9(cotmnencing with Section70(0)of Division 3 ofthe Business and Predestine.Code) SWIMMING POOL ELECTRIC VALUATION
y_oe orthat be is exempt therefrom unit the basis for the alleged exemption.Anyviclationof p
FZQ Section 7031.5 by my applicant for a permit subjects the spattered to a civil penalty of OUTLETS-SWITCHES-FIXTURES
EjG not mom than five hundred dollars($50(t). NEW RESIDENTIAL ELECIR _SQ,FT, STORIES TYPECONSTRUCDON
p1 m ❑ I,usownerofthepropeny,ormyemployeeswithwagesastheirsolecompensation,
y3_ will dorhework.mdthe atoctuteisnm intendedoroffered forside(Sac,17(A4,Business
and Professions Code:The Contractors Limese law docs not apply to an owner of
property who builds m improves thereon,end who rices such work himxlf nr though his
OCC.GROUP
ownemployeca,providecithat such improveemsaenot interaedoffered fertile.If,
mor0.15.UNITS
however.the building orimproverent is sold within one yew ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
W<.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Les rject(Sec.7 em sites irontraaing wishde:)n Cmitrmnto
construct theProjectno,apply to
luno Busowner of
pe Professions Code:)The Conbwmr's
License law dcesnot epplyroanowcerof popery who builds m impovesthcreon,and PERMIT ISSUANCE
who contracts for such projects with a conlmctor(s)I ieensed puauant o the Convector s -
1 L taros L w.
ALTER-URA(N& T 1'R ) FEE SUMMARY
\ ❑ I nn exempt undo See. .B R P C for this reason OUTS'
LADE
BACK FLOW PRO' CT. 6 1 ITAR YN
Owner Data RECEIPT#
DRAINS-FLOOR, REIrE
WORKMAN COMPENSATION DECLARATION C L A% YN
❑ Thereby affirm thmtlhaveacenificere mfcmnsem to self-insure,orecenifimte of FIXTURES-PER TRAP RECEIPT'#
Wmrkcn'Compenution lnsuran<emecertifcd copy rhereoF(Sec.3800,Lab C.)which PARKFE YN
covers ill unpbym's under this permit. GAS-EA.SY 1 M-11 .4 RECEIPI'p
Policy# BUILDING DIVISION FEES
Company - GAS-EA.SYSTEM-OVER 4GEA) PLANCHECK FEE
❑ CcnificalmpyisherebyfumishW.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEEL
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need posts,completed if the permit is(atone hundred dollars($100) SEWER-SANITARY-STORM EA.200FP. ENERGY FEE
or lest.)
I cenifythar in the performance of the..,it for which this permit is issued,Ishall WATER HHATF,R W/VENT/ELECTR
not employ any person in any meanerasto cram,subject m the Wmk,m PAID
ComweDate Receipt It
irst Iawsof Califsrme Da• 6ef�' WATER SYSIEMIDUL TING
zx. Applicant e�✓—�D_u
NOTICETO APPL NT:ILaftermmking thins enifictiomf Exemption,you should NEW RMIDENTIALPLM13 SQ.FT. TOTAL:
,r V) become subjauo Ne Workers Compmeation provisions oflhe Labor Cede.yoummt
P� 5 Forthwith comply with such provisions or this pernir shall be deemed revoked. BUILDING FEE
12.1 "
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm then there is i mad(Sm.3 lending agency Ibr the performance of
V O TOTAL: ELECTRIC FEE
the work for which tMs Details is issued(Sec.3097.Civ.C.)
Lenders Name
fi �
Lendera Address QTY. MECHANICAL PERMIT FLEE PLUMBING FEB
I<enidy Net I have read this application and state that the above information is MECHANICAL FEE
a reset.l agree to comply with all city and county ordinances and sum laws relating to PERMIT ISSUANCE
building construction,and hereby mthoriu representatives ofthis city menter upon the
U Z above-mentioned prop
arty for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in f the gree ting of Nis er 1.
c emcee AIR HANDLING UNIT(OVER 10,"CFM)
'ippatu of Ap wMConuaaor pts EXHAUST HOOD(W/DUC1)
PAID
HAZARDOUS MATERIALS $CLOSURE HEATING UNIT(TO 100k000 BTU) Date Receipt#
Will the applicant or future building occupant start or handle limitations material TOTAL: S
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I M,W B'TU)
Code,Section 25532(,)7 VENTILATION FAN(SINGLE RESID)
El Yen ❑No
BOILER-COMP I3HP OR l0JW BTU) f SSUANCE DATE
Will the acomarmmrfamrt building by the .eequipmcn Qualitc Martaghemit I o Z
heaardo.
air cmtammanu m defined by the Bay Area Air Quality Maragencm BOILER-COMP(OVER 100.00)BTU) (/�/A,
Disrriut7 v'Y
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hmvrdous materials requirements under Chapter 6.95 of the n't4h 1993
Gdifar..ia health d:gafwy Cute,Sections 25505,25533 and 25534. 1 undemand that `Ur
othebuildingdoes not currently have etemnt,dent it ismynesponsibility roundly the
occupant of the regairemeats which must be met prior to sentence of a Certificate of
Occupancy.
Owner or authonxed agent Date TOTAL: ISSUED BY: