25454 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO BDILUIN(:—LIALNU AAL - PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 25454
�5 n4 J 4 C A
BUILDING DIVISION - IIUIL,ULN(;PROJBCT IDRn"1'IFICA'1'lON G J
BUILDING AUIlRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE
-Z� 7 O UH#
0 'RS NA i PI{ONE: CONTRACTOR'S NAME: LIC NO:
/ N/C CONTROL a
�AR.1I IIT,CT/]ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG BLLCT PI UM MF,CII
PERMIT ISSUANCE ❑ El 13LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Metz I hereby affirm that l um licemed under proskionsol'CM1apler9(commencing with
[I100 Section'/LYl01.f Division Sof Ne Businessand Profusions Code,andmy license is in PANELS
full full force and efeffect. /'mak
FZW fosc Class LIC.M UP T03fM1AMPS
m=y Dntc Contmcfor NII IIgq AMPS SQ.FT.FLOOR AREA $/SQ.IT.
ZFONZ ARCHITECTS DECLARATION OVER 1000 AMPS
O Z—❑ I understand my plans shall he used as public records.
F
NF W SIGNS ELECTRICAL
Licensed Numssionol
Q�d '-1 '
C y�te'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ax'OyU I hereby affirm that 1 nn exempt four he Contractor's License Law far he
tL30 following mason.(Section?031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F-t�-O< which ms,m ,a permit to cnnstrucl,alter, m
,improve,deolish,orep
rair nny strvure
d
,W>: prior to its issuance,also requires the applicant for such permit tofileasigned statement POWER DEVICES
y�j K,0 that he is licensed pursuant m IM1e provisions of the ContiLicense Law(Chapter _
cW SWIMMING POOLEL I
66 9(comframe.g with Section 9001 of Division 3 oflhe Business end Professioru Cade) VALUATION
,nm orfhat he 1,cxcmpuhereRom andthe basis loathe nllcged exemption.Any violation of Ir.
FZQ ,,Section?03IS by any appl katal for a permit subjects me applicant m R•'a civil Penalty of OUTLET'S-SWITCtII> P �, R
5E than five hundred dollars(350h. NEW RB.SIDENTIAI.ELECIR _SQ.FT.
�Fo owneroftheprrqeny.ormyemployeeswilhwagesmtheirwlecomp madon. STORIES TYPIi CONSTRUCTION
d � wlndothework,andthestrvemrelanotintendedorofferedforsale(Sec.0B44.Business DATE
and Professionx Code:The Contractors License Law does not apply to an owner of
p a,,whobuil&mimprovet thereon.and whndoes such work hiannJturthmughhis -'--
empluyas,provided tM1m such impmrcmenu art notintondeJ uroffered fmsale.If, OCC.GROUP RES.UNIT'S
however,the building m improvement is.w wild within one yearofcompletion,theowner- TOTAL'
builder will have the burden of proving that he did not build or improve for purpose of
aalcJ. QTY. PLUMBING PERMIT FEE
❑ 1,asownerofthepmpeny,amexclusivelycontractingwithlicensedcontractonto FLOODZONE APN
instruct the project(Sec.TOM.Business and Professions Code)The Comonforx
La,,rcLuwdoesnmopplymmo-mi-ofpmpeny wh.buildsorimpr.veathereon,and PERMIT ISSUANCE
who contracts for such Projects with acontramogs)licensed pursuanuothe Convector's ALTER-DRAIN&VENT-WA'T'ER TEA) FEESUMMARY
License Law.
❑ I am exempt under Sec. .B&P C for this mason BACK FLOW PROTECT.DEVICE. OUTSIDE FEES
SANITARY YN
Owner Dat° DRAINS-FLOORROOI;AREACOND. RECEIPTK
WORKMAN COMPENSATION DECLARATION . , SCHOOLTA% YN
❑ Thereby affirm that I have acertilicam ofeon.¢nuo self-insalgore c(rtificamof FTXTURES-PER TRAP RECEIPTN
Workcn'Cnmpenmtlonlmurancwna mnified copy rM1em.f(See.3R(gl,l.nb CJ which - PARK FEE Y N
covers all employee a under This pcmtii. GAS-EA.SYSTEM-1 INC.4 OUTLETS' HLCLIPI p
Policy# BUILDING DIVISION ITIS
Company GAS-EA.SYSTEM OVER 4(EAT PLANCHECK FEE
❑ Ccnificd copy is herby(actioned.
❑ Ccnificd copy is filed with the city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF E- EMPTION FROM WORKERSGREAAP SOILS FEE
COMPENSATION INSURANCE
(This+ectian need n.l be completW if the pertnil is finonehundoWdollars(S100) 3WER-S ITARY-STORM PA.200F1'. ENERGY FEE
m IeuJ
I certify that in the pemorname ofthe work for which this permit is issued.)shall ATER HEATER WNFMAELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compensation Laws of Culifomiu. Dine WATER SYSTEMOKEATING Date Receipt#
O z Applicant
zO NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. TOTAL
L-
� :
1"' L,) Mcomc subject to the Workcrs Compensation provisions ofthe Labor Code.you mml
a > forthwith comply with such previsions.,this pemtitshull be deemed rev.krd. BUILDING PEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
z Ihenbyafficttfhatthere ise,o-traction leadingegcncyfortheperf.mmnccof ELECTRIC FEE
UO the work fur whi,hthis permit is ismW(Sec.3090,Co.C.)
Lenders Name PLUMBING FEE:
V' F^ lenders Address QTY. MECHANICAL PERMIT FEE
V I cenify that I have read this application and state that the above information is MECHANICAL FEE
>. W comas. lagrec mcomply with all city anJ cnumy ordinances and stain luw.a relating et PERMIT ISSUANCE
F" building construction,and hereby aathoriu representativesofthiscity to enter upon she CONSTRUCTION TAX
U Z above-mcntioncd property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Ilahllities,judgment.costs and Cxpcuses which may In any way accrue against sold City AIR HANDLING UNIT(TO 10,M)CFM)
in consaryence of granting of this permit. � /
<2 ' AIR HANDLING UNIT(OVER 10,000 CFM)
Sig ppllcnnUCarlooelor Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1110.000 BTU) Data Rrecipta
Will the applicant or future building occupant store or homme hazabsous material HEATING UNIT(OVER IW,"BTU) TOTAL:
us dcfined by the Cupertino Municipal Cock,Chapter 9.12,and the Health and Safety
Coda,Section25532(q
13 Yes O No? VENTILATION FAN(SINGLE RUMD)
ISSUANCE DATE
Will the npplicunmrfuturehuilJingmcupnmmaequipment.rdeviceswhich emit BOILER-COMP(311POR 100,000 BTUI
hazardnax air communicant as defined by the Bay Ana Air Quality Management BOILER-COMP(OVER 100,000 BTU)
GO ismict?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ^ /
I have mad the hazmdous materials requirements under Chapter 6.95 of the
California lleallh&Safety Cale.Sections 25505.25533 and 25534. I understand that ��
if the building does not currently have a tcnant.that it is my responsibility to notify the r
cupeol of the retryircmcnts which must he met prior m issuance of a Cenificon of FJ j,2
Occupancy.
lilt Y
Owner or authorized agent Dam TOTAL: ISSUED BY:` it
OFFI