25178 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL 111( .i- LLCI RICAL PERMH NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25178[ 17 o
O
BUILDINL;DIVISION I{IIILDISG PROJECT[BENItFICATION LJ
BUILDING A1DfDl�R�Ii55: C ,n[,[w/ a^/ SANITARY NO, APPLICATION SUBMfITAL DAT[
y ar ;7 � ) '— `• M UNIT# LOT#
DOWNERS NAME: PHONE: CO ACTOR'S AME: -� hIC NO:
S'1_ I l n _ SIC CO OL#
R('jiITECI'/ENG EEH: LIC NO: ADDRESS: 1A4
� ❑
4.. CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE O El El
CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
py.Z Iherehyaffumlhal lam license)underpmvisionsof Chap¢r9(commencing with
P100 Section 0000)of Division 3 of the Bminessand Professions Calc.and an,license ism PANELS W
z U full force and effect.
<Z, License Class Lic.# UPT02MAMPS
vljy Dae Contractor 201-1.10 AMPS
Z 0,z ARC]I I TECI'S DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA 5/SQ.FT.
0z I und<ntand my plans shall be uxd as public records.
Ft C W SIGNS ELECTRICAL
¢ySj Licensed Pmfessamal
KC W< OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/M[SC.
k.0?F I hereby affirm that I am exempt from the Convenors License law for the
u13Otn following rcason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. _
which requires.pencil to cormrua,.l¢q improve demolish.or rtpair any swmum `
.�r7 prior to its issuance also rapineslbeapplicrnt Fritsch permiuo fiRit,ignedstamment POWER DEVICES
K�0p( That he is licensed pursuant to the Provisions of the Connector's License Law(Chapter
9(mtmnencing with Seclion]0)0)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUA'T'ION
WM, rr that he is exempt therefrom and the basis for the alleged exemption.Any violation of _
Y Sermon 9UJ 1.56 applicant for Permit then I OUTLETS-SWITCHES-FIXTURES
FZa by Penni j pp icannoacivilpenallyof
�� tmmctM1en five hundred dollars($SITU).
ed I.uownerofthe n yemp 5 g pensation, NEWRESIDENTIALELECIR _SQ.FT. Nrp
O ❑ pope y,orm en ed.,ohwa esavtheirite cam Pa � - TYPE CONSTRUCTION
will Jn the work,and the struc W m iv not in[atdcd or nlfercJ far hale(Sec.]094,Business
and Professions Code:The Contractor's License Law does not apply to an owner of '- ♦ # {
property who builds or improves ihemon,and who does such work himselfor through his
sco
employees provided that suchimpovemamerenot imendploreffereE forsale.If, CR=1lT0_UP RES.UNI R
however,the buildingor improvemem is sold within one yearofcompletion,theowner-
builder will have the burden of proving that he did not build or improve for puryose of
❑ lues he project(Sec.
Businsivelyconwttiion,C lh:)n Cmdctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE ppry
mciaml the project(sec.]094,Business ane Professions Cale:)no Comrnetor's
whocrel.awdFr sec applybewith acotracto contractors)
)whased pursuant
thereonand PERMIT ISSUANCE
whocantmcts for such projects witM1acnnwaor(s)IicenxJ pursuannothe Conwcmrs ALTER- ( )
License law. DRAIN FA FEE SUMMARY
❑ I oro exempt under Sco. ,B&P C for this remora TBACK FLOW PRF .DEVICE OUTSIDE FEES
?41TAr
Y N
Owner Date DRAINS-ILdOR, F, I I RECEIPT'#
WORKMAN COMPENSATION DECLARATION LTAX Y_N
�. ❑ lb'Comfealm tha ImumamniewiFeconscnnoxlf-icc.380 .L.h ifcateof Fl%TURES-PER P // 1 I RECF,IPT#
Workers Compensalonlmuhisper viceaifial copy lhawF(Sw.3800.L.M1CJwhich 1111 d � FEE Y N
coversy all employeds under this permit. GAS-EA.SYSTEM- .40[fTLETS RECEIPT#
~ ' PO1ioyp BUILDING DIVISION PEES
Company
❑ Certified copy is hereby famished. GAS-FA.SYSTEM-OVEQ PLANC . KFEE
❑ CerifeJ copy is flet with the city inspcmirn division. ORFASFJINDU Ir WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
phis seainn recd not br atmpincd flhe permit is Intone hundral dollars($100) SEWER-SANITARY-STORM EA.200FT. [NF.RGYIEE
or less)
I really but in the perfumnmem of the work for which his .it is issued.)slmll WATIA HEATER W/VENT/ELECTR
not employ any Person n any narmer so m to herone,subject to the Workers PAID
z Compensation F.awanf Califaniu. Date WAI'17R SYSTEMITREATING Date H¢cipt#
Q Applicant
z NOTICE TO APPLICANT:If,afee,making this Certificate of Exemption,yau.vhruld NEW RESIDENT IAL.PLMB. SQ.IT' TOTAL:
F LObc<mmc xobjecl m the Workcr's Compeosunon provisions of the Labor Code,you most
forthwith comply with such provisions or this pcanit shall be deemed revoked.
BUILDING FEE
y Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I bemby of Ion Ila ,ben,is a construction anding agency for the perfornanm of
U O the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
w0 ULenders Nnme
Under�Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I renify that 1 have read this application and scat,fibra[he above information is
F0. covert. lugramcomply wish all city erM wunty ordinances anJ state laws relu0ngm PERMIT ISSUANCE MECHANICAL FEE
� building construction,and hereby authorize representatives ofthis city to enter upon the
U above-mentioned property for inspection purpexs. ALTER OR ADD TO MECH. CONSTRUCIONTAX
(We)agate m save,indemnify and keep harmless the City of Cupertino it,iml
liabilitiea,judgmems,costs and expenses which may in any way accrue ag' turd ly AIR HANDLING UNIT(TO IBM CFM)
intun-gteencee he granting of this it. (l/v-_
CVs AIR HANDLING UNIT(OVER 10,000 CFM)
Sig m n pPhcanVC nwcmr D EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE I
t UNIT 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant some or handle hasedous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety UNIT 100,000 BTU) TOTAL:
Cale,Section 25532(a)?
❑Yes 0N N FAN(SINGLE RES ID)
Will the applicant or Future building occupant use equipment or devices which em i BOILERP(JHP OR IIXI,f1W BTU) ISSUANCE DATE
hazardous air conmrninants as defined by the Bay Area Air Quality Management P OVER IW,UIIO BTU
Distdcn )
❑Yes ❑No NTIAL MECH. SQ.FT.
1 have mad the larardoos numenals requirements under Chapter 6.95 of the PAID
'
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that Ir
ifthc tent o t e requirt currently ements which must
met it i is myssuanc of a Cerfiao oca the
O cup an of the requirements which must be tan prior to issuance of a Certificate of
oreapnncy.
Owner m aahorred agent Date
TOTAL: ISSUED BY: if