27171 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOmEDINIx-ftl,M,A AICA. FERMI I NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDRN'I'IFICA'I')ON 27171
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBJvl DATE
N LOT# it) 1107
3WN ML: /QIIt L': CO T C'I'O NAME LIC NO.
YY b N/C OM'KO #
ARCIII'I iCT/IiNGINEI: LIC NO: I
. . / -1 ❑
CONTACT: PHONE QTY. k- 1 i.
d ° BUILDING PERMIT INFO
,CI.ECTRIr PERMIT `FEC
-BLDG F1.ECf PLUMB MECH
PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
Metz Ihereby affirm that l am licensed underprovisionam'Chapter9(commencing with 30B DFSCRIPIION
ta100 Srerinn]UBo7nf Dives on3 of the Business end Prnfessinna Code,and my license is in PANELS
y—f+l�F. fullfnrce and cff
a ZVz,OVj License Clan Lit.p_ UP10200AMPS
y6y Dam Contrucmr 201-TWO AMPS
ZOyZ m an
DE O OVER 1100 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 1unersmn y sshallbeusedmpublicrecords.
yr w SIGNS ELECTRICAL
11th" Licensed Professional
Com` OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aann55,�00.F 1 hereby offion that I am exempt from the Contractor's License Law for the
ot¢ following mason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F�r to mi
which requires a pert to construct,Wier,improve,demolish.or repair any sure ucn:� prior to its issuance,also requires the applicant forsuch permit o file a signed statement POWER DEVICES
p0 That he is licensed pursuaano the provisions of the Contractors License Law(Chapter
p' eltiy 9(commencing with Section 7")WDivision 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
m..m nr that he ie exentpnbemlrom end the basis for the alleged exemption,Anyviolilion of OUTLETSSWITCHES-FIXTURES
Section 7031.5 by any applicant for a permit subjects the applicant -
to a civil penalty of '
aG not more than five hundred do11vs(5500). NEW RESIDENTIAL LLECTR
cull ❑ I,usnw crortheprnperty,ormyemployees with wages a stheirsolecompensvuon, —SQSTORIES TYPECONSTRUMION
d willdothework,and the structure isnot intended orofferel forsale(Sm.V044,Buslmeea Pa 0 %)
and Rnfessions Code:The Commena's License Law does not apply to an owner of
property who hu I Ids or improves thereon,and who does such work himself or through his
own employees,providedthat such improvements arc notimeadedaroffered forsale.If, OCC GROUP NES.UNITS
however,the building orimprovemen is sold within one yearofcompletion,the owner- TA
builder will hove the harden of proving that he did not build or improve for purpose of
❑ I,as owner oftheproperty,am eacrosivelycoadmiling with licensed contractors to QTY, ; PLUMBING PERMIT FEE I1001)ZONE APN
construct the project(Seo.7044,Business and Professions Code:)no Committers s t s
L.icemc lawdoeanmapplym aammarofproperty who builds or improves thereon,and FERMI"r ISSUANCE /
whocontmcts for such projcats with aconwcmr(s)licensed pursuant to the Common's AL'ITK FEE SUMMARY
[.I,.'e Law. DRAIN&VENT-WATER(UA) . . s;
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE _ DE Frins
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AR EA,COND. RFCF.IPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby effimtthetl heveacrni0cme of wnum to self-insum,ore cenificme of RECEIPT'#
t Woken'Cnmpensution Insurance.,a ceniliedcnpy thcreaf(Sec.3801,Lab C.)which 111 FIXTURES-PERTRAP PARK FEB Y N
covers all employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RRCEIInL#
Policy# BUILDING DIVISION FEE'S
Compaoy GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE:
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with Ne eery inspection Jivisi.n. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCL
(This section need not he completed ifthe permit is formal,hundred dollars(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY 17EE
or less.)
I certify that in the pcdo..of Ne work for which this permit is isaued,l scroll WATER HEATER WNENT/ELECTR
not employ any person in any manner Is,ns to become subject I.the Workers' PAID
,z Compensation Laws.f Califomio. Date WATER SYSTEMiMEATING Date Receipt#
Applicant
z2 NOTIC17 TO APPLICANT:If,after making this Cerificate of Exemption,you should NEW RBSIDMTIAL PLMB —SQ.IT. TOTAL:
(r^ Enj become subject to the Workers Compensation provisions ofthe Labor Code,you must
24 ; forthwith comply with such provisions or this permit.hral he deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY 4. SEISMIC FEE
p Z I hereby affirm that there is a construction lending agency for the performance of
0
the work for which this penalt'a issued(Sec.3f19'/,Civ.C.) A : ELECTRIC FEE
U m
0 U Lenders Name
Lenders Adores. QTY IvICC11ANICAL PERMIT FEF.
PLUMBING FEE
C) I I agree
a to 1 comply
,cud this application and store that the shovelaws
information
cnrect.emsourmco.mad hearchldtyaad countyordinancesand stemlawsr upon gm PERMIT ISSUANCE MECHANICAL FEE
UZ abov.ngcoaswctiooert herebyaectionerpses. vas enter upon the CONSTRUCTION TAX
L) z shove-mcntigredp save, forinspectionnd purposes. ALTER OR ADD TO MECH.
(We).grim m save,indemnify and keep harmless theCityacco Cupertino against
intoitieFair,m II cons un a meswhich may in any way attmeegainst said City AIR HANDLING UNIT(TO IQ(IB)CIM)
qne enl the mate This'permit
Way
AIR HANDLING UNIT(OVER ID,WO CFM)
Signe ury cunt1fraftmm le EXHAUST HOOD(W/DUCTI PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 110,0f8 BTU) Dam Receipt It
Will the applicator or future huilding occupant store or handle huzandous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
m defined by the Cupertino Municipal Cade,Chapter 9.12,and Ne Health and Safety
Ede.Section 25532(a)1
11 Yes ❑No VENTILATION PAN(SINGLE RBSID)
Will thea licentorfuwre buildin BOILER-COMP(3HPOR 100,0010 BTU) ISSUANCE DATE
pp g.ccupanmueyuipmenmrdevices whichemit
hazurdau.s air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0(0 DTU)
•Uisrricr? . . .
11 Y. ❑No NEW NIiSIDENTIAL MECH. SQ.FT.
1 have read the hazardous materials requiremams under Chapter 6.95 of Ute
Calif.mia lfeollh&Safety Code.Sections 25505,25533 and 25534. I understood that ®�� s
if the building does not currently have a tenunp that it is my responsibility to notify the
cupcom orequirements the requir mens which must be met prior to issuace a nof a Caddem of
17
Occupancy. la f ( L
i,r
Owner or undaunted agentDate TOTAL: ISSUED BY: tcv
OFFICE