25918 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-LLLLI KICAI. I PERM(r NO
APPLICATION/PERMIT PLUMIIINO-MPICHANICA1, 25918
BUILDING DIVISION BUILDING PROJECTIDENOFICATION
HUILDINf1 AOgRI��S.->� G / /,M /� I SANI'1'ANY NO AP'I'7LICATIONSUBMfI'1'AL DATE
275' //WA/PEto UNIT# LOTM
IOW�� NAMy� �/ PIION'L ��jCONTRACI'ORM a / LIC NO,
JJ!!// N/C CON9 ROL#
ARCHITECUENGINFFR: LIC NO: ADDRESS.1Gb�? -e //Q � • El T
1.CONTACT PHONE �/oa J BUILDING PLRMIT INFO _
Q'I'Y. LLECTItIC PERMIT FP.L
' _ I BLDG ELECT PLUMB MI�IiCH
- PERMIT ISSUANCE - 1 ❑ ❑ la
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1
Iherebyaffinnthatlambcensedunder fna t 9(commencin IOH DESCRIPTION
Ortiz 00 prvirofeso per (commencing
tv10{01-� Seetum]tl(NI)nfllrvl>Idninf the Business and Professors Cal,and my license is In ppNf3L5
fall force ad Q�",lacenx
f-ZW effen, ZO — UPT02WA.PS Class LIC:# /Z l A C-CA�
'nay Ilene Con motor 201-1(00 AMPS
Z Oy- lundrntandmy I sNholllbeusedas)publerecofds OVER 1000AMPS @° p /�SQpf•T FLUOR AREA nI E/SG Ff.
OZ-0 o, h— II ALE ® Iu13
Fm SIGNS ELECTRICAL
a t I.ICe I h Prof i.lnmtl ^ r. „ . T F 1
OWNL'R-BUILDER DECLARATION SPECIAL CIRCUTOMISC ( II,VV(III J��..rr11��__yyll
141CC0aU 1 hereby affirm that 1 um aempt firm the Contracors Ltcense Isw for the
W Spa following reason l Seron]031.5.Boam,.and Prnfessom Code.Any toy or county I TEMP.MFTCN OR POLCINST
G X10< which rcymrcs a Fcnn 1 m construct,alar,unpomr,di moli>h,or repair any ameatie
pnor to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
'<0 that he is licensed pursuenun the Few man,of the Cnnvannr's License Law(Chasm(
0. OK 9mazeneing with Section IIlWlof Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECIRIC VALUATION
pSj_,LLn oahm he is exerptthemrmund the basis for theulleged eaempnon.Any violnOon Of OUTLETS-SWITCHES
Section 7031.5 by any appbcwt forapermit subjects theepplican uoo civil penalty of FIXTURES
Ca not more than five hundred dollars($500)
� ❑ I,roownerof thepopeny,ormyeonployenw nh wages as theirsolerompenswlon, NEW HESIIIIiMI'IAL ELGCTR —SQ.FT. STORIES TYPE CONSTRUCTION
ywllldo thewrrk,ondthestrucmrmsnuti wndialmoffemdfnf mle(Sec.904i,Business
and Professions Code The Catharines Laenx Lew does not apply m en owner of
property who builds or improves thereon,and who does such work him el fonhrough his
wit empinyee>,pmvidedih:a such imprnvemenbare not mlendedoroEered forsxle.E. OCC GROUP RES UNITS
however,the bmlding nrimprnvement i>solJ within one year of completion.Ne owner- I I.OTAL
budder will have the burden affirming that he did not build or uoprve for purpx O of
sale)
❑ Las owner nftbe propcny,mn exclusrvelycammmmg wish licensed convemnrno QrY. PLUMBING PERMIT FEE FLOOD ZONE pl'N
onnruct the protect(See ](Fed,Business and Professions Coi The Contractors PERMIT ISSUANCE
Lmenx Low dcesnotapply toanownendprnpertY who bmldsnnmproves thereon,and
whoamimasforsuchprojecuwuh uamusewd>)licensed pumuanumM1e Contacco', gL'OiR-DRAIN&VENT-WAT'IiN(FA)
License Law, I FEU FEES
❑ 1 am exempt under See. B&P C for N m
is eson BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner iNT10N D°te I (SCHOOL TAX Y.f FIPT# N
WORKMAN COMPENSATION DECLA DRAINS-PLOOR,ROOP,AREA,CONU
IJ I hereby affirm that l have acerf careo feemem to sel6msum,oracenificme of RECFUT# _
PeskyNl Compcnsm ion Insurance warn ediFed copy thereof 3X00,Lab C)which FIXTURES-PERTRAP PARK PER Y N
Wailes RFCEIPT#
(employees urWer ibis permit GAS-LA.SYSTEM-I INC 4DOI'LETS -- '--"
� BUILDING DIVISION FEES
Corsican- - - GAS-EA.SYSTEM-OVER 4MIA) PLANCHECK FEE.
❑ Camped copy is hereby funnshed.
❑ Cemfied copy is filed with the city inspection division GRHASFgNDUSTRL WASTE INTERCEPTOR (GRADING FEE
CHR'I'IFiCA'117 OF EXEMPTION FROM WORKERS' GRFASETRAP (SOILS PER
COMPENSATION INSURANCE
(This section need not be completed tribe period is for ne hundred dollars($100) I SEWER-SANITARY-STORM EA.200FT. (ENERGY FHE
or less)
I cemty that in[lie performance of the work for which this permit is issued,I shall WATER H EAT I'R W/VEN'I'/ELIiC'I'R
not employ any person In any manner s0 re,to co b3 Wodas' - - -- - PAID
Contaminant Laws of alifomi D e WATER SYSTEMTMEATING Daa Receipt#
O O Apploam AT^-
z 0 NOTIC�TO APPI.IC MT f.l fter maAing thisCmificme of Fsemption,you should NL'W RESIDENTIAL I'LMB SQ,pT TOTAL:(
.�-o become wblceno the Workers Compenxabon pronsions of the Labor Coda you must
� > forthx rth comply wish each pnrvuions nr this Permv shallMdcemed revoked. BUILDING ME
0. [� CONSTRUCTION LENDING AGENCY SEISMIC PEP.
OI hereby affirm that there is a construction lending agency for the pertonnunce of
Z the work for which this permit is issued(Sec.3(10],Cm.C.) 'TOTAL: ELECTRIC LECIRIC FEE
l erdee>Nar-
LLF-• Lendees Adhei- (QTY. MLCIIANICAL PERMIT FEE: PLUMBING FEE
U I certify that I have mad this application unit state that the above Information rs
cancel, licame to Comply with all city and county ordinances and state laws rclabng to I PERMIT ISSUANCE 1 ��) MECHANICAL FEE 1l'(a JQ
F' bumldntru �,and hereby authorize sestance of Ns city mentrupte y CONSTRUCTION TAX �(
V Z above-mennoned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,nalemmfy and keep harmless the City of Cupemno agama
liabiliticsqu n(N�-1 It suny 2S�"J` AIR HANDLING UNIT(TO IO,O(NI CFTfI
in con.eyu (t11'.e grun f ia, t 2 AIR HANDLING UNIT(OVER 10.000 CFM) 11
Sogeatur/ofnpphcent/ umrunor o > EXHAUST HOOD(W/DUCT) I ('AID--�-
'C L^ f f l I HEALING UNIT(TO 100,118(1 BTU) ---Date
HAZARDOUS building weapon DISCLOSURE Receipt#
Will the applicant Cu,iotmfmure bupal Cade.Chapter 92.handle huvafdousd Safety UNIT(OVER 100,00 IT]U) TOTAL nT
as defined by the Cupertino Municipal Code.Chaser Y 12.end the health and Safety I
Code,Sermon 25532(ep VENTILATION FAN NESID)
❑'Yes 11' No _
Wdltheappliculol fumrehild,ngcecupomuxe u,pmeinordeviceswhich emit I BOILER-COMP QHP OR Ryi BTU) ISSUANCE DpATIi
hazardous air conmmmanu as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 1W,OW BTU) CC I P9 ® I
Dishim9
❑Yes ❑Nn I NEW RESIDENTIAL MECH SQ FT
1 have read the loomolous matenuk mmarenerns ender Chapter 695 of the FEB 14 1994
California health&Safety Code,Sections 25505,25533 end 25534, 1 ondersa nd that
if the budding doses not emacony have oamboaddhou 11 is my ttsponsiblbty to scuff the
occasion of the mommarma s which must be met poor to issuance of a Cemficahe of C10 yr 1#UrreM I UYV
Occupancy. T
Ownermauthoved agent Date I TOTAL: 2�_ 00 (ISSUED BY. I f��G �VC��./
OFFICE r