25493 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO xmL=:-.1, CrRrt`A' PInMITNo'
APPLICATION/PERMIT PLUMBING MECHANICAL 25493
BUILDING DIVISION F BUILDING PROJECF IDENTIFICATION
BUILDINGADDRESS: _ J ^_����tl� p�NE s� SANITARY NO. APFUCATIONSUBMIITALDATE
L� r/ UUNITI LOTH
OWN IRS RAMI- PHONE. CONfRAOT)R'S NAME_' LIC NO:
6 - l V Q / N1C CONIAOI.X
.RCII'M.CUENGINEIR: LIC NO'. ADDRESS:
O ^C � � Flp-S �1 . "i7O wA A wSEl
ONI'ACI': PFIONE:
Rq L,P H 5 PW 1 ALIO -415 q q'S }I} Qom' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I� BLDG k1.ECf PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JO DESCRIPTION
CZ I hereby efFmm that l am liccasm utderPmvisions ofCbep,9(wmnertciny with
00F Scaim 7")of UviimnJaf Nc Budta eM Professions Code,ud my licenm aim PALNpl
TO2(
�d(J full force end eE cl. �y I
l¢.G(wJ Littnrt—� LicX �O UP T0200 Ah1P5
+�6y Due Cmtrct«. WI-IWAMPS
zONz ARCHRECr'S DEC O SQ.FT.FLOOR AREA S/SQ.FT.
OZ— 1 urferued my pens shell he used as blic records. OVfR 1000 AMPS
F'.n;s SIGNS ELECTRICAL
y<KJ IJMu4l Pmfeai«ul
C IyU O"ER-BUILDER DECLARATION SPECIAL CIRCTfi/hISC
xxOn I hereby.ff.that I am excmp from the Contractor.U. emec Law fon the
W 3vFi following reason.(Section"1031.5,Businem.rd Pmfeaiora Code:Any city«county TEMP.METER OR FOIE INST.F4�5 which requlm.pvmitmromsron..lw,itrtpmvc,drnoliN.arepvr anY structure,
�DYm primo,m muuetce,el re, imtheapplicant for such partu".file.sig«dsuwnent POWER DEVICES
6W<0 than he is Iwrnsed, - to the pnviaiav of the Cmvs-ta'a Lorna Law(Chapter
P' o�y 9(connmemir,with Safim T00()of N vision 3 of Ne Bud.anal Prof..Code) SWIMMING POOL ELECTRICVALUATION
«than he ueacmpt thercfrmtt W the hands for dte.11eged exemption.Any violatim of OfITIL+fS-SWITCHES-FIXTURES
tzaSect 7031.5 by any applicant for np-mmlt suhjecs the applicant b.civil pnaltyM
t] rand m«etMn true huntLed dolHe(S5o0). NEW RFSIDENTIALELECfR _SQ.FT.
z ❑ I,vuwrvoflhcpngeny.«my cmplmym with wngm evtheirsderompere.tial. TORIES NSTRUCf10N
y will
end dPomfrncu.Canmdcd:r TIc Comu.msiisn[.it.1,wdoes
TOeWn,own,aof
pmpety wnobWlds«Imrpmvm Neeon,aM whodoa sucfi wank hitraclfa Nmogh Ns G ROUP .UNITS
wn employcm ldin,m the sur bcox a s cmrntn art tad i,&r.fc m,Reted f«sale
If,
h ilder ,illsvi the
i f roeN umld within ateycm ofrompletlm,Neowrcn TOTAL:
builder will nave the buNen of poring tom M1e did cors W Nle or Imptovc ran pupae n!
we).
❑ QT y" PLUMBING PERMIT FEE FLOOD zoND APN
LgLiW I the roJect(Sec.7614,Basham and Profeaiau Code:)The Contractors
Licrnxlawdon rt«.pply men ow«rofprrapeny who huildeaimptavm thertm,erd PERMITISSUANCE
who contrera for such pvjeca wiN amnnecta(s)li¢nscd Putuant to Ne Caerecui•
Lkmr Iaw. ALTER-DRAIN&VENT-WATER IFA) FEE SUMMARY
❑ 1 van escaop unser Sec. .B&P C fa Nix canon ^ "
BACK PLOW PROTECT.DEVICEp .
Owner Dwc DRAINS-PT,OOR,ROOF,ARFA,COND. RECEIPT.
WORKMAN COMPENSATION DECLARATION YN
El hereby uffims Nalhevcamtificme of conrnuo xlf-Insurt,«aazrtifiaa of FlXTUR� PER TRAP Jt RECEIPT.
Wonkm'C«nPrnmdm Irtsurerac«.cmifiedarpy tlnmf(S«.18o0,lib C.)which Y N
ars dl employce'e undcr Nis,emlt. GAS-EA.SYSIEd-I INC 4 0UTL RECEIPT N
Policy. )TNG DI ISION REFS
0sm,an- 5 �• GAS-IA.SYS EM-0VER 4(EA) PLANCHECK FEE
❑ Cenifed copy is bertby faedshed.
'5;?Cemifted copy is film voo Necity impection division. GREAiUNDUSTRL WASTE INTERCEPTOR GRADING FEIE
CERTIFICATE OF EXP.MPION FROM WORKERS GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(T'hia xaionned rase4cumplclm if Nc,emit isfm mehandrm dnllma(SIDT) SEWER-SANITARY-STORM EA.20UFT. ENERGY FTE
«lea.)
I certify than in O,e Perfmtwoc ofthc work for which this permit is i.om.I shell WATER HEA TER W/VENf/ELECIR
rot employ any,moor in any manner sec as m became subject to the Wonted PAID
O z ^mrmpermtim lewu of California Due WATER SYSTEM/IRFATING Dex Recsiptat
O NOPTIICE TO APPLICANT:If.al making this Cenifletne N&mrson,you should NEW RESIDENTIAL MAR. SQ.FT. TOTAL:
> fcr xbjethe,to thWoriora Compcm.dmn Imviniora of Ne Tabor Code,you rman
crop Ay with neh covision,a Nu,emit shall be deemed Q Am. BUILDINGFEE
1 CONSTRUCTOR LENDING AGENCY SEISMIC FI e
V Q I nacby all that Nert is•canstrtetim krdhig.�mcy for theperfmmeruc of
the ooh fm which this permit u issued(Sce.3097,Ov.C.) TOTAL ELECTRIC FEE
L cneer'a Name PLUMBING FEE
U Landers Addres. QTY. MECHANICAL PERMIT FEE
1 comfy than T have r mina, Ificad n end awe But de above infrmmtion is MECHANICAL FEE
comm la0. er¢mcamplYadN all city anal country«dlru«e.aM sate laws Rating to PERMIT ISSUANCE
huilding cnnnrumim,and hccby.mh.rvcraprtxn,u,csof Niecityo emerupm the
U Z eMvc-mmtlortm progeny foo ir' Irian ptrposcr. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agme m save,in:amm,srd keep Ion the Y of Cupertito.gvmt
IieMliue.jtdgnacnu,amu W expeaaew " w.y.drue.Seiw s.W Ciry AIR HANDLING UNIT(TO 10,000 CFM)
crnseyuenceufibe tin of
AIR HANDLING UNIT(OVER 10,M CFM)
Sigtmaart of Applic�nUCmhxtm o etc EXHAUST HOOD(W/DUCU
PAID
IIATARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001)RTIE Date Rettig.
Witt Ne applicant or future building occupant none m handlehnadaua materiel HEATING UNIT(OVER IOO.o00 BTU) TOTAL
as Jc ited by the Cupro cniMunicipal Code,Chapter 9.12 and the Iluhh and Safety
Coo,gMEEl 25533(e)1
El ye,' 11 No VENTILATION ION FAN(STNGLLs RFSID)
ISSUANCE DATE
Will Nc licumor
future WilNn BOILER-COMP(311POR IW.IXp BTIIJ
ttma ¢occupant ux ryuiprrcntmdcvlm which axed
h.anrdau+air crxtumittann m defined by de Bay Area Air Quality Mwgement BOILER-COMP(OVER JW,M)BTU)
Dwnci ?
❑Ye,, ❑No NEW RESIDF.NhTAL MEC[L SQ.Ff. �y pp
K
I have read the h.>abmu�m.ted. ntcn
ls obpr a urdm duper 695 of Oto r I D
Califomia lle tb&Safety Coee,Sections 25505,25533 etre 25534. 1 undentmd Net
if the building don not currently have a tena L than it is my resp«ui4hty In notify die
«vupa«of teyubements which must b,met or m iuoana ora Certificate of
OccuPamY.
Owrerm euNarired.gent Dae TOTAL ISSUEUB3/ L f