25324 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
IN PERMIT NO.
CITY OF CUPESIO NO APPLICATION/PERMIT PLUMBING-MECHANICAL, n C /� n
4
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L J L
BUILDING ADDRESS: L SANITARY NO. AH
^PPLICATIONSUBMTALDATE
W01164i �rh�.�1 kle UNIT# LOT Ift��
OW NA 1': ' w PHON;j -� CONTRACTOR'S NAME: 1JC N0: N/C l CONTROLM
RCIIffF,Cf/G'GINFLR: LIC NO: ADDRESS
fA : ❑
ON' CT:: ^ PHONE: Qom, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
V
YI @'I k) a �I A,57—ss-/, B PLUMB MECI�
i VFRMIT ISSUANCE 'TMTI
LICENSED CONTRACTOR'S DECLARATION
Q=z I hereby affirm that l am liamdl under mysiau of Claps 9(commaol wish APPLIANCES-RESIDENTIAL JOB DESCRIPTION
icn
�U� f lllfotcc and)effacof iaion 3ultM1e Business and Profevion.s Ceske,and license,is my liin PANELS
G W License Chav Lic.N UPTO100AMM
F�y Thee Conneclm 101-1000AMPS
h
F yZ ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA S/Sp.ET.
cz-M l understand my plara shall be used ss p Itficu ods. OVER 1000
P� w SIGNS ELE Llui
16u6''Y ...]1 I3cenad Pmme inial
y < OWNF,R-BUILDERDECLARATION SPECIAL CD2 IT
O U I hareby inn that I am exempt from the Conhacmh Licase Law for the
w3 tLy follmur,orawn.(Berrien'/0315,Buairca ad Profwaioxu Code:Any city ur county TEMP.METER ST.
tsJ�, which m0uima o pmnit to dosomd,alta,improve,detmlish,m repair any structure
>; pdmm its i.vsavrce,elm enquires thevpplicam fa.uch permit to fkiln,,ed statement POWER DEVICES
Apt¢ that he is llromel pumuom m Fe provisions of the Cumramafs Lt.luw(Chvpter
9(commencing wi th Secload7000)af Division 3 of dee Busi.and Profession.CMC) SWIMMING POOL ELECTRIC VALUATION
W_rn on hn be it exempt dterafrwn and the bate for the alleged exemption.Any violation of
Za Smcoure703ISby any appl'eanr for a p.mmit subjects the epMiralt ro acivil penalty of OUTLETS-SWITCHES-FUCCURES � 1 ��/�
nn re then❑vc huN�ddlers(SSWJ� �(J
m 1 owrcrof lhcprupcny.mmy cmployaswith wegcautMirsokcanpcerWion, NEN'RESIDENTIALELECIR _SQ.FE STORIES TYPECO.N'STRUCION
y _ the watt.erd the structure isna tntendedmnffoul far sale(Sa.'10.44,Busiercss
w d Professions CNe:'IM Cmtnscto'a License Law dors not apply m sur.weer of
puty urea builds m improves tlmrem,wd wMdocs such wa0t bimselfmthmagh his
cmplayxa,ptoviMd thatsahimpmvemen,sartttainteMedmnliued fmsele.if. OCC.GROUP RES.UNITS
however,the building ur impmvetrent is add within one yem of cwnplaion,the owner-
builder will have the burden offal that be did rot build or impose for prove of
oak.).
❑
[,mner4thepotinny,amexclusivclycantmning*idllcei ntmctmio QTPLUMBUNC,PERMIT FEE FLOOD ZONE APN
msvua the project(Sec.7W,Basi.and Rofevlms Code:)The Commoners
Limenae Law dots not apply toanow rofptopcnywhobuilttsmimpoves mm,md PERMIT ISSUANCE
who contracts for sech pajcas wi0.cotmmra(s)licasaed pmvvmt m th Contmeto2s
Tiernan Law. ALTER-DRAIN&VENT-WATER FEE SUMMARY
❑ Iwn uempt urda Sec. ,B&PCfm Wcreason
BACK FLOW PROTECT.DEVI E
SANITARY Y N
Owner Dole DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ih=byofrimiMtlhave.anifateofrnn nttoself-ieume,are artif rc of RECEIPT'#
FlXTURFS-PFR TRAP
Wmkai Cmerycruat'wn lreuranameccnifte cotpY lhcmmf(Sre.3800,1ab CJwhich PARK FEE T N
m all arepioyea'a utdmr this Penni, GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DIVISION FEES
CompattY GAS-EA SYSTEMOVER4 DIM PLANCHECK FEE
❑ Ceerifi i copy is hereby fumiahed
❑ Cenifte mapY is filed with the city itupmmian divi.im. rld-
GREASEANDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXFMMONFROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE,
(This section reel not he,complete ifihe permit is forme huedte dollars 1$100) SEWER-SANITARY-STORMEA.100FT. ENERGY FEE
or lens.)
I certify that in the perfonrena of be,work fm which this pemou is beandl,Isloll WATER HEATER W/VENfITLECIR
txg employ any perared in Any m as m bccioue subject to the Waken' PAID
Cumpaumim laws of CWifomia. Lane m WATER SYSTP.M/IREATING Date kaeip#
Applicant
zO7�-I NOTICE TO APPIJCANFE If.after making this Certificate of Exemption,you should NEW RPSIDENHAL PLMB. SQ.FT. TOTAL:
t-' bacome suhjat to the Worker's Cosnpatseuon prrm.iona of the Lab«Cade,you muco
�i ? forthwith amply wito race serves..or this .it shall be deem irevo4ed. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7. z I hemhy affirm that them is a Oundmetim knding agency for the Performance of
U O the went for wench thiaprnN,is isme(Sec.3099,Cat.C.) �_ FLECIRIC FEE
T<tder'a Name
77,
IeMAddress QTY. MECHA
I r MFLOWING FEE
CAL PERMIT FEE �+
fS.l madly that 1 have read this applkwion etd state the above informnim is
ora,lugreemcomndl wireysuffiurd rvuntyonlinmrtawd stem hntrdeting e, PERMIT ISSUANCE /� MF,CHANICAL FEE /—
bullEing-usenttsund barvor,herebyautbmim,cwe,ntatives of thiAcity mento-upon the
above-merttime property fm irtspr<tion CONSTRUCTION TAX
U ,'� purpura. ALTHR OR ADD TO MECI I.
(Wc)Agree m save,iMrmnify and keep M1amk¢he,City of Cupertino against
liabilitin,judgmenss,coslsand cxµns Rman mryin any way ettrue agaivtsvd City AIR HANDLING 11NIT CTO 10,000 CFM)
the gmntin8 (tris Penni,
X3 AIR HANDLING UNIT(OVER 10,000 CPM)
'igrcuum of A,alkam/Con Date EXHAUST FOOD(W/DUCIJ
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dote obanpl0
WLII nam applecanl or future building ocaupont nam M b.tdle haurdom no mal
as defined by the Cuprtind Municipal Cade.Chapter 9.13,cod the Health aM Surety HEATING UNIT(OVER 100,)00 BTU)
Coale,SeaiEl 25533(e)?
El Yes ❑No VENTILATION FAN(SINGLE RESID)
Will lose applicant or futtuebuildingoecupeen use e,so ruent mdevicdt which cmh BOILER-COW LAIP OR I Oil"BTU) ISSUANCE DATE
M1azardoas air contaminants ss&Food by the Bey Area Air Quality rtagem
Meent BOILER-COW(OVER 100,000 BTU)
DinmC 1 D
❑Yes ❑No NEW RESIDENTIAL MECH. Sp.Pf.
'-1 1 have mvarm
ad IM1c hdem, neria,s tecuimtents underthis,Cheer 6.95 of p A
L2]
nmia l lwllM1&Wooly Code.Satious 25505,25533 and 35534. 1 ardmntatsd but
building dues rot currently have a transit.that it is my respona'billty to notify
pant of the rt0aimnsents whim rental be reset prim 10 1..-of a Cmiervm of
pency. r.rlla
I'
r cur uudimircd.amtnate ISsI W-
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OFFI