24987 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPELMrrNo. - _
APPLICATIONIPI RMIT PLUMBING•MECHANICAL 2498
BUILDING DIVISION .,p;BUDAINC PROJE(.TmBMiFIGTION:;••;��,,;{yy: l
BUILDING ADDDRRUS:; SANITARY NO. AP%X_�ONSUBMIITAL D A I
In
vZ) T2—UNIT• LOT s' 1/[-yi�Gag w`
RS N E: ' PHONE: CONTRACTaO�R'S�NA7d��/,`-, [j�I ,,JJ LIC NO:/.w �
1.C'C -iU1S Teal.\IVa�N Y�W.�JY CN' N/C CONT0.0LI
.RCNITER/ENGWEFR: LIC NO: ADD U / _ Q�� ❑
CONTACT: PHONE '
' DILDIFia PFRAh'1�INF0 ..,[:
BLDG ELECT PLUMB MECH
. PERM[[ISSUANCE ❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RPSmEyT1AL
-YZ Ihcrcbyaffimrrhmlamli...s -dwp visiemafChv.9(commen sys JOB DESCRIPTION
S - NIl of Division J of me Business and Prefwiam Cadc,and my iiceme is in PANES �a�r �+
t V all force and effen. // G/w. air/T/V G.�tIF„��Tt/\
Date veGw `�O Lic.xw— UPTO 200 AMPS
'nQy Dae CcrsDr 3111-1000 AMPS
Z Z ARCHITECTS OEC public,
me ION OVER 1 ` SQ.Ff.FLOOR AREA 3AQ.PT.
Z_n 1 unden..mtl my plans sM1ml be used as public rsrodv _
<-�- LIttmN Profeuiond '
^zQ OWNER-BUILDER DECLARATION SPE TDSC
1 hereby affirm that 1 m eacmP been de Cmmands U.law fur me . . . -
-3CG foilawing reaanrl(Saron]0313.Buorms and Pef.reeu Cade:Any dry orcoum, TEMP.MEEK OR POLE DIST.
n which requires a permit m catuuun.alter,unpmve,dmmliah,or repair any mycete f�
<.,mL>� premiss issuloce.also requites me appikuufeesudr perttitmfikaalg-dsswmms PO' DevDATE
_zCp der be is OccroN pusuw m me pmviumsof aloe Cmuacmla license lar(. SWIMM-NO POOL EIEC11UC .
�a-,x 9lmmmrnrint with Srcd-]000)efUivisico3ofine easircoand Pmfusiom Cede? VALUATION
dKj=y
than he i'tunmpt muefem surd the basis fatly alleted caemptiao.Any vialadmd _
r_ T Sued.70313 OUTIEl3-SWD'Gff4-FDCDRlF3
Z byanYappliamv it svbjcn the applicmtmaavB peoalryd
-Q m rope man five huNred dollvo(WW1S30oh .
mF� ❑ i,aown.o(drepropmy.eem NEW RESmFNMLF]ECIR_SQ.Pf.
Yeroployemvimragnumeirmkwmpemadoa STORIES TYPECONSTRUCTION
a3= win dod.ewors Code, saucmeu-ammdel Lawdces"aSe]Oan eualms _ .
and Pmfasima Cade The Csnmcmts Ilrmu lar don not appy m an oweee d . .
pnpwryWMbrllldsormrpMnmwv 4utlrhu Mn allcllw'oh E®sCI[RWW�W+ .
uwnecoploYe.ildingdrdnarev mpovemen.we one
nuardNoroRered fee an V, - GROUP
RES.UNITS
however,dwbuilding mimpmememu mldvimieom Yewofcovrpleaian.meownw- - 'r .. -
btllhrwBllevcdub.vale dpmdetalus be did om bdWeempwe[ee pulp-d tea'
We).
❑ I.0 ths,mi.
7&$4,anti—,
Prookerwas Ecvrsedcoevumam .FLOOD LANE APN
co.tmuet me pejta(Sec]041,Bualona W Pmf.ums Cade:)The C-rra.oJd L. .- .
licwuelawdmvaapplYmanmmdPopnyrhobmldaaimpovnmwmamd PERMIT ISSUANCE
wMconvsmformdrpejrrn wimacootrsw(s)Bcwudpvmmsmtle Cwvxtda ALTER-DRAWkVFNI':WATEl(FA) 71 7
License law.
❑ lam eamrp mdw Ste. .B R P C formu aeuoo BACK FLOW PROTECT.DEVICE SANITARY O-:Y N -.
A
�° DRAWS-FLOOR.ROOF,AREA.GOND. .. - RECTBfx
WORKMAN COMPENSATION DECLARATION .�<' 0 SCHOOLTAI Y " - 'N •"
.❑ Thereby alPom mulhamaawu0aedme+mtmzH-ivime.enaasdfiamd pgEq- ..;:: •_.":2:RECEPT♦ ..S
Weekm'C-pwadoobweeanmeeamdfdmpy mvad(Sm3800,Ld C)MsrbPARK FFPi.r.Y=_•"� m ••r
maws W CIFOYoea nota this pound. '..:a OA4-EA.SY .. .>(.' r '•:y�,pH�[x ••,
Policy e w BUBAING DIVISION FEES'..'
ComPmy GAB-EASY I RANC2ffACFFE "a`-:.5-'�'. ..�.-.
❑ CesdfiedcWYbheraMMrdahed. -'�a_7x::
❑ Certified copy is fdd with the dry inspection tivisieo. GRFASFJMDUSTRLWASIE INfF]t _ INGFEEe'-
:J. :el-1Y
CERTQFTGTE OF EXEMPTION FROM WORKFR3 GREASETRAP1 '
COMPENSATION INSURANCE - - FFE .' •v^`�F:•.�:.. .ae'�"- '`
(This.noodnotbacess, chePumis6[Qamh®me6doWn(SI00) SEWER-SANITARY-STORMEA200FT. ^3 a FNEIOYFEH-'y �' ,.;:-:•`t?� :: 'j:`Sl. '�'.
Imdfy matin de pwfama-edtbervk[eewhich m)s pvmituimed Ishan WATER HEATERWry@lGEIECfA
.'-::_ "• -:` :1'.
set�Y any Peron is avy mmvw m u m become subject m the Werke' . .PAm:•• : . - ;Ti- '- a;'_r'�s;�`.I
CeeWenareo ism of Cali[eeva. Dae WATER SYSfIIdARPATING Dae _. R.mpe
ZZ NOMCEn NEW RESIDEN[LAL PI2v[B. S PT. - .
NOTICEI'O APPLICAM:H.aB.mathtt this Cwdfinm dEa�deq you should Q.
brmanmde WaAde CemPmerm pmvidoelofdr VbQCada y-mm v _ _
.Y � fvmwnds im mcampy wimsoch pmddomeedabs p.mil abaB beBUILDING FEE '.;:
y CONSTRUCTION LENDING AGCY SESMI
ENCFEE
Z) Z llrese alBrmt th=isaemmumm fume wmmmof
;, O tle wmhfeewh'eb tltia pea®shiswed(Ss 3071.Gv.C) - .. .._L...._�:....:....-...:,.. -- f1P.CIRIC FEE-_'+.•-5,?—
by �ni4mT pd
`L f"' Lender's Name
Addrva PLUMBING FEE
dI sad%than I have herd oris pplioum ad mm mw my above informed-IS
ISSUANCE _ MECHANICAL FEE
ap- PERMIT
motsclWCM*Yr acayudmvo maLteLun
-yordinWtm .: .
vy buildir.tcmwwN-,andh.cbY usmwiYa repeentuiwdWarifYmwuaup-the CONSTRUCTION TAX `6 -
Z Wee-nmdmMl Taco,tee inspersion prposea ALTER OR ADDTO MECH.
(We)agree m save.indemnify and knp hand.. of Cup.dm stales -
IiabiOfialudprcnw.rousaMnpaun whicb.yie scot-agai.mssd Gry ABI HANDUNG UNIT(TO 104M CFM) "+-
inmmequrncodthe got tlra 'c
ABI HANDLING IINIT(OVER IO,OW CFM)
eign-m.fAoishinalMon. Can, P AUST HOOD(W/DULT) .
PAID
' FIA7ARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100M BM Dae R.eipx
Will the applicant or house building oavpant sere or handle havmem ma-ial IffATiNO UNIT(OVER 100.000 BTU) %
as defined by the Cupertino M..ipal Cade,Chem 9.12,W the Health and Safety
Cade.Sad.]3313(.)] VENTILATION PAN(SINGLE RFSID)
13 Y. C3No
ISSUANCE DATE
SOBER-COMP(]F@O0.100.000 BTU)Uw applimns ar fume building mcupannuse rquip-nt ar devicn wNclr emit
air con. nus u defined by the,Bay Anes Air CaWiry Managmw BOILER-COMP(OVER 104000 BTU) P A 1 D
Dismm]
13 Ya 13 No NEW RESIDENDAL MECH. SQ.FT.
t,
I have red the haaamous materialsrequi-rcnu under Chap.6.93 of me APR N
C:difomia Helm 2330
R Safety Cade,Sections 0. 90 333]]and 3]334. 1 uMenrand mu
if the building does nor cumemly have a tenant,the it is my respoesdiliry to notify me
1wcupanc of the nor toerom.Which mus.M met prior to issuance of a Clotfl.of
Ow-raaum.ia,datcns Date TOTAL: ISSUED BY: ✓� ^ a'
C