25747 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25747
BUILDING DIVISION yln,., ,,%R ,',BUH.DINGMOJECTMENTIPICATION--br'y3;tA»- I
BUILDING ADDRESS: R� SANITARY NO. APPLICATION SUBMITTAL DAIS
UNITM LOT#
OW ERSN M �{O I�Irs CO ACfOR'iNAME: ` ��� WC NO. NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: A S: J
of '4t"Pl TQ qALn ikmo
CONTA�C)Tj:�� PHONE:Wasyy}9 r,VF r+'". C:e.,:nx 1r `.pa, � k " {':•a''rx.-'4 •SUII.U1NG PeRA4•f INFO`&`' d'v'tf
/N ( �/J /y`/p�/• / n'ZS, Ce xvt r�i [`cl.�' ++ ..1 b ii BLDG LUMB MECH
---JJJ"`��� '^^'^^"" PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION IANCPS MARIJENDAL
.CZ Ihembyaffsrmthelamlime underMvisionsofChapte9(cotnmencingwith JOB DESCRIPTION
=00 Section 000)of Division 3 ofda Insurers std Rn,f11essiom Code,and my license is in
`zF fullf Casale. mL Llc.#�1ys1 AMPS
-« au • Conuacwr 01- 000 AMP 1•
_ ARCHITECTS DECLARATION VER SQ.FT.FLOOR AREA WSQ.FT.
1 undersand mY else rhNl be used u public records.
I its
.Ful SIO CAL
EJ Licensed Professional
aI< OWNER-BUILDER DECLARATION S IX /IASL. AL
=i u 1 hereby aer that 1 M except fNrll Bic Cnnpaelnr6 License 16W for die
'ts i fo0ewing rwson.(Section 703M,Busbtee and Profession;Cade:MY city or county TEMP. OR POLE INST. E F1
_01wNch requirrs•pemdt a cmaoum.alter.improve,detrmlusM1,or tepa'v wY cavemen
MMFUTE
�Y� priamiuissuumc,elha rsquurs the appnuntfor aveM1 pemdt to file arignedaaluncnt POWER DEVICES
Yup then M us Intentional pu muse,to the provisions of the Coatrubls Licence Law(Chapter
�KK 9(commencing with Sarion]000.1'Divinon Sof Ne Boom.mad Professions SWIMMING POOL ELECOUC Cade) DA
__•to m that he is exempt Bari ad the basis for the alleged cwmptian.Myviolarion
Z< Section 70315 by my applicant for a perababjects Be applimnt to a civil pess
_ lry ofze
011'ILEI'S-SWITCIiL'S-FIXftIRES O�
stn mem thin five hundred dollen(5500).
sb_� ❑ I,ssowrteofdmpmperty,ormYenPloyeawithwegauthe'vwle cmnpewtian, NEW R�mINITAL ELECTR -SQ'Fr' TORI TYPECONSTRUCTION
:3— and dothework.wdtnc rwetmeisrlminLicam Law
ripely an onosskw
end aywhProl. ba Gude:TM1e Cases.ad Mismatch
law dace nal apply lf rd owns of
Ismpmywlwb,pmirimprovathimpm.had numnotinwn hhimffuedfrWe.Iselfordmonth us
OCC GROUP RFS.UNITS
ownaver,Mea,pmvieMtlwwchint is mid ill"mrs,mmmledoroledon,ar We.ar,
Iww&er ,wthebuildingurimprovement is hathwithinau yev ofc prove for
theowne-
Mldtt wBlhave the burden o(proving Out he did rot build m improve far purposs of
uleJ. s 'A' tx❑ cvaaeu.svo,' uc+y I,ssowneroftlm popeny,wexclssivclyconMecting withiiamed conmuTorsm PL INO PEBMI'f' # PEBr" FLOOD ZONE APN
wa.a�..mrapa a
conxuuct the pmjM ISm 7044,Business had Pmfmiau Code)The Conuacmr's
LimuelewdoanoepplYmwowneofpopetywM1obuildrorimprovrstnemon.erM PERMIT ISSUANCE
acohoacnfmwcb Pr^laa with acanvanm(rJ liwnsed pmsusutmdm Convwtm'e a±,
licm . ALTER &
-DRAINVENT-WATER(EA) - .`y*.,sipzw".y'r,`I'y+Wj'_`p;; 4$E svlviivlAitYr};�£ :-0
Liwl.w "..
❑ 1 em exempt uMe Sa. ,B Be P C for this rrsson OUTSMETM
BACK FLAW PROTECT.DEVICE SANITARY Y N
Owner WORKMAN CONIPENSA77ON DECLARATION DRAINS-FLOOR,ROOF,AREA.CORD. SCHOOL TAX YECEIPT# N
.❑ IM1emby efrum thuihaveacetifir4a ofemuentmrelf-inane.oracttdfimm of FIXfURF.S-PER TRAP RECEIPT#
Woken'Compumann lmmmce maeerdfied copy thereof(Sea.3800,Lab CJwNCM1 PARK FEE Y N
covacellenplaywimulethis Pe LGAS-EA.SYSTEM-1 INC.401JTI.E15 RECEIPT#
Policyg BUILDING DMSI FEES
Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
',M enPY is hereby funtiehed.
cap,is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAIE'IRAP SOILS FEE
COMPENSATION DJSURANCE
fOiisveamrxx4rwtbecompletedrfthe pemdtufmone humbed dallem(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE t�
orl.)
1era*dutinthepetfonnanmofthewarkfmwMch Uspa tisiuued,lshall WATER HEATER W/VENT/ELECTR
mi employ any person in on,menntt w as to become subject to the Woken' PAID
Z Crnryeuetion laws of California. Des WATER SYSTEMTFFATING Dec R&p
J Appbunt
2NOTICE TO APPLICANT-.If,after meting this Certifiers of Eacmpdon.You should NEW RESIDENTIAL PLML SQ.FT. TOTAL:
J y Mane subject to the Workers Compensation provisions of Ne Leben Cade,you must
forthwith comply with such provisions or this permit mail be deemed revoked. BUILDING FEE
is
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
J Z 1 family,&from the there is a construction lending agency for the performance of
j the work for which thus permit is issued(Sa.3097,Co.C.) ELECTRIC FEE
(]
Lender's N. :tuc.-, �n.Yn'xanwrcw N�•t
Lenders AM. QI'Y:, MECHANICAL PERMIT x'"' ":'PFBM PLUMBING FE
+ ^t' b
1 aetify thus I have reed Nis eppliwtian oral sum that the above mfumntion is MECHANICAL FEE
- 6. conal l&gme to comply with all city and county odimnces had some laws miating0 PERMIT ISSUANCE
building construction.end hereby aushor n representatives of this city to enter upon Me CONSTRUCTION TAX
Z above-mentioned pwpeny for inspection purposes. ALTER OR ADD TO MECH.
(wU egme to suss 'eft fy end kap harmless the City of Cupenim against
liabilific,j nu, expenses wNchtmyin my way acme against said City AIR HANDLING UNIT(T010,000 CFM)
in con o(Ne - gof to reit.
/ Z AIR HANDLING UNIT(OVER 10.000 CFTI)
�.,mfp of ApplicablCimman., Due EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IMON)BTU) Dae 11 #
Will the applicant or furore buildin6 ac...nt rmm m handle haeedous,m cmJ HEATING UNIT(OVER I W.IXp BTUI
as defined by the Cupertino Muninpal Code.Chapter 9.12,had ire Heahh end Safety
Cade,Suction 25532(&)?
❑Yrs No
VENTILATION FAN(SINGLE REBID)
❑
ISSUANCE DATE
Will Nea liuntorfutumbuildingacu enmx BOB LER-COMP(3HP OR 100,000 BLV)
pp P Ment not Quality
Mem,edmit IIS
,MmMou e'v ennuminwu ss defined by the Bay Arw Air Quility Management BOILER-COMP(OVER-100,000 BTU)
' ❑Ye '❑No NEW RESIDENTIAL MECH.-SQ.FT.
I have read the fetyC de.s.rent ions 550oup5,2mena under Chapter ersa d tad CY -
ifMebuieHetlthRSafcryendyhaveam nt,thin
nibs had 255M.responsibility
1ityconend Nat fit• L`
if t uperst Of the rs nm curt,which m menet.thor n is my.nsponsibf.Cara tify the Occupancy.of the mquimrcnu which must be met prier We...of.Certifima of
Occupancy. '
CMvemauthoriud agent Date ISSUED
VJ
OFFICE r