25999 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIN.-MF.CIIANICAL
BUILDING ADDRESS: BUILDING PROJECT IDENTIFICATION 25999
/mss ,O ;NIC
RY NO. APPLICATION SUBMITTAL PATE
^ s'1 Cf 7- UNIT# LOT# `
OWNE NAME: PHONE: / CONTR R'S NAME: LIC NO:
G `�(r `gyp G� /// / CONTROL#
RCHI'TECT/ENG EER: LIC NO: A S: (uJ [O
x f W o al/c'
ONTACT: PHONE, z.
Y,)j ;I'C y)cr
QT)T;fI'�a s HI.EcTRIC.-PERM IT FEE BUILDING PER INFO
DG
LICELECT PLUIv]B MPCH
PERMIT ISSUANCE irif{\
ENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pKZ I hereby affirm chat an licensed under MvisimsofQapmf9(commencingwiN TOB DESCRIPTION
^aaa 4A
00 Sema.l000)of Division 3 of the Busineu and Profesaiaa Code,and an,license is in ppNFrc
Fy V rF�Fr��--1 full force and
6p-ZLL1 L)I�+^IS Class a Lic.# UP T0200 AMPS �.wl�i1
mDN ex Contractor. 201-1000 AMPS 1�� �}
Z O rims 4 ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
F m 0 1 understand my plans shell be used ns public records.
SIGNS ELECTRI
a�,Y�� —enxd Profermonal
ft
L'�V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
3O C,U 1 hereby affirm that I am aempt fr,m the Convxtor's Lt..Law for the T
�0 following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.M 1 T.
� which requires a permit to construct,alter,improve,demolish,or repair my awccon, m
N prion,int issuance.also rtyuires the 1 pe g it
¢� appons oforach acw ,file eei nM etaummt POWER DEVI
Lp p that he is licensed pursumu,the provision of Ne Contracmra Liana Lew(Chapin nt
hde 9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING FW—lm VALUATION
Wss�� y onhm h7031.5 by sthexfmm and Ne peom,s the is the
exempti to civil Enmity
ty of /
ZG not am T03at byes undredico Ras($permiuubjena Ne applicant macivilpmelty,f OIA'LEfS-SWITCHES.FIXTIIRES
0 not more than five hundred rollers yemp.
o ❑ Laowne,andflroparty,ormyrimendedoneffagesathe(See.7mnpcnadm, NEW RES DENTIAL STORIES TYPE CONSTRUCTION
y 00
Mild.hewons Code:
The num Contra roti,License
Law
dos not apply to an weer of
and Professions Code:The Convector's Liana Lew does not apply to m owner of
property whnbuildsorimprovesthere,n,and whodoer such work himselfmthmughhis
employees,paviddtbmsuchimpmvemmBa notimenddmoffered(orae,If. OCC.GROUP RES.UNITS
however,the building 01 Improvement is sold walinmeyearofcompletim,tbeownnr-
builder will have the burden of paving that he did not build or Improve for purpose of
ale.),
❑ 1,mowmrofthepmp M.Mexclusivelycontractingwithlicensedcontracmrsto QTY.. l PLUMBING PERMIT FEE FLOOD ZONE "Nconstruct the project(Sec.7044.Business and Profusions Code:)The Comracus"
Licrnxlswdcesnotapplymmowner,(property whobuilW mimprova there,n,aM PERMITISSUANCE
who anomers fmsuch pajects with acumactor(a)licemsed pu suanuothe Contractors
License Ltw, ALTER-GRAIN&VENT-WATER(EA) FE17 SUMMARY '
❑ 1 am exempt underSee. ,B&P C fm thisreason ID ES
BACK FLOW PROTECT.DEVICE
Owner pare SANITARY Y N_
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARPA,COND. RECGIPfq
❑ Ihcmb affirm thalheveecennificate ofmnxm axlGns SCHOOLTAX YN
Y r art.mecrniBcme of
WmkerACmuNmation Ins umnceor acedified copy lareof(See.3800,Lab CJ which FIXTURES-PER TRAP PARK FEE YECGPT# N
covers v]l employee's under this permit
Policy M GAS-EA.SYSTEM-I INCA OUTLETS RECEIPT N
BUILDING DIVISION FEES
Company OAS-EA.SYSTEM-OVER 4(EA)
11CmiBd ropy ie hereby famished. PLANCHECK FEC
❑ Certified copy is Bled with the city inspadon division. GREASEpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION MSURANCE
This section need nosh completed Hdep,mB is for one hundred dollars(SEE) SEWER-SANITARY-STORM EA.300FT. ENERGY FEE
orless.)
I eerily that in the perlomrenca ratio work fmwhich this permit is issued.I rhes]] WATER HEATER WNENE(ELECTR
not employ any to any maim ba ayyyct, ty the Waheri PAID
O z Co nsetio of a Ca fomia. = 7 7 WATER SYSTEM(FREATING Date Receipt#
ICE �L
z OTICC TO APDL CANT;If,eOtt makin this CeniBcate of Empdonyou, NEW RESIDENTIAL PLMB. SQ.Er. TOTAL:
�+ xe&come subject to the Worker's Compensation provisions of the Lahr Code,you most
forthwith comply with such provision m this permit shag h deemd revoked. tME
E /x
k2I A CONSTRUCTION LENDING AGENCY
,- z IherebyafBrmtutiflu Baconswetimlarningagenyfrtheperformmceof A'
V O the work for which Otis permit is issued(See.3097,Civ.C.) C�ir� T L.Lenders Name
lenders Address i
Q U Q�7 MECHANICAL PERMIT. FEE ' EEI cannily Nt 1 have read this applicatim and sWe tMt Neabove irmm bar it comet I agree to comply withal]city and county ordinances and state lows mlating m PERMITISSUANCF. MEbuilding construction,and herebyeurhmiu rcprexnumerwafthiscity no emttupon meU 7 aove-melmond property for inspection p upwass. ALTER OR ADD TO MECH. ON TAX
r7 (We)agree to save.indemnify and kap humlus the City. Cuperino against 'a
liabilities,judgmenv.msv and expensuwhich nay in any way vac staifiry AIR HANDLING UNIT(TO IBM CFM)
/
in<,n ttof the ting of Nis permit. �` L/ Y
�i��� ��✓ / /(n AIR HANDLING UNIT(OVER 10,1p0CFM)
Signaturcof Appian ,ntacmr to L EXHAUST HOOD(WIDUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,003 BTU) Date Receipt#
Will the applicant m future building occupant er 9,m handle Health and
a defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety Hf+ATINO UNIT(OVER 100.00d BTU) TOTAL:
_ .. Code,Sudor 25512(a)1
13 Yea 0N VENTILATION FAN(SINGLE RESID)
Will they licmtorfumrebui]din ,acumt uses BOILER-COME QHP OR R0.000 BTU) ISSUANCE DATE
pp g p equipment ordevic'awhich emit
VD1.51
7a au contamimms as defined by the Bay Area Air Quality Mmagemmt BOILER-COMP(OVER 100,0110 BTU) � p
❑Yes ❑No NEW RESIDENTIAL MECIL. SQ.FT. // A 1 0
I have read the haard,us materials requirements under Chapter 6.95 of the JAN
Californialbuilding
do&Safety Cade,Sailors 25505,25537 and 25534. I understand Net #R 9n^
if the building Jcesnot cumndy have uenmt But it is my msponsibility tonotify the /a7 k�
Oce pontc f the"Warenenu which must h met prior a issuance of a Cci ificate of
ry y. V t
bwnttmauthnnsd agent Dao T ISSUED BY. 32
OFFICE