25542 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO11.1 NG-LLKUrRICAL PERNBI NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL (J C 5 /14 L n
- PR
BUILDING OJECT'IDENTUICAT[ON. L J J
BUILDING A DDRESS: - SANI IARY NO. APPIJCA HON SUBMfITAL DATE
10(059 DEEP CUFF- DR. CurEa CA 950144 LOTp
IO N'ERSNA E PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL x
• �o w -25 - 959 k ODt_A a tD 2 ^2
•^ H, CT/C GINEER: LIC NO: ADDRESS: ❑ C 7
CONTACT: PHONE: +'+ t5t-^ !-A' 4" a •^"
QTY M Y'F S ELECRC PERMITP k {IY.e.;•FEE
BUILICD5I4NG PER
BLDG ELFT PLMIT INFO MJD,O YP&KjowFe� 7-v8—G.J7— WS PERMRISSUANCE
"•
(]j
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑WZ Ihenelb iditm that l pmlicensedundcrprovisions of Chapter9(commencingwith
a00 SeederI00010f Division 3 of the Business and Professions Code,and my license is in PANESfall ^^
zvw Litrnrceaad effect. AAn �Y7..J
<Zs:1 Date
Clava — — Lica .�DS O UP TO Vp AMPS
v;jy Dam Contract., Qsr+ .EV C0ftJx C,4 201-I1 A
F t.2 ARCHITEC7'S DECLARATION SQ.FT.FLOG AREA S/SQ.ET.
O`^— I understand my plans shell be used ss public records. E 1 ad S
_=L;i, N GTRI
y'<<_ Liccnud Professional
-yy< OWNER-BUILDER DECLARATIONRfZ
SPECT 1 T C.
�F 1 hereby affrm Net 1 sm exempt from the Canoazsor's License le
C)<
following reason.Sachem 7031.5,Business and Pmfessiom Code:Any ciry R INST.
—y: which requires a pennn to construct,Wet.improve,demolish,or repay anyY2 prior m its ismansx.ako uquireOISsri plicanrfar such permit to file.sigmdPO EVI1 re Nat he is licensed pursuanmo the provisions of the Connector's LicenceLawX0� 9(commencing with Section 70001 of Division 3 afthe Business antl ProfessioSWIM TNG POOL ELECTRIC VALUATION
< or than hcisexcmps therefrom and the basis for the alleged exemption.Ar,violadm of S FIXTURES 2S"•7 ��i e-��
Section]031.5 b I'cant fora
OUTLETS WITCHES- L i
Z Y anY dt pemtit subjam th<eppiimns to s civil pevlry ofLP
not mom than frac hundred ePTOdollars(SS(p).
Y!-p ❑ I,azowncrofthrpropcny.ort. IoyeeswiN wa ramtheirsolecam NEW RESIDENTIAL ELECI'R —SQ..FT
ycmp g pcnvdan. T - STORIES TYPECONSTRUCTION
will do Nework.wreathe he,cture Conisaona License
La does of a See.90 Business
of IIS
and Ponto,who
Cade:Thr improves
trumrs Licence lean docs or apply tort rough of ..
ownpm,ertywhoes,prolds arimproveschimpr.and who arenotsuch
tendo himulfar f r aide.I,
employees,theesildingr that imprvemenprovcmcnuat not eatrdcompled or eed foraide. I^ OC G1{OU RES.UNITS
however.11havedingmd"ofpnmm ishat he thlnet mild
of completion.thrpose of
builder will have thr beard"of proving that he did ms buiM or improve for purpose o! /
tale]. r.•e-t:/,�+._ .N, n
❑ Les mwnernfthe propenp.am exclmivclY contn<tinB with licensed cono-actorsm �•.�•`�''�`'4�PI•UMBING PERMIT-_Rrr,fl eat^�:- h.� rvE DPN
,F_O .ag.y;,{;;.;H.nr.-.m:•-+rs.:r.axr sxs, M. ,
rakes she pro,oct
sow(See OBnO Business and Professions Code:)The Cantncbrs
Licencelewdasnos a primers now scramostodsHicndesd psorimproves theeon.ars PERMIT ISSUANCE
ubocamostsLaw.for such pojecu with acmwetor(s)IicenuA ptmuant Bothe Contractors _
License Law. ALTER-DRAIN&VENT-WATER(EAI �NrvµS^�•."`=i.rs FEE,SUMMARY ll;ya l�d,T, nl>�'s!
❑ 1 am except under Scc. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE IluT'SIDE FEES
OSANITARY Y N
Ottwer Dec DRAMS-FLOOR ROOF.AREA.CONE. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N_
I' Thereby affirm dmlc conumso self-insure,oraccnifcam of FIXTURES PERTRAP RECEIPT-
�ray B"urkera'Compewsionimurancc orattnifW copy thercof(Sa.3800,lab C.l which PARK FEE Y_N
covers ell ceplovee's under this pemtlt GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT-
CeCa BUILDING DIVISION FE p^
GAS-EA.SYSTEM OVER4(EA) PLANCHECK FEE g-Oz
Qnif W mPY is hereby fumishrtl.
Carifed copy is fleet with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE Soo
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE O r.OO
('ITis sectinnnad nm be completed fife Permit is for one hundred dollars(SIW) SEWER-SANTTARY.STORM EA.2WFT. ENERGY FEE -.N
or Iai.) tW�
I cenifv shat in the perfomme,of the work for which this permit is ismed.l shall WATER HEATER W/VENT/ELECTR
not employ any Person in any manner so as no become subject to the Workers PAID
Compensation Laws Of Califomia. Dam
Z Applie.mI,em WATER SYSTEIATREATING Data ReceiPt
Z O NOTICE TO APPLICANT:If,after making this Cersificnc of Exemption,you should NEWRESIDENTIAL PLh1B. SQ.FT. TTA a
— let become subject no the Workers Compensation prowisiomafshe Labe Code,you most 0-1
Y 7
forthwith comply with such provisions or permit shall be deemed invoked. BUILDING FEE Sys
CONSTRUCHON LENDING AGENCY SEISMIC FEE wZw �V
ZI hereby affirm that thein is a contraction lending agency for the performance of
J O the-work for which this permit is issued(See.3199,Civ.C.) TOTAL: ELECTRIC F[E
Lender's Name - F.. ........,vva. x...„ ., sr
Lenders Address QTY. �f g�";•,MECI{ANICAI:PER MIT-' ' -.FEE t.`r; PLUMBING
V 1 certify ties I have read this application and sine sin the above information is 4' '
} CL cornet.I agta no comply with all dry and county ordinances and Stare laws elating to PERMIT ISSUANCE AtEC11AN'I AL a__
V) building constitution.and hereby authorize representatives ofthis city to curer upon the
;) Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONS O
(We)agree to save.indmmify and keep hamdess the City of Cupertino against
liabilities,judgments,caassandexNews which may in any way accrue easiest Cis. AIR HANDLING UNIT(TO 10.000 CFM)
is co 9uence of the granting of this'rain.
AIR
LING
�� ��-�D 93 EXHAUST
HOOD
UNIT VIDUCER I0.000CFM1
Si nnum of qp anUConu for pare E%HAUST HOOD IW/DUC-I')
PAID
HAZARDOUS .state DISCLOSURE HEATING UNIT TO IW.000 BTU) Uam Be iptp
Will she applicantor hf M buildingoccupantneeor andharedle hawdoanmaterial
as debned by the Cupertino Municipal Code.ChaMcr 9.12,and the Health and Sa(a5. HEATING UNIT(OVER IM."BTU) AL:
CMe.Section 25532(e)?
❑Yes 0N VENTILATION FAN(SINGLE RESI))
Will she applicant orfmum defer m occupant useequipmentordevices which,mit
BOILER-COMP OHP OR 108.000 BTU) ISSUANCE DATE
..Istnal m air conmmimnm as diluted by sM1c Bev Area Air Quality Manegeeem BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
NEW'RESIDENTIAL MECH. SQ.ET.
1 have read the haerdous materials requiremems under Chapter 6.95 of the tv
Califomia Ifemb&Safety CMe,Sections 25505.'_5533 and 255]4. 1 understand that
ifthe building does not currently have a hmnt,that n is my responsibility to notify the O"T- 9
occupant of the requirements which muss he met poor to issuance of a Cenifieme of OCT
Occupancy.
Owner or amboned agent Dee TO l ISSUED BY/UP -
OFFICE �