25333 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOH¢aTN ' "' PERMH'NO. r�
APPLICATION/PERMIT PLUMBWG-MECHANICAL, J
BUILDING DI VLSION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APNUCATIONSUB.MIfTALDATE
:219:21 Garkenview LOT#
OWNERSNAME: 1 64A ^O PHONE COIZTKACOR'S NAME_ LIC NO: l
K N/C CONTROL#
ISI RCHITfiCT/PNGINEER: LIC NO: ADDRESS:
116 -9/7-3
❑
CONTACT: PHONE QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
_3899 o PLUMB Mol
PF]tMIT ISSUANCC
LICENSED CONTRACTORS DECLARATION APK[AhICFS-RESIDENTIAL TOB DFSCRIPf10N
IEerehyofflrmlhu l 3 of B. NuMcrpmvieiomofCh.p ,mal toy icmgwiN
00 Sufvcv 00U)ofllivision3altM1C Business end Ro&sdom Coh,.M my lkena is in PANELS
IJ,crocemdcffm. ^
I.iccnae Clue Lich UP TT3200AMP5
fn¢4' Wtc Con. X11.1000 AMPS
7ONZ ARCHITECTS DCCGRATION - SQ.ET.FLOOR AREA M.ET.
O Z—0 1 uMer....n rq plan s1uU be rued er pltblc r¢ordd OVFA 1000 Ah1P5
N C SIGNS Ef.ECIRICAI,
Q Y K�K J Uo i Profeaiorul
OWNER-BUI0'u 1 hneby.firm thu I.m ex mlix fmmDER U ftCatlratocs Licaue Law for Ilse ECLARATION SPECIAL CIRCUIT/EASC
CLL�� winch 1mgluru•x,ctrut Invo vada.Iln,irt,rovcfamnUCatle:AciNYa TEMP.ffB-IFA OR POLE INST.
priorloitsiuvurwhi so uc
ouuitn t1o,"licanl for• h pend to filuma
eignesIvic n POWER DEVICES
M.y K OO that he is licensed msumt to tk pvlbm Gmlrcla
oaof the 'a Liam.Taw(Ch"W
s WIMM NG POOL PI FCIRIC
CX'� Y(nwmercing with SlAliun 9fXlfp o(Ulvidm3of Uw Budnev.nd Pm[wioro Code) VALUATION
w_N a ,i hcia amyN tyfpf L,Wlhc bviaf«Blc.11egedeaemgiao. civilP•tien of � S-SWITCHES-FlXTVRFS �DJ1
tZQ Satinn]031 Shy my.p tloilfnr.permit subjav Nc elglicmtloecivil pvuhy of v
w�� not maf Ihm five num daune cssod).
❑ I,nowrernflhcpopmy.armor la¢esHthM NEW RESIDENTIAL EI.ECIRSQ.FT.
3 Y W Y gn uNeiraolecompcm.rim, STORIES TYPECONSTRUCTION
p, _ willP n,f osi Co&:Tlo,C.n1.1 i,Licm m a.docs
a.k(Scc.to an
ofurlJ PntTeaaiau Code:The ConlmclNa Liutuc law drcs Iw apply m m owner or
propmy wlnbuilMaiortprovnthereon,sod who6 such himselfa Unough his
sun employes.,provided Ulu such implovcnems.not lcte orcffered fa We.If,
OCC.GROUP RFS.UNITS
however,the WiNing mor t is sold within atvth
e ye ofconnkcon, ..- t
men
builJer suit I M1uvc de burJeR of proving Ihnl he did M buiN a improve for puryme of I TOTAL:
We).
ElI,aawns oflhc prop<ny.uncaclu.ivcly rnnlnclillg wim limnad cmvaluslo QTY. PLUMBING PERMIT FEE FL UzoNE APN
cordons,the pojea(5ec.7oaa,Businea and Professions Cafe-)The Contractor's
I.iernx Law donroupplY lomownnofpmprery who bulldem Uopmvn th2rtal,W PFRAUT ISSUANCE
who contracts for such ,*u with a convatm(s)Iicrn punuml to to Connectors
LinLaw. ALTFt-DRAW&v1T.WATER('G)
FEE SUMMARY
❑ 1 mteamtpt uMcr Sec. B&P C fa Jlu rmaen BACK FLOW PROTECT.DEVICE SANITARY o Y N
Ower DelcRECEIPT N
DRAINS-MOOR.R161,A
• WORKMAN COMPFNSAT ION UECT.ARATION SCH iI N
❑ Ihacby ailnn thntl hevicecmifiulc of consent to self-insurt,a.urufne of — RECIiIPfN
FlXTURES-PFR TRAP
Work' s Compen.uion ltuurmcc orecmifed copy thvmf(See 3m,Lab C.)which PAR Y N
ovm.11 cmplgcc'a mdv tMspmnit. GAS-UA.SYSTIJrf-I INC. VTIE'T'S� RECEIPT♦
Policy N BUILDW G DIVISION FEES
Company - GAS-UA.SYSIF.M-OVFR4(FA s KFEE�
❑ CenifkJ Copy is Meby fumiahM
❑ Certified espy is fled with the rity insp%4on division. GREASF/INDUSTRL ASIEI
FEE
CEICHRCATEOFEXEMPIONFROMWORKERS GREASETAAP SOILS FEE
COMPENSATION INSURANCE
(This inion nmJ on,be completed ifde pemdl is fa one hurdred dolls ($10(1) SEWER-SANITARY-STOR)vI EA.200FT. ENERGY FEE
or I..)
I WATER HEATER WNEN'DELECIR
lanify lMlin the peRonwce of Ne watt fmwhich thispmnh is ivoed,ishell
not cmplq my Anson in my mmrcr so as to bcwoe subjttv to the Wcnkvi PAID
Conn a WlonluMof Ceffvrom Due WATER SYSBINETRIATING
Z
Appliuot Dale Rmpt#
ONOTICETO APPLICANT.If,.fucroaltg this CWBuleof anotxion,ylwahould NEW RESIDEMIAL PLMB. SQ.FT.
TOTAL,
Fbccvrrcabjcnm the oich pr Compenadon peon, rMoftbe Labor Code,y, vlun
> forthwith eomplY with each pmvisiau or thu penmt shall be deemed rtvakN. BUILDING FEE /^
z CONSTRUCTION LENDING AGENCY - SIJSMIC Fti
1 himmy.fMn tlw dim:is.cmouucuon Ie 1.'agmq Inc Be peUaolmce a/
U the wort for which this pccndt is tou lScc.3d9T,Cl,CJ TOTAL: ELECTRIC IEE
LcMcla None O FLUMB W G FEE F L+dar'.Addreas QTY. MECHANICAL PERMIT FEE
U 1 mrtify that I hove rnd that prpliulion and sate Rut the.bove infomu4on is
axrm. l.'ecto wnPly with all cily.Ncoort,adinmcce.rof state lnws rduingm PERMIT ISSUANCE MIiCHANICALFEE
F-' bulWingcmulrunlon,and hueby•oNari: tcfneanuuvn ofthis city tomtn upon de
�J 'Z aMve-memionMponnty For ins ion purpose. ALTER OR ADD TO MECH. CONSTRUCTIONN TAX
(W.)a to ave,itWcmrufy.rd krcp h.rmleas the City of Cupmim.g.iw
hallo it , onus deapum which may i n my way anoc agtina avid City AIR HANDLING UNIT(TO 10,gM)CEM)
(Iheg t of this permit.
m cn 7—/g—
AI R HANDLING UNIT(OV IUt I E"CFM)
Si rte re of Applicant/ mnecla Due IXIIAUSTHOOD(W/DUCI)
I PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IULIX10 HN) Uem Rcaipl N
Will We eppliam orfomm buildi"oavpmt atom or hanik haIDrdau onalmal BEATING UNIT LOVER 100,11(X1 BTU) TOTAL
a defined M the Culettion Municipal CW e,CTtpter 9.12,ud the Hcallh told Safey
Code,Section 25532(.)"
❑Y,,, ❑No VENTILATION FAN(SING LU RFSID)
Will the BOILER-COMP(3HPOR IU),000 BTU) ISSUANCE DATE
opplicanl afummbuilJinga<upum uxeympmem nrJwica which emit t�
hvvdaua•iT contmdnanu as deftaci by de Bay Area Air Qu•liry MwgmemV
Diaoiai BOILLR-COME(OVER IW,(X
FR p BTU)
A ,
❑Ya ❑No NEW RISIDENHAL MP.CII. SQ.FT. I�
I have rt.d the humino tommola roc,o nu undo Chapin 6.95 of the 1 6
Cnlifomio Hmhh A,Safety Chic.Smlions 25505.25533 and 25534. 1 undereuN that l
iftkbuildvtg don mtcvnrnJy haveetmmt,that it is mY onponaibiliry to ccoylhe v -1
Ocupanl of the mluirucnu which may M mel piam isaomce of a Cenlf to or
ccuparcy. t VUr I.
(TvrcramlhorireJ•gnl Due TOTAL: ISSUEDB .