25100 (2) APPLICANT TO FILL IN INFORMATION WITKIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUI LVING-HLECII RICA L PER1,11TNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDENI'METIMN 25100.
BUILDING ADDRESS SANITARY 0. APPLICA1[ON SUBMI ITAL DATE
/ffA44,04 UNI'l 0 LOT# "�-2
E is -o-
OWN NE: CO ORSNAME LIC NO:
ahRSNAM PO r — N/C CONTRGL#
Aiij< �//A//Azsss 4 20!5-
Ir!1jr IF LtNo
'Q1zzzi4_- 'DDHLSSI
ONIAcr PHONE QTY. ELECTRIC PERM THE BUILDING PERMIT INFO
PERNIITISSUANCE PLUUB MECH
S&V& IL5.- �v X_ A- 10IT
LICENSED CONTRACTOR'S DECLAILYTION APPLIANCES-RESIDq\MjL H DESCRIM
hereby affirin that I con licensed underprovisions ofChapha9(commencing with
rea,lic,aw,itin
full Come and effect. PANELS
1.200 A*V Ak�
up FA Al,
Lo Dole—Connote
=oo VI Als V 07
Z8�7� ARCHITECTS DECLARATION J�4 $/So FT
OZ—Q Imiderminnintyplaux.h.11 Itearedwiptibliemexarx., to r PS e- ,,, F DOE AREA
ro,t- MN)VIECTRICAL liz .
gj�j Licensed!Pouring...I 1�z
re:< OWNER.HUILDER DECLARATIO CIALqRCN7MIS
R�u I hereby affirin that I am exempt from the C.ouract. ill L a. I ........
W mot; following mrson.(Section 703 1.5,,Bitairs.,itrid Professions '�'y city arc,anny TEMP.)MkTkR ORA ST./
yaract
I:Eil which mquirws a Permit to commou,alter,improve.derawlis , I or I, ma
�:F proor to its issuance,also"itims the applicant far such pariah first'isolintat'norat P0 US C 9
that hi,is licensed Pursuant to the provisions of the Contractor's License Law(Cf marr
9 femannomm,w0h Section 70100)of Division 3 of the Business it Prefellican CWc) swim 001, .:CTRIC LUATION
S2o, or that he is exempt therefrom and me basis for the alleged exemption,Any violan an of OUITRTS-SW�/CH� -.FIXT"URES
< or anne than fiso hundred dollars HI500). 16 __ j_
I-Z Section 7031.5 by any applicant for a Permit subjecta the applicant to a civil pano ty of �NIIAL ELL boo
NEWRESI/NTIA cTR —SQ.n%
1 YPE CONSTRUCTION
ja� willdo the work,and the stracture istratimended comfifirard finitude(Sao.7044.Bin mass
and Pronfiessionei Code:The Conarnmes License Law does not study to mr,nor er of
own courloyces,provided that such impi-avenortaine not mandedorofficuedporsele.If, OCC.GROUP RES,UNITS
however,the buildingor improvement issoldwitharioneyearrofcompletion,therwase'. r,MTfv,
builder will have the burden of proving that he did not build or improve for purpose of
.]a
[I QTY. PLUMBING PERMIT FrEE FLOODZONE AIIN
curourim,do,project(See 704,L Basin., ad Profession,Cwdr:)The Cientriectim'a —i— ---I assas"
License L.wd...�t.,,I,t.....,,.fp,o,�y�h.b.ild.�impmvesthe�n,wd PERMIT ISSUANCE.
whotiourstax frustum pl-jech asiffix,tiounwho(m licensed purrommummaCradessalm', --k— --L—;
Licturs,Lrow� ALTER-DRAIN&V WATER(EA) FEE SUMMARY
QLn RIFE FFTK
Imormena,ea mrdcrS.._,B A,PC for this reason BACK FLOW PROTECT.DEVICE —SANITARY Y_N_
Owner Dr. RECF1PT#_
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.ARJEA,COND. SCHOOLTAX Y_N_
0 RHCEIPT#
WorkeraComucausaficin tax...occur.cerfirW]copy theof(Sec.3800.UmC.)which FIXTURES-PER IRAP PARK FEE Y_K_
*$cover,all employees under this Permit. GAS-E.A.SYSTEM.I INC.4 OU71. RECEIPT#_
Policy 0 BUILDING DIVISION FrElL
Company
[I Cenifird copy is hereby finmishrul. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ME 5 ZZ 0
C3 Conifitdc.,is filed with the city insper,timidiviabso GREASFJINDUSTRL WASTE INTERCEPTOR `GMDING FET
CERTIFICATE 01:EXEMPTION MOM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need not fir completed lithe peorritisforonsculandurldoliturs($10p) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
mr less.)
I comy that undic ponficaussence affair work fierwhi,la dar permit it issues,limall WATER HEATER WIVIBODELECTR
hot employ any person in.1 insurer 1..1 1.become subject 1.the WmIcares' PAID
Cimpermami-evs,ofC.1ifired.. Dole
0 Z All...I WATER SYSTEMITREATING Data Receipt a
Z 0 NOTICE TO APPLICANT.If,after making this Cimificathe of Exemption.you should NEW RESIDENTIAL PLMIL—SQ.FT. TOTAL
EV) bounnor subject to the Worker Compernsation provisions of the Labeir Code,you must
5� f."hwith comply with mich Provisions a,this permit sh.11 be drenrov] vidird. BUILDING F2H a—
Wj ;�
P. CONSTRUCTION LENDING AGENCY SEISMIC HE
::) z I hereby afrim that doure is a construction lending agency ficarthe performance of
U 0 me work far which(his permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
�T. P Under a Name
0 U Under a Address QTY. MECHANICAL PERMIT FEE PLUMBING FCC isat'saa
>� I cratify that I have exand this application and sure that But,above infoarrimmican is — I MECHANICAL FEE
comext.I agree to comply%fth all city and county ordinances and shire laws relating to 4 PERMITISSUANCE 1�
building construction,and hereby andarrize representatives of this city to enter upandare a
U above-mentioned preivorry for inspection pupmael. ALTMORADDTOMECIL CONSTRUCTION TAX
(We)agree to save,indemnify and keep harandoor ike i agan.n.
lutbililiess,judgmenuccuoressandesparm brincyr.fly. a stakiCity AIR HANDLING UNIT(TO I0.000CFM)
:>L gouni this 1.
AIR HANDLING UNIT(OVER W."CFM)
Signuiu�r;'-ofrA3p]j��nOConimcior Dr EXHAUST HOOD ff/DUCT, PAID
HAZARDOUS MATERIALS DISCLOSURE I MATING UNIT TO 100.0100,BTU) Dole Receipt#
Will the applicant or future building occupant mom or handle Interactions material --t— 9 —
res defined by the Caperton Municipal Code,Chapter 9.12.and the Health and Safety I 1EATING UNIT(OVER 100.000 BTU) TOT
CWe,Secuden 25532bm? VENTILATION FAN(SINGLE RESID)
13 Y. 0 No
'Will thesprlicuntorfuture buildingescupentard userecuipmantordevionswhich that BOILER-COMP LIHP OR 100.000 BTIB ISSUANCE ATE
ous air conerminsions as defined by da,Bay Area Air Quality Management BOILER-COMP(OVER 100,0110 BTU)
4#7imirriel? P A I
Cl Yet 0 No NFWRESIDENTIALMECH.—SQ.IT.
I Ition, it the hormclaries andered.recittirrovern,trader Chapter 6.95 of the
California Ificalth&Safety Code Sections 25505,25533 ad 25534. 1 tundentratudded 1993
if the laulding does nor currently have a Imaral,that it is ny responsibility to notify the
occupant of the requirements which must IN,met mor to issuance of a Certificate a CITY ur Lurrm
Occupancy.
Owne,ormummor.l.oprit Date xa� IssimD BY:
OFFICE