25574 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING.M1115CIIANIC-AI. PIiRh11I'NO.
BUILDING DIVISION APPLICATION/PERMIT 25574
_Y,tF! UILBNO ROJE 1 NT FICA ION.*ssnsp.{a.;,;•'
BUILDING AE RES( SANITARY NO. APPI-ICAIION^SUBMITTA1.DA'IT
III.LZ (TMJ \✓✓ T VWPo �lJou LOTto
OWNERS NAME: PIETIF. � CO TRACTOR'S ML� f / LIC?t Nrc CON'1'ROLN
CHITECI'/ENWNEER: WC NU: ADDRESS: 1•/LY4 ❑
ONTAFl� PHONE: QTY. 1 w I,P�•pRIC PEBMR' # 'T I FBB � ) i' ?r .`;1.BUB,DINO PERMIT INFO
97S;2 Y 9a f, r T"'a`"rrlt w xp f far aa� P vtt LOO ELECT PLUMB MLCII
PERMIT ISSUANCE E] 1:1 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DPSCRIPIIO
t0w9Z Ihereby alfiw that am licensed underpmvisionsof Chapter9(commencing with
FJVICfull
Sectioon cee A)ofevissiioonn Sof the Business and Professions Code,and my license is in PANELS �. �, p0o2
C7 A0
¢ZUZ Luh License class_fL_Lic.N �• i0d 1000AMPS
rrFs<a Contionor PI'.FLOOR AREA S/SQ.FI'.
Gin ARCHITECT'S DECLARATION OVER I W AMPS S Q
Z—A I undersmnd my plans shall he used as public records. I{
y'-f Pi\V,
kd LiccnuJ Pruluseional SIGNS ELECTRICAL
y OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC. /y
O 1 ngreas affirm that I am exempt from the CosionsCode:
s Licensee Law for the
Sal�¢"n
following reason,(Section lUJLS,Business and Professions CW e:Any city or county TEMP.METER OR POLE I �
�m..l which requires a Penni,to condom,him,improve,demolish,or repair any animateY� prior to its issuance,also requires the applicant forsuch pewit to Ne a signed statement POWER DEVICES
Q p that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter,
SWIMMING POOL[ELECTRIC VALUATION
0�4 9(rnmmencexemjob
therefrom
and
Division the
eed exess mend.Any violation of
�w
Seor ction
7031.5 by
applicant for
the baspenisforbe is the,ppi tea In. elvilonsion of OUTLLTS�SWITCIIliS- 2-(c, F-y T -
Y cT-
nmum do. v hundred
undre dollars(11500).Permit subjects the applicantto.doll penalty of FIX V tel/
nm morethan Bveill dpM dldlarmyemp.
KK ❑ Lesnwnernldre propeny,ormy empleyeeswi,h wegamtheimolecompensation. NF.W RFSIUFNTIAI.F.LCCfIt _SQ.f?. STORIES '1'YI'Ii CIINSTRUCIION
y3� will do the work,and the swcture is not intended or offered for sale(Sec."/044.Business
and I'mfosinm Code:The Contractor's License Low does nm apply In an owner of
properly who builds or improver thereon,and who does such woo Is himself or loorigh bis OCC.GROUP RF-S.UNI IS
son employees,providad that such improvements are not intended conflicted forsake If,
however,the building or improvenetn is sold within one yeorolcompletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of '�dd
sale.). QTY njr}'+•V aI PLUMBING PBRMIT 'Epnz aa d�+ 9a FEE zJ
❑ 1,as nwnerafthe pmpeny,am exclusively commcoing with licensed contractors, ,y, Aa, {-;x,tv,. e,s n. .r e,eki,n,(Yr# IF' �.. ate ` F(•OOD ZONE
AI'N
ensiruat the police,(Sec.70144,Business and Professions 7oI The Commctora s
Licensclawdcexnnupplyman nwnerof properly who huildsorimproves,hereon,anA PERMII'ISSUANCE
whocnmmmx for such projects with ecnnvemot(s)licensed pursuanl to the Cenuamors ALTER-DRAIN&VENT-WATER(PA)
EBB$UMM
License Law. AR
Yo i
❑ O . , S
BACK FLOW PROTECT.DEVICESANITARY Y
N
tuner
Date DRAINS-FLOOR,ROOF,ARFv1,COND. RECEIP`p#
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX Y N
I hereby off rro that l have.cent feme of consenuo set f-imus,or a ceni0cato of PIXTIIRE.S-PP.R TRAP RECEII'F#
Worker,'Compensation Insurance or 0.cent fed coy thereof(Sec.38tH),LebC)which PARK PIiE Y_N
IPI If
cove,,all P. ye wed h' ,. _ GAS PA.SYSTEM-I INC.4 OUTLETS RCCT:SION
PulicyN lC��/--r�r7-- BUILDING DIVISION FI!lig
Co ny [rTaF Q A� GAS EA.SYSTFM-OVER 4 PA) PLANCHECK FEE
LJI Codified copy is hereby famished.
enified copy is fled with the city impectinn division. GRBASUNDUSTRI.WASTF.INTT:RCBPTOR GRADING ITE
CERTIRCATFOFEXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This action need nm he completed ifthe permit is for one hundred dollars IS IIIc) SEWER-SANITARY-STORM EA.20011. FNIERGY PER
or less.)
I cenify that to the amfowence of the work for which this permit is issued.I shall WATER IIF.ATER W/VENT/ELECIR
an, and,any pcovm in any manner so as to become subject to the Worker, PAID
Compe...linnlawsnf Cnlifomio, Date WA'1'IiRSYS,1iM/TRFAI'ING [),are Receip,N
Q Z Applicata
7O NOTICETO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y bermne subject o the Worker's Compensation provisions of the Labor Gate,you must BUILDING PEE /N
LLLL� > forthwith comply with such provisions or this p mait shall he deemed revoked.
W ASEISMIC ITE
CONSIRU(TION LENDING AGENCY
I hereby alfrrn Ilia, here ue nmrucuon lerdmgagcncy for the perfommore f
O IDI AI ELECTRIC FEE
the work for which this permit Is L. ed(Sec 7091,Civ C.)
ILLI Under Nome
EC••Is LemET,Address QTY ur;( ' MBCHANICALPERMIT,x r E;^u 'o� E3',�W' MAIMING FT:F
read mi.,application sad mate that the al.we mferm
C I certify that 1 have emanation
Ila correct legree tocomply with ell city and county nNinmmex end stare laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby amhorrim representatives of,his cloy to ant upon the CONS'IRUCI'ION TAX
V 7 eMve-mentioned pmpeny for inspection pu5ph.rrh
o. ALTER OR ADD TO MECIL
^-i (We)agree I so ,indemnify sod ke ,he Ci,yof C rfno agsin.vl.
Iiabilities,jmig n 'mtam,despen manywsy againt said City AIR IIANDLI NG LIN I"I IT 010.(X10 CIT)in cmarche of egmming f % AIR HANDLING UNIT(OVER III,WXI CFM)
Signature of ppdcanl/Contmnor t EXIIAUS'IF HOOD OVIDUCT') PAID
HAZARDOUS MATERIALS DISCLOSURE IIEA'ito fINC,UNITTTO.100,IXX)BI UI Ua,e. Receip,q
Will the.pplicam or future building accupein mare sir handle hazardous meeftal T
on defined by the Cupentnn Municipal CWe,Chapter 9.12,end the Health and Safety HEATING UNI I'(OVER Ilkl,ll(NI B TU)
Code.Section 25532(¢)? VENTILATION I7AN(SINGLE RFSID) �•
❑Yes ❑No
ISSUANCE DATE
OWill the applicant or future buildognscrprm usecyuipmenmrdevices which emit BOILER-COMFORT OR 100,000 BTU)
azardou.,air contaminand as defined by the flay Arc.Air Quality Management BOILER-COMPLOVER I4g0,000 BTII) P A 1
ado?
❑Ye., ❑No NEW RESIDENTIAL.MECIf. SQ.FT.
1 have read the hazardous Core.
minion., 5505.25533 under Chapter understand
or the SEP 2 2
Cotif have
email t e hoz CWe.Seater 25equire ent end 25534. I understand the,
if the building Jces not conically have a¢rent,ohm it is my rmpo sibili,y to notify the
Occ upon sir the rcgnirmnena which meat he me prim m ixrvance of a Cenifeme of Mt\`I�ov
ccupancy. -
Owner sir imli imd;i"ra Date TOTAL: ISSUED 9Y:
OFFICE