28250 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
RUIZ, MECHANICAL pF:RMI'1'NO. 28250,a ��O
APPLICATION/PERMIT PLUMBING CI IDENrj1gU 2 8
BUILDING DIVISION PUILIIING PROIECT'IUKMI'IIgCA'I'ION
BUILDING ADDRESS: SANITARY NO. APPLICATTONSUBMHTALDA'IE,
UNIT# LOT is
WNHRS NAME: PHONE: kI C RA OR'SNAME.: LIC NO:
CO 142
r 1 NIC CONTROL#
HI'IE /FNGINY #og ^IC NO
r �+ ElO (� ✓
C/OaICACr: PHONE' QTY, ELECTRIC PERMIT FEE ' BUILDING PERMIT INFO
RIIJQ,(rJ .GL((,{So B EL PLUMB MEC
PERMIT ISSUANCE 7
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ION DESCRIPTIONOmz IherehyafHmr that lam licensed anderprovivionsofChapter9(commencing with
q0O Section 7000)of Division 3 abbe Business and professions Cole,and my license is in PANELS
d F full force and effect.
I<.ZW LimnClass Lic.M (atUPT02MAMM OW—
Date
Date G.m S D 201-1000 AMPS SQ.Irl'.FLOG AR7:A E/SQ.FT,
F'O
ARCHITECTS DECLARATION _(7►_',71(}1_l+1
t&'J OVER ION)AMPS
O z =p I understand my pliersshall be used as public reemds.
_ u1 SIGNS ELECTRICAL
�cd F=W< Licensed Professional
y�< OWNER-exempt ER DECLARATION SPECIAL CIRCUIT/MISC.
aJOyU 1 hereby affirm that 1 am exempt from the Gmtmdors License Law for
tai'+Wy following reason.(Section"10315,Business and ProCode:Any CoAny city or county
'ILMP.ME] OR PULE INST.
C iS O
oo which requires a Permit m construct,aper,improve,demolish.,epair any suucem
f Y� prion.its issuancgalso requires the applicant for such Permit file a signed statement POWER DEVICES
O<p That he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
anp�o 9(commencing with Section 7000)of Divisio )fthe Business and Professions Coale) SWIMMING POOL ELECTRICV�ALIIA'1'ION
to dolW_m Sech. 7031.e is empl therefrom and iM1e ku.' orlhe lleged Any violation of LETS-SWITCHES-FIXTURES / lJ
aas
tza Segion'l03 LS by un n rtnil subje alba applicennoecivil pena0y.f
O UT
untlred dollars(5500). NEWRESIDENTIALELECTR 5 FT.
pro rthe w add
shmrty,ormyemtended wit red forsthei(Sec.7044,Business Q' STORIES TYPE CONSTRUCTION
q Il I'mids work,and the he Cwhi s uo',License o d...not
apply to an, evoc,ss
t Professions Calc:The improves
chemo a License L.os, Joes mol apply m an owner of
pn mywyobuimam imphin suchen pourve who J«a uchwmkMmsenedfmugh his
w employees,provided tllbei such impmvememsawn t earocdor.ftim.the.w.IL OCC.GROUP ERUNITSbo egillhave tie burien ofp enti,hathethin.n yearor improve for p rpsee ofbuil er will have the burden ofpn ingthathedidnm uildmimmnve for puryoae ofIasowner he Ise corms,, gwithhe...edemmanofsmQTY. PLUMBING PERMIT' I7iE" FLOODZONEPN
con. mac the p 't ss and Profs,s ns Code:)The Contncmr's
Li Law a to�r.wncrofpmpcny b Idaorimpmveslhereon,and PERMIT ISSUANCE
wh mundesforst'h rojeaswilhacontmm licensed uaneorhe Commercee ALTER EA
Lie se Low. ( ) 3 t"
' PEE SUMMARY
❑ I am exempt undcr See 7li.z� ,B&P C for This,earn BACK FLOW PROTECT.DEVICE O .Irl. SEE
SANITARY Y_N
O r Dam RECEIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WO 1AN COMPENSATION U[CEARATION SCHOOLTAX Y_N
❑ Ineuby effi that I have a certificate ofcewetn m self-insure,.,a certificate of RIiCF:IPf#
FIXTURES.I'I?R TRAP /r
Wo err'Cn malt.Insurance orucenilied copy thereof(S C.)which PARK FEF. Y N
covmpl.ya's undcr this pcnnil. GAS-EA.SYSTEM-]INC.40UTLGI'S RI?Cl?IPTR
Policy Y BUILDING DIVISION FEES
CompanyCan GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy ix hereby fumishcJ.
❑ Cerilied copy is fled with the city inspe odivision. GRI?ASEANOUSTRL WASTE INTERCEPT OR GRADING FRE
CERTIFICATEOFF PILON FROM WORKERS' GRIASETRAP SOILS FEE
COMP: .ATION INSURANCE
Ghissectiommeedom omplcedif Ne Penothem herabodd.11as(SIM SEWER-SANITARY�STORM EA.20OT. ENERGY FEB
or lcssd
IC
cermfylhain eperf.mmnce.f the work whi rte pcmrit is y It 11 WATER HEAT ER WNENT/I?LECIR
of employ any pe. n m any manner so as I ubj t IoltM W en' PAID
tels
C.mpenadmor law s. Caif.mia. Date "\ WA TERSYSTEM/IREATING Date Receipt#
Z Applicant
ZZ�-I Q NOIICETOAPPLICA T:If. er ia n 'Cent Rcut;;.f/c,dormancoof
wild NEW RESIDENTIAL PLMB. SQ,ET. TOTAL:
[� >
becomes Wn e'a orlon prov,�6f Nmust -
L••"�"r forthwith comply with we p v .r this pay`,\ he be BUILDING FEE
(] CONS U NLENDING AGENCSEISMIC FEE
z I hereby affirm that her iaaconstructionlendingagene
U O NKilso
e work f n which this permit s issued(Sec.309],Civ.O) TAI, ELECTRIC FEE
Lender's Name .
C, U Lenders Address QTY. MECHANICAL PERMIT _ FLF
PLUMBING IEE
L) I vicinity that 1 have reed chi. application and scam ar the above information is MECHANICAL PF.E
cored.lugrcemcnmplywith tall and cmumy mrd .aces and stnmluwsrelnlingm PERMIT ISSUANCE. ��
�+ buildingcmrimullitm,ted herebyuut riecreprese lives ofthis city to enter upon Ile CONSTRUCTION TAX
V Z ab.ve.mentionetlpropeny forms ti purpos LTERORADDTOMECII. �^
(We)agues,to save,indemnify and awnless the City of Cups,///bo against
liabilities,judgment;cost...dexpcnua which may in any way ega{,Seyl City Al ANDLING UNIT(TO 10,000 CFM)
ce of the granting of Ihix pertnif �7
AIR HANDLING UNIT(OVER 10,000 CPM)
gru ten App1i<anVConlmcinr Dae HAUST HOOD(W/DUC)
PAID
rD
IIA'LARDOUS MATERIALS DISCLOSURE I[RATING UNIT'(TO 100,000 BTU) Date Receipt#
WO I I he applicant or l'umre miliingoccupanl some or handle h..ardo.e mmen.1 HEATING UNIT(OVER 100,0(h)BTU)as defined by the Cupertino Municipal CWe,Chapter 9.12,and the Health and Safety
Cade,Section 25532101
❑Ya 11 No VENTILATION PAN(SINGLE?RFSID)
BOILER.COME(JHP OR IHU,W0 BTU) nISSUUANCE DATE
beedWill lheaPPlmorma furore building by the
nBay Am.Air Quality Management
r A f D
Nitrdmus air c.nwminenE as define)by the Bay Area Air Quality Management BOILER-COMP(OVER 1010.001)BTU)
Dislria7
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. !'r `-UrkEk
1 have read the hamNous materials recuircmems under Chapter 6.95 of theCalifomiu Health&Safely Code.Sections 25505,25533 and 25534. 1 undersand Thaliftbe builiirtdoes am curren0 have.emir,that it ism Ig y yrespmeofla ternotify the occupant of the requiremrnts which must be mei prior to issuance of a Cenificna of .
Occupancy.Owner m authunced agent - Date '1 AL. ISSUE
DB
OFFICE