25853 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPEECTRICAL PERMIT NO
SIO NO APPLICATION/PERMIT PLUMBING-MECHANICAL 25853
BUILDING DIVISION BUILDING'PROJECT'IDEM'IFICATION
BUILDING ADDRESS: SANITARY NO. APFLJCATION SUBMITTAL DATE
/OgBS t]21pal/ Ayr, UNIT LOTH
INNERS NAME PHONE: CONTRACTOR'S NAME, LIC NOPu 77q- CZ41 : '`�T_
MA/ 5VL a NIC CONTROL N 1
RCIUTF;CUENGINEER: LIC NO: ADDRESS: ❑
L67Y 7LAERs 2 5,J. cMu
r CONTACT: PHONE Q.n. ELECTRIC PERNUT FEE BUH.DING PERMIT INFO
FJECf PLUMB MECl/
PERMIT ISSUANCE ❑ ❑
LICINSED CONTRACTOR'S DECLARATION APPIJANCES-RESIDFNI'IAL
py.Z Ibmchy of rmO.tlem titan#uMer poviaomofCh.pur9(comme ing wlN JOB DESCRIPTION
�00,W E[ S-fulltimforce emi of Diriaimn 3 M the Bmirte,and Pmfemivns caee,and my Plane u in PANELS
<Z, License, hM cRcct. Lic.If UPT0200AMPS
FZw Dire Cts., Cm
may
Dire C waw 201-1000 AMPS
zcy— ARCHITECTS DECLARATION OVER 1000 AMPS �'�'� �� Q.PT.—
OZ—MO ImWcn,sW my plao,.hall W bad m public mcord,.
F rn t W I SIGNS ELF.C"IRIGV.
aWuanmd Prorm,im�W
K� OWNER-BUILDER DECLARATION SPECW.CIRCUMMLSC.
XO FV. 1 hereby nffrm that 1 an,exempt from the Contractor'.Liceme Law Enc
w3arGi, fNbwing re...... (Section]031.5,BusinesaM%ofaiom Cale:Any city or emumY TEMP.METER OR POLE INST.
which require,.permit to mnnruer,alter,improve,xmoli.h,or repair any nmtpum
Ft2r7 pmi-to its i.v ,also requires thc.pplicaru forosch Perron W file a,igaed sumenect POWER DEVICES
�%<o that lie,m licensed pmu.mm,be(revi,imbd the Contractor',Liceve Ltw(CTapier
aXs 2' Y(cwwmciny wiN Batten]000)MDivision 3«de Basin "Pmfevdmu Cale) SWIMMING POOL PLECPRIC VALVA,,
W'9_'tn -that,he is exempt therefmn ard,he bvai,fm de alkyed escmption.Any.idauon of OVII,EIS-SWI'T'CHES-FIXII)RFS 1^ _ ((���'�
,Z< Section 7031.5 by my aWlicam for a pmmt mbjcv the apdicism m a evil penalty of
me mire date five hundred Mlms($500). NEW RESIDENTIAL H.ECfR SQ.FT. 111 �rrAAWNN
ElI,a,own of,hepmpcny,mmyemployeeswithw.gmmtl:'v,ok pen , STORIES TYPECON.SRUC110N
a3— wmMde w«t..ndtne,wc,urti.to,intmdmaotferm toemle(sen.]oa4.ebatc,
OCI
mrd Pmfessimu cox:The Contract«.IJ^"••Ww does rte apply w an w-s or
IeoPeny wit W dale-imrravmmermr,,ane wl,oeaes.-n was nimmratl,ra,gn nit n
m,ptoya,,Pmvixd Nv.ahimpmvmenDartnxin,etdvlaMfertd fasele.If, 'I f\ r ROU y^ I
rowe.er,,newuain{a intPm�en�ti,>ow wiaina.e yr,.ofc«mpletw,,browneTOI L: � � Ill N
Mui Wcr will have the bunko of proving Nat h<tud m,bWIJ a imlassve far purpme of
r�
El Lavowner oftM pm,ery.unexclusively comes,"with licensed canda4m to QT' PLOMBING PERMIT FE VOCpz MI! APN 2
cat,trum the Prt(Sec.7014,Bbvnesa.rd Pmresuve Code:)The Cmoeer«s
Lcenw lawdoesnor•Pplywo owncrofpopmywMb Wsmum vatM1emn,.rd PERMIT ISSUANCE
who contrera,fasuch projectswithitconeYlo .)ranted Purwann to the Contract«a
Lice.Law. ALTER-BRAIN A VENT-WA'IFR(E u—m—m#1ky
❑ I am exempt uMa Sec. ,B k P C fm this,newer
BACK FLOW PROTECT.UF.VICIi SANITARY Y N
Owner Dec RECEIPT N
DRAINS FLOOR,ROOF,AREA,CONU.
WORKMAN COMPENSATION of ONem to seRATION SCHOOL TAX Y N
orkm.'Com,f onlmmv a oNrrauof counhermf(imbrt.a.ani.)wteof FlXTURCS-PER TRAP RECEIPT#
Wakerv'Comrmsmlon lnwarse ore anifiM copy thereo[(Sec.3g00.lab C.)whiN PARK FEE Y N
coven.11 m,ploye<'t uMer Ni.permit 135'7341 GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
party N BUILDING DIVISION FEES
rC N GAS-EA.SYSTEM ER-OV4(EA) PLANCHECK FEE
�irea nary Hnewrrm,d.l,w.
CmifiW copy is flcd with the,airy inspection division. GREASEANDUSf1U,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FJ(EMP TION FROM WORKERS' GRE.ASE'RtAP SOILS PEE
COMPENSATION INSURANCE
[13dssection sed rel W cmtpleud ifdc permit is fm arc hueNed dollm(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
car J
I ccnJYthou in the perfomtuee of Ne wool,f-which,this permit is is.ua I shall WATER HATER WNENPQELECTR
out employ any prawn in any manner w as to caerie subject to the Waken' PAID
C-npao.tion fawn o(Califmrtia Date WATER SYSTIE?4IREATNG Due Receipt O APpli.
Z
NOT[CETOAPPLICA :lf,ewmaking Nit Cenlflare of EaenWti-4ywahoW NEW RESIDENTIAL PLMB. SQ.FT. TOTAL
(/] becarcaubjcct,o de,Wake,Compmenian mviii.a the Latin,Cole,yw oma
> tathwith contply with,uch povi,imu car,N,permit that]be dxn,ed rooked. BUILDING FEE �.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a csm uaon Rrding all bar the,pa(arratxs of
U O tic work for whichBit,pemut la lmued(Sec.30 q],Civ.C) TOTAL: ELECTRIC FEE
lodes Neste fFE
F LcomA Adore_,. QTY. MECIIANICAL PERMIT FEE PLUMBING
U 1 testify don 1 Mvc mad,his algravim and.thatthe most,Information is
axrecllagrc to comply with.11dry.rd coamty mwtatr«,.md sone Wws rtladnem PFR,11 ISSUANCE MECHANICAL FEE
Wilding c-vtrvction.eM hereby audentercpresenudves ofthis city toemeropon do CONSTRUCTION TAX
() Z adtvemmb.dpmpmyf Inspection PurPe"c" ALTER OR ADD TO MECH.
(We)-pecm. ,e.i Hy andw, de,City of Cupmioo agromax
Ii.bilities,judgment,,c dcx yinanywayecmuagWw,.WCity AIN HANDLING UNIT(TO 10.000 CFM)
W cunxq 'ns of W'
AIR HANDLING UNIT(OVER 10,00(CFM)
S' aim u( ppi eau E%IIAUST IIOOU(W/DUCI'1
PAID
IIA 2A to.No Mint, AIS DISCLOSURE
IIF,VDNG UNIT(M 10(.0)0 BTU) Dau ReccigN
Will the,the Co,erin future loon l C tcspam awe m herdle havrdau d S sial
as def meal by the Cupertino Municipal CaW,Chep,a 9.13,and the Ilolth and Safety IIFJ.TINO UND'(OVER 100.000 BLU) TOTAL:
Cale,Bandon 25532(.)'1 VENTILATION FAN(SINGLE RTSID)
❑Yu ❑No
ISSUANCE DATE
Will the arplicam mfwae Wildin acu rove tooJevicawhich emit BOILER"COMP(JIiP OR 11p,IX10 BTU)
g pan Area Air
• ha vdwn air muaminenn m xf d by de Bay Area Air Quaky MuWcmenr
BOILER-COMP(OVER IW.WO BTU)
Dimmest
11 Y. ❑No NEW RFSIDENfIAL MP.CH. SQ.FT. A to
I Luvc retail the hnvNom maenals rcquiretrcnts urda Barter 6.95 of the I/I��O
California HealthASafdy Code.Sections 25505,Z5533 en
5505,25533 d 25534. 1wJcrvtaN that V/� ���
if Be,Wilding does not currently haven 1.dot it u mY tmpomibility to tuufy the „ A
oau,im,of the rtgbirecom.whleh crmt he met nor to mumu-of a CcruGwu err 4
occupancy. YUh Lf,
,None,-.uthonzW Byrn, Dam TOTAL ISSUED BY: "�
OFFICE