25669 APPLICANT TOFILL IN INFORM }TON WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -ELR�TCAL ""MITNO� 2 5 6 6 9
PLUMBING-MECHANICAL.
APP: (CATION/PERMIT
BUILDING DIVISION _ BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRPSS: SANUARY NO. APPLICA'1^10N SUBMOTALDATE
UNITY LOT*
Lo-L�Q
IBtS N`N,E,: PHONE: CONTRA NA C: LIC NO: l•/
CONHtOL♦
CIIITECT/FIJGINEEFER:R: w LIC NO: RES: El
CONTACT: PHONE; QTY. ELECTRIC PERMIT / FEE BUILDING PERMIT INFO
PERMIT ISSUANCE BLDG EEC P UMB M1fE
CH
ly El 1:1 El
LIC GI IM mnlrc 'IRACfOR'SDECof Chsser ON pppL1ANCES-RFSIDEMIAL TOB DESCRIPTION
yO� modem hoo,isions;
SSeerfull Rcc porde atvtaaonl 3 oflMH imcas ud Professions Cori,9and my)if.inn PANELS n
IF< gnac.,, LiClw Lk.Y UPT0300AMPS
n'y Nit Canmctm XII K()OAMPS
Z�N> ARCHIT'ECT'S DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA S/SQ.FT.
O Z- a l undcnumd my plus shau be wad er public ra«dn
G y F w SIGNS ELECTRICAL
Qy$:j LcemhJ Podession.l
ceayce:6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
fxxy 06 F 1 lereby�that I tort esem t fain the Co.'.Lhxme taw for dre
so
W 3 i ¢ following rtewm.(Sadao 7031.5.Baaiw.end Pmfasima Code:Any city«awry TEMP.METER OR POLE INST.
which mquim a pc mit to comfort,otter.improve,demolw,or repair""lo etre
a� prior to its1.nuance,also rryuites the app)'•,^•for such permit to fit.sigll.' PDWFA DEVICES
µ1C0 mist he it lircnsca'morntmtM pmvisim.oft Cmtr.mor'.Licrnu Law(Chepbm
Y4 9(romecing withSabort 7")of Division 3 Nthe Bminm word Pmfmimos Cole) SWIMMING POOL ELECTRIC ^ VALUA]'IQ(♦L_
or that be ise.emp therefrom and the buisfor the alleged cscmpAny y videtim of OI1TlElS-SWUCIIPS-Fl%TURES 2
Fla Seotim'1031.5 by any eppli,mo for. mnitsubjecu the ep,lionntma civil penalty of
metre ttw f ere hurdrM Jdlus(SS(M]).
aE0 I.vownerofthe NEN'RPSIDINIlAL F1ECfR _SQ.FT. •
p.apmy,«mycmoPlnymwithwegmvtM'veokrompm•orlon, RIPS TYYI: O U(7IION
a3 r dnlM
it dr matMeo-unmei.rwt weweaaearrer,d r«aek(sa.T0g4,Bavlhem
erre m.Cox:the c«waaa.u�.,e law aaa ort appy m.,aw,er or
pgerty wmbaux«imrmpove.thuma,n,end was"M,surf w«khinnelmtmm�ugnni.
howevempoyae.pmvixdth.te'uchlmpmvemenuame«rtintarxdmMfined!«sale.U, OCC.GROUP RFS.UNITS
er,
the building«improvement Is sola within me y...Mcompletim,the.weer-
buikor wif I Mere the burden of proving(het he did Mn hill or improve for purpme of TOTAL:
sale). QTY. PLUMBING PERMIT FEE FL DZONE APN
❑ I.tiowrcrjec,(Solsrty.une.aior.ivelyconobersg Coco,) The,Ctmetml'.
n.tr r tnr proiat eser.'llwa.Bu.ine.a wM Pmreeeimr.code:)'1he crnuaet«a
Liar UwdmmtaWyto.new ofpolmywbobuiW.ortmprovc drere«n,aM PERMIT ISS C NO
whwawf.en forsoch penials with a cmts.cloo D)licrosea pursuant to the Confator s
Liccn.c law. ALTER-D I & If-INAt ) FEE SUMMARY
❑ 1 em exemq order Sec. .B&P C fm this maven BACK Fl,O D F
SANITARY YN
Tm rOwher n" DRAINS-FLOG EA,Cf RF.CF,IIT
1 WORKMAN COMPENSATION DECI.ARAIION ZOO TAX V N
} f❑ IhmebyaRrm thellharcacenifirate of CglSGlt to slf-imurt,m.cenlleate of �'" RECEIPT0
y WosA. omp ora huufmce or.ocrifeop
d cy dnmf(Sa.3M,lab C)which FlKN y_PBR RAP — KFEE Y N
1.—41 empdoexe.under this permit. GAS-EA.SYSI1?M-1 INC.4 OUTLETS RECEIPT#
Pulley IfBUILDING DIVISION FEES
Company GAS-G.SYSTEM-0VER 4(EA) PLANCHECK FIE
❑ Cenifiedmpy i.bercbyfumishW.
❑ Cer iBad copy is fled with the city my omsr division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EKEWTON FROM WORKERS' GREASETTAP SODS FEE
COMPENSATION INSURANCE
(Mds satin heed ort be c«npleted iflhe permit u for me hmdrtd ddlws($Iw) SEWER-SANITARY-STORM EA.2(s)FT. ENERGY FEE
or lm)
Icertify dint in the perforromsee ofthe wart for which Ni pernot is iswc ,I s l WATER HEATER WNFM/ELECIR
nus employ any perm u my fwna to u to Mmhe.ubjat to the Workeri PAID
0 z CAomm.d
peonlawsofGffohmi Due WATER SYSI'EM/IRPATING 0. RcaipY
ppBcw R
O NOTICE TO APPLICANT:If,after forking this Certificate M Exemption,you should NEW RESIDENT IAL PLMB, SQ.IT. TOTAL
(/] ahs-,subject to the Worker'.Cmnpvaxdon p.aviai«u M the labor Code.yea mmw
� > fsthwith omnMY with mch(romests or thu pamR.IWl W sand revoked. BUILDING FFP.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby aff.that theme is a cohh er mn Imding.gency for the perfornwce of
U O Ino work for which this permit is i.v.ued(Ser.3IN7.Civ.C) TOTAL FJ.ECTRIC FTE
D.. lender'.N.
1< .Amfinea QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify thu I lore meed this appliutim aM woe dor the.bore urf«mutiort i.
cenat.I.pxbromPly with all city sod county mdirmsu and Nle law.renin,m PERMIT ISSUANCE. MECHANICALFFF-
f•-' building cmsuumic ,.nd hemby roffimnemerrmsrnralives ami.city to emerupon the CONSTRUCTION TAX
U Z above-mend damproperty for inspecdon puryma. ALTER OR ADD TO MEC'H.
(We).gree to..ve,iMcmnify W kap hermlms tk City of Cupertimro.gums
liabilities,judgmcnu,cu mdcepenseswhi m.ylnmywaym:cmc.yuw.mid City AIR HANDLING UNIT(TO I0,000CFM)
In mnsc9 M of
ZS AIR HANDLING UNIT(OVIiR 10,100 CFM)
ngwurt of Applicant/Cmtrutv Umo E%HAUST HOOD(W/DUCn
PAN
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I (),000 BTU) Due RaeipY
Will the"If.,or fume buildlns coculrant nor,or lumdle hsur romerml
av defrnd by the Cupen lno Municipal Cade,Chapter 9.12,end IM Ik.hh and Safmy HEATING ON]](OVER IM,000 BTU) TOTAL:
Cade.Salim 25532(01
❑Ya ❑No VENTILATION FAN(SINGLE RPSID)
ISSUANCE DATE
will the.pplicuu or fuuve budding«culwluuequipmmto-xvkeawhicbrmrrit BOILER-COMP(311P OR 100,00)BTU) p� Ya Y
hvatdow it awumiwma a
a cfmd Fifty theFiftyrt.
y AAir Quality Manegennent BOILER-COW(OVER 1(10.000 BTU) tr Y'�
Uislricll
❑Yes ❑No NEW RESIDENUAL MECI I. SQ.FT. OCT 25 1993
1 here rend the hm4mdnu mmedafs rtquimerrrnu under Chaffer 6.95 of the
Califami.Ilultb cit Safety Coat,S,moms 25505,25533 and 355th. I umdmm.md that ? C111 VI k/U
al.
if IM beiding rlo-not cunrntly hove a which,tit 11k my mespmdbility to notify tie
accumt of the megwrtmrnu which mut be mm pn«to comas of.Ccrumc to of
Ocmgwrry.
Owxr a eudwnad.gmt Dome TOTAL: ISSUED BY: