25958 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOX9 5 tl.11'DINC�'L. A MIT NO.
BUILDING DIVISION
APPIACATION/PERMIT PLUMBING-MECHANICAL. 8
BUILDING PROJECT IDF.N IFICAI']ON L J J J
BUILDINGAD ESSSS{�/ SANITARY NO. APfl.ICAIION SUtlMTITAL DATE
UNITN LOT1
' Rg NATORSNML
CTAOR�SA
1rCN d-rLTI` Y �p.� NIC CONIROLI
ARt
HITS( /ENGINEER: LIC NO: Sqq':�����
YC'o .5llt)jQcyye„� l/w(i BLw��#/fi9 El
CONTACT: PHONL
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE FQ
LICENSED CONI tuader R'S DECLARATION APPLIANCES-RLSIDENMI, JOB DESCRIPTION
p00 Thereby of nnivion 3 of the
eduMerpovlsiovica,Code,said any lining wish
�sf00 Secdonl0oidefe,'.C.t3ef the Businecs or,d Prufe.vions Gwlr.said myliamc is in PANELS
Lich farccCW cRccl./r �N n UP T02W AMPS
y Q c !2—11 T Canwc ur dY 201-1000 AMPS
F '' —AARRCIITITCTS DT:CLAItA'ITON OVER IhB0AMP5 SQ.FT.FLOOR AREA $/SQ.IT.
FO=W ;Ivioncruesid mypWs.hNl4 usW mpuhlic recarl.
SIGNS ELECTRICAL L IN
2��a Li emcd lhofcuinnel OWNER-BUILDER DECLARATION SPECIALCIRCUIT/h11SC.
xI hereby of ndi that I am exempt from License Law Corboodol.Liclaw fa the P
W 3 LL ti following rmson.(Section I0313,Burim nsoon Profeeiwe Code:Any city a M
county TEP.METER OR POLE INST. �p-
ER
t E°5 which rtqulrca a pvrnit to c.unuct..her,impore,d mol h,a riptide vny urvnwe DATE Z
KW prior to irx iuuance,also ieyuires theowlirnnt for such Peemit to file.shoed starrnloh POWER DEVICES
wcOs diu he is licen.ed purwant to the leovuiau of tM1c ConOxtcYe Linens taw(Clreptc
p
% SWIMMING POOL ELECTRIC
F: LL 9(ca wiMwhh Sectiiml0m)ofNvision3of0 Bu6,m Prafr ion CMI VALUATION
n'_9',, -shat he isexernpt therefrom turd the b¢sisfa the alleged exemption Any violation of
tKQ Sect on 7031.5 hY en,ap(dinin,fore pemdtsubjecb the applicant to.civil Pvulry of OUTLETS-SWITCHES-FlXIURPS
SSSSSS trnarethm,fvchun,M1M dcoll.(SSW). NEW RESIDFNTIR _
LAI.ELECSQ.ET.
� p m❑ I,ssowieroOhepropcny,.mycmployca with wager mthrirsdeeompem.tion, URI1 TYPECONSTRUCTION
a will JoPoifi work,Cole: heCa curoa.Liec aMf does s.k(Sec.ID 14,Busii,a
and etty w1vioboa.ldsor The vm Barco', nd who Lew don cot appy to N owriv M
propuo ayeiildsa imlmvsu ch icon,and who dues such work hien credthrough hu
wvon vrrploy¢sildin, WdW sucM1im is sold ithinn sue neyot esr.NmnHncd tbe.fievricle.B, ROMP R
bowevn,die sve buildin, Iono ofprrcntiswone," otb)w of caPsove herin,de ow of
bdildn will ure pe burden of proving that he did rd build a Improve far puryox M TOTAL:
we.L QTY. PLUMBING PERMIT FEE FL D r. APN
❑ Iuct the er Mthe Aape W,Business
wid,lits)The anact.nm
Uv aoun the project p4y omo Busiofp sold y Mesdom Cade:)The Con suis
whocelawdaa och lonYtoenowriicarn. tttyaMWl foroanprova Craton,,and PERMIT ISSUANCE
when.1'..fmvuchpmlrcuwiih.c,mveetor(sl hrenmlpunuvnito Nr CwYrectds ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
license law.
❑ I.mtrampuntefSec. ,B&PCfor,hisreaxm BACK FLOW PROTECT.DEVICEOWSIVE FEES
SANITARY YN
Thee, fy¢ DRAINS-n.00R,ROOF.ARFA,COND. RLCEIPfN
n WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ilertby a(Mn1Katl Nve aceedfu¢of ean.cnt to wlf-insurt.aettnifintc of RECEIPT#
FlJCfIIRES-PFR TRAP
Wa,tui Camhlyee inlfeunnttcannic fon copy thveof(Sec.Jgm,lsb C.)which PARK FEE Y N
oven all empinyas under,his prnnic GAS-EA.SYSTEM-1 INC.4 OUTLETS REEF
Policy N BUILDING DIVISION
FEES
C' Y
d. GAS-EA.SYSTEM-OVER 4 TA) PLANCHIi FEE
CcnifM coPY is M1crcby fumishc
❑ Cenif.l copy i.fled with the city inspection division. GREASP/INDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
This section reM not he mnryhetN iftic permit u(orale hw,dreel dollars(SIM) SKIVER-SANITARY-STORM EA.2MF1'. ENERGY FTE
encu.)
I cenify that inthe pc,fannnaofde wont for which do,pninit is lassoed.I shell WATER HEATER W/VENTXLECTR
not empby any Person in any riw,n<r ser ea to lemme subject to he Wakm' PAID
O z ^imspe ionlaw.of Cdifumu. Date WATER SYS1EMl1RFiSTTNG lyre Rceeipt0
PP
Z 0 NOTICE TO APPLICANT:If,after making thin Cerd f to of Exuapion.you sFauld NEW RFSI DENTIAL PLMB. SQ.FT. 'IOI'AL
/) boon,subject to O,eW.kn'sCanlcnssoion provib
o.of he labor C ,you mu.s,
C4 > fonfai,A comply with wrh Tvwisiara or thu Permit shall be decried revoked. BUILDING FEE
Uj �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) Z1 Meby Jfirm the,there is a nmuroction Lending agc.,for dic Pcrfmunce of
1..1 O pie work fm which this penmt is iscurd(See.3091.Civ.C) TOTAL_ ELECTRIC FEE
Lef.a None PLUMBING FEE
0 F Ledo,Addreu QTY. MECHANICAL PERMIT FEE
V I cerify hon 1 hove,evd this application nM sale thin the.hove information is
correct.l.occroromply with all city sod c.mry oNinameeM son¢leas mluingm PERMIT ISSUANCE MECHANICAL FEE
,t buildingconso.don.and hereby wdiadve rtprov,Wivn Mthisciry toenterupan the CONSTRUCTIONTAX
(� Zobum
ve- entioned piopeny for itupectioa purposes. ALTERORADDTOMECII.
(We)vtirecto save,indemnify and kecp harmless the City of Cupnfm agama
IUGBtiec,judgmenu,cosissoxf expmsex whkh my ip.ny way niagaiml said City AIR HANDLING UNIT 0 10,LGO CFM)
to cocof de dngof Nis it.
/�/, AIR HANDLING UNIT(OVER I U."CFM)
Simuce of Applicmn/Carametar Dole EXIIAUS HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE IIFATING UNIT(TO Im,000 BTII) Was ReccipN
W ill the.pplicont a fah.huiding occugW scare ne hudle ha anl.n rvterial HEATING UNIT(OVER I W,LUO BTU) TOTAL:
m dcfired by 1M1c Cupertino Municipal Code,Chapter 9.1;.rid,k Health end Safety
Cade,Section 255J2(e)^
❑Yet El No VENTILATION FAN(SINGLE RESID)
Will he.pplicontafuwm onddiiig.nupant usccquipncnt-device wM1ichemlt ROILER-COMP(3HP OR IMJXW BTU) ISSUANCE DATE
M1vvdaua air eanamln.ma as defined by the B.y Arca Air Quality Muwganent BOILER-COMP(OVER IM."BTU) II]
�• Di:,nn'!
❑Y. ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have reed the hesardws maemals myulreinenb undue,Cheper 6.95 of theDEC 11993
Cafif.nia Hicahh&Safety Code,Code,Seetio35505.25533 end 25534. I undttvW lAN
if the holding Jaes not currnuly hove•tenant.Ihso it is on,responsibility b,unify the y ���
occuleam of,M rcyuirnrcmv which inion he met pna m isswnee of s Certifate of - CI IY Ur ,,U,J..��1
Occupux5t Jr..`J�J
Owiwrir author�agrnt Due I ISSUED BY:
Tow• 1
OFFICE