25693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING MF.C'HANI RICAL PERMIT NO.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 2 5 6 9 3
BUILD6 j$DD$ISS �^Yu �� _ uA,Kl�,cl SANITARY NO. APRJCATIONSSUU/BMfITALDATE
�f 44 1. �rOO VV a�� (_'1_/1Y W✓ON]T# IAT"
O NERSNAME {..N PHONE CO R'S NA B: LUNG: N/C CONTROL
RCUITECTIEN
M '
A^yTI� INEFJI LICNIADDRF 5: I ❑
COM'ACT: I PHONE QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
'¢kv,T) Swim �Z 7-"v ECf UMH MNCII
!l PFAMIT ISSUANCE
LICLNSED CONTRACTORS DECLARATION AL'PI.IAN(ZES-RESIDENTIAL
GCZ Iberrehy.Rrm that l em liecmcE order pmvisiams of CTeper9(cotmncrrcing with - JOIVDESCRIMDON
+f-10y10 Section]000)of DivWm 3 of the Bmimisand Profeed.Code,sed my liccrs is in PANELS �O ��
sy'U� full fnrm mrd cff«I
cG.GW I;ame LoLe�$5Sl8 uProxroAMPS
y6d Ihte Connr. ({.5 201-1000AMPS
FO-Z HITF.CTSD ON �S .h1G S/SQ .
mY allWwedmpobBcrtm OVER IMMAPS
OZ—D
3
QNyE� Ixcns SIGNS PT RCIRICAL
d yvt M o OWNER-BUILDER DECfARATION SPECIAL CIRCUTDMISC.
O a I... I Mneby eff ter I.m caemlrt fmm the Cnnvectds Licosa Law for the
W�i LL♦n fullowirp noon.(Salim T0313,Budin,arad Pwfnuas Cotic:Any city Q county TEMP.Ml?IPR O0.PoIE INST. c C/
wh sch Tey mrn r Permit to rnwriet.Wier.improve,Jrnnth,on reMkmy auctae
Priam is imwme.d.w rtyuiss thespplinnt for lamb perndOo File.signal simmmn POWER DEVICES
<0 that he is lieconsed purvunr to the parmal of the Conhecter's Lkvrs Law Chorister
n— 9(commrning wit S«tiun)0(NI)of Divisim 3 of the Bmineta.M Rofessiau Code) SWIMMING POOL FLECIRIC AL A
ear that he ueamtpl therefrom sand the bmia for the Jkgetl marrytbn.Any violuim of OVHPfS-SWITCHES-FIXTURES
�7¢ Sectim]031.5bymysppliumtfar apermlt.ubjeces the sf,dic.nt to.civil pvWry of
e roma ilia five WrWeil dollen NEW RFSIDFMIAL FlECfR _SQ.FT.
C��o ❑ I.mawrcofthe pmpcny,amyemployenwithwegesmtheirsdecmnpmnion, STORIES TYPE CONSTRUCTION
B:°2 will drill work,mal trestmuurcie rot intended oroffcrtd fors.k(Ses,711,Busies �� ��
errd Prof.Code;Tic Connects Dame Law don not apply m en owner of �_
p,Werty w W W ills err impmvu 0rrton..M w W don sacM1 woh hirmelforrtuovphhis -� NI
own cmpbym,pMed that such improvmens erre not imed m
cndofferW fasele If, � I Z
Msvever,rte WllJingaimpovernanuwld within one ycuofcmnpluion.Jrc owe-
huiber will have the W Nen of paving that he did tw W ild m improve fo puryos of J I�\��
sde.).
❑ 1,n<owrrerofthc prrperty,.m cxclu.ively mnvecf gwit liceesedconv.elanto QTY. PLUMBING PERMITFEE TE hLOO APN
antmnl the pnject(Sec.]Ofd,Basin—turd Profenim,CW,:)The Co ',
PERMIT ISSUANCE
Lic Lits donna.pplymwowmed"riW
pertywWilda
s impovn dvcm,voad
wMr—.1 Lrrmch Prnrk v wit a wntractur(s)Inemed Punuanuotse CmvwtmS
Vn�Vw, ALTF,R-DRAIN&VENT-WATI:R(FA) r FEE SUMMARY
❑ 1 wn eauryn umk Sec. ,B&P C fa tis rtvan BACK FLOW PROTECT.DEVICEi
SANITARY Y N
^l Owner Due RECF.IPI'tl
f DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION DRAINS
TAX Y N
❑ I hereby a t.tet l heves eenif tc ofconsnt to sIf-insure,ora cenifime of RECEIPTtl
Waken'CampvLution Imuovoee«. ed FlXTVRES-PER TRAP
mPy therrof(S«.3600.L.b C.)which PARK FELE YN
clem,oil employeeM
',ucr Its,PemtiL GAS-EA.SYSTEM-)INC.♦OUTLETS
RECEI Y
Pdiryl at BUILDING DIVIVON FEES
Company s GAS-EA.SYSTEM-0VER 4 WA) PLANCHECKF -
❑ Certifedcopyfshmoryfumishol.
�Cenified copy is filed wit the city iwpectm division. GREASPIINDUSTRL WASTE INTERCEPTOR GRADING FET:
CERTIFICATE OF EXIZMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This scmim tell nm be completed ifibe Permit or for me hmdrul dollars($100) SEWER-SANITARY-STORM EA.300FT. FltERGY FEE
ark )
I cenify tbu in the perfanunee ofthe work fm which thi.pvmil uiswW,lshell WATER IIEATER W/YENT/EECIR -
oat empby my Porsvn b any menrecr w as to became subject to to Worl PAID
Comtpcnsuimlrwsof C.lifani& Due WATER SYSfFaf(fRFATINGetc Receipt#
OO NOTICE TO APPLICANT:IL.Icer making that Certifrote of Eaempim,you.twuW N2W RESIDENTIAL PLSIB. SQ.FT.
r/] buomcsubject to the Wast ICompm.Wn Provisions M the lsbor Code.Ym mus BUILD �#
foMwith comply with ach Provisions or this permit shell be d«rncl reverted.
0. Q CONSTRUCTION LENDING AGENCY SMSSIC
Z) Z I hereby.ffinn Out done is a mnlvumm lending Uma,for tc performat of
ted work for which this Permit is Issued(See.309],Civ.C.) ELECTRIC FFJ:
i," Lender',None
• F Lerdc tAddress QTY. MECHANICAL PERMIT FEE PLUMBING `.
CJ I cenify the I hove rud this epplintion Nd same that to above infamedm II
>" Du. concn.l.gt«mcanply who sillnty.M camty ardin.naa end stuc6w rtluingb PERMIT ISSUANCE MECIIANIC FEE
F-'
0.
Wilding mmtrunim,.nd M1arby.uthoire oeprsertunves aftis city mpon t
enter uc CONSTRUCIt #TAX
L) Z ubose-mentioned property her inapunim pur{msu. ALTIIR OR ADD TO MECH.
(w ree m nso ivaemrdry surd keep Cry of Cupenirw.g.imt
Bath n,j Prnseswhicbrreymmyway .=std City AIRHANDLINGUNIT(T0IL"CFM)
in artlegrm Ws Permit.
-T^ M AIR HANDLING UNIT(0V 10,000CFM)
Sigw of ri5r. matnm vDuD e EXHAUST HOOD(WIDUC
PAID
HA]ARDOUS MATFRIAIS DISCLOSURE HEATING UNIT(M 100,M)BTI!) Uarc RaxIN♦
7�Wi0 tc.pplic.nt on fmure Wilding ncculsnt.msn as b ill.hvardou,metvial
u.defined by the Cupertino MuniciWl Code.Chapter 9.12,all Bre Hiss th road Safety 111iA1'INC UNIT(OVER TO."BTU)
Cade.S«tion yetis ❑No
e)?
Tn
❑ VEbITILAT'ION FAN(SING LE RFSID)
W,11 me.lvnrntarame baidingaaannt usyaipmmt«aevades wM1icnrndl
BOILER-COMP(3HP OR 10o,000 BN) ISSUAN DATE
m1 u,di comborm.m dcnncd by the Bay Arae Ali Quality Musgeirsom
BOILER-COMP(OVER 100,000 BTU)
ne11 P A I D
❑Yw ❑No NEW RESIDEMIAI.MECH. SQ.Irl'.
I Isve sed the hvvdoua materiels myuimtenD under Cbsper 6.95 of the �OV 9 O 1�n/gw�'^
r
e Wier I lmlt&Sefery Cao.Section em,th?Ss3J ami 2553x. 1 urderuud tht .MN�e rnia irrgdaa Wit Wert'Cdehvvecres n55.lh6mYmpmeibililY tonotifyhaa �IVYIJIme spat of t e rcgairtmens which mus be.1 prion to usuaoec of.Cmifrmte of,pneY, CBy ,er a wthmveJ agent Due TOTAL: ISSUED BY
0