25433 / -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOTMJ-FTECI KICA PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL
25433
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AI'ITJCATIONSUBMITTALDATE
-73� .C�✓+I no r . . C2�3
M .UNITY hUTN
OWNERS NAME: PHONE L _ CONTRACTOR'S NAME LIC NO:
e �:/y Q� NC CONTROL
1R HITECr/FINGINEER: LICNO::/ ADDRESS: ❑
CONTACT: RHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
RRMIT ISSUANCE El F-1 El
LICENSEDCON'IRACTOR'S DECIARATTON APPLIANCES-RESIDENTIAL
00:z Iherchrynflnm tM,Ism lian.ed uoccrpnvuionx fChWer9(cvnmercinp with JOB DESCRIPTION
roc oc Su n emdeRegaslon Softhe Business turd Professnnu Cottle, m,license u in PANELS I ///��� /
FF<..ZW Llceoe CWv Lic.Y UPT0200AMPS ,.I �(„ n „/e/
r�<y Dau Cam nox 201.I"AMPS vv``{�YYY vVW "`LLL /
zoy� ARht0the CTSDPCIARATION _ OVER 1000 AMPS SC. AREA 1;/SQ,FT.
oz-0 lurdmurd mY plgma.0 F= DECLARATION
SIGNS ELECTRICAL
Fy �
_ Licrnscd Profasimul
< OWNER-BUILDER DECLARATION SPECIAL CIRCUUMISC.
O U 1 Meby allirtn thm I am exempt from the Cnnuectar”ua'em e law for the
3 u[—ii following carol.(Smim]031 S.Bu,ines,wd Pmfadm Code:MY city omuntY TEMP.METIER OR POLE INST.
��°� which myulm,npnnitwcmvWcl,eller.iummve,OcnwlW,or repair wy,trucmue C
Woof poor w irs usrcry
use,aho tuirt,the eppliesra f«arcd
h pef, lmrde.ugrtN wutrnt POWER DEVICES
that he ix licenced pumutunt to the pr rvision,of the Cmlmmor's Lice,ue dalaw(Chapter d 9(coruencinB with Secum]000)af Dldarise ardro
sim 3 e BPressimu Ccde) SWIMMING POOL PIECIRIC VA1.UAT1
or thm he is exempt therefrom and the brans for the dkged exemption.MY vidaliam of OUTLETS-SWITCHES.FUTURES
L�'Q Sation]03136y enyhoexi amfoapcmtil aubj¢I Be eppliom wadWl pemlty of
X � no,mac than fixe FwmEM mI Wer NEW RESIDENTIAL ELECTR _SQ.FT.
❑ Lvuwnc.ofde p, t.am of irmoyen wilhwagnaa theril for We(r ca ,Busilim, IFS PE CONSTRUCTION
a3— will mthewart,and lc ,The colmclainlj emxeow closnot apse.to rut wl of
aN Pmfevimu Code:The Cmtfxesx a liana law doe,not apply If r owl is
pmpcnY who builds m Intpmvn thereat and wIw does wch wort hiwelf a through Itis
however.me
or nmverhimpmtold wi are Ila year
mfompReRd for owmer- �GROUI' UFS.UNITS
M1uwevewthebuildingoihm o comes addetJid aneyn,ofcompktim,theowner-
brildcrwill hove the burden of proving Bun he did trot build a improve for plupwe of TOTAL
❑ I,uowrterofBel*Werty,tum excluuvcly convening with lionmdwnarctaaw QTY. PLUMBING PERMIT FEE FLOOD ZONE APIN
uemucl the pmjen(Sec.](144,Bm mu,end Profnvioru"tn;)The Cmvanor's
Liar Lrt.dm not apPly w an of propeny who builds or improves Besot,ami PERMIT ISSUANCE
who cmvecu!«,ltal pojeeu with ere,nonaor(a)lienved punwntwthe Conlnmar', ALTER-DRAIN&VENT-WATER IDO
Litt law. ( FEE SUMMARY
1 un
exempt ludo Sec. ,B&P C for this,coon BACK FLOW PROTECT.DEVICE '
SANITARY Y N
Owner ale— DRAINS-FLOOR,ROOF.AREA,POND. RECEIPT#
W R�' NS 1PENSATIO CLARATTON SCHOOL TAX Y N
❑ Iteuby tuff Bw lM1aveacenlficau ofm emlwdf-imuu.aaartifvuofRP,CEIPTY
Waten'' mnprnsWwrceaacatifidcnpy thctwf(,Scc.38(qFIXTuRF_S.PER TRAP,lab C.)which PARK IEE Y N
ars all employee a undercler his permit GAS-EA.SYSTEMA INC.4 OUTLETS BETEL Y
Policy ss GAS DIVISION Fl;IS
C'rnpany GAS-FA SYSTEM-OVER 4(EAR PIANCHECK FEE
❑ Cenifletl ropy Is Meby funliabed.
❑ CmiBM appy is BIM with the city inxpmim diviaim. GREASFJINDUSH1 WASTE INTERCEPTOR GRADING FEE
CERTIFICATE;OF EXEMPTION FROM WORKERS GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This,cion reed not be eompMd ifthe permit is for ore hundred m11sn($100) SEWER-SANITARY-STORM PA.20(YF, ENERGY IIP
«lay.)
I By thin in Be pnnRomxtes ofde wort for whkb this Permit is ivucd,I shall WATER HEATER W/VENT/ELECHR
not empiny amy person in any m u In become xubjcm w Be WmAcs PAID
Cmtprnmlian laws of Cdiformu. psi m WATER SYSTEM/IRFATING Dau ReaiptY
p z Applies
NOTICE TO APPLICANT:IL saes reeking Bra Certillae of ex TOTAL
'Z empDonht,you NEW RESIDENTIAL FLMB. SQ.Ff.
� [n becameh burnP y the Water's,i mprnutian exon oro oI Be 1aGr eo you roues
5 fuMwithcamplywithsuchpovi,imumtN,pvmh,M1.llbemoneduvoked BUILDING FEE S DD
CONSTRUCTION LENDING AGENCY SEISMIC FEE /1
I hereby a1Tnm duel thcu is a mm�vvalm k g a{erey fo the perramuty of
U p the wort fa which thix permit i,iuued(See.309],Civ.C.) TOTAL' ELECTRIC IEE
Lh. Iffier',Name
O Leder',Adorns QTY. MECI IANICAL PER MIT FEE PLUMBING FEE:
I ccnify thm 1 have reed Nu applicsmoo ed swe But the above iN«nudm hi
correct. lagree.to mnpay with Al ary and evumty orchro ees and gene laws Meting to PE1tW7 ISSUANCE. MECUANICALFFE
I-' ,l building convrucBun,ext heocby aul of repeecnuBv®ofthis city to enter upon the CONSTRUCTION TAN
C] Z above-mennimned popu,y fa impcction p,vpaa ALTERt OR ADD TO MECI.
(We)agree w vertu,Imdmylify end keep hamilexx the City of Cupe ret al l
liabilimn,ju w -e prnowhich mtvyin any way accrue agaie.t vidCry AIR HANDLING UNIT CFO 10.000 CFM)
Be (Mia permit.
1 m AIR HANDLING UNIT(OVER 10.000 CFM)
morn 'er pte EXHAUnHOOD(W/DUQ)
PAID
HA9,ARDOUS MATERIALS DISCLOSURE HEATING UNIT('IT)100,000 BTU) Dne Rcceip N
Will Be appli.t or fmwe buildingaaupsmstere or hudle lurardotn material (HEATING UNIT(OVER 100,00(1 BTU) IOTA
u defiuN by the Cupertino Municipal Code,Chapter 9.12,emd the Herrin ard S cty
Code.Section 25532(o)t
Dy. ❑No VENTILATION FAN(SINGLE RFSID)
WBlthcapplicamafuuu WBdmgoccupsntuse egdlunerllmdcnmwhichmdt BOILER-COW(3HP OR IW.000 BTU) IWAACf IOTE
bacx a,nor co mmimm,n deloed by the Bey A.Air Quality Mtmo emeat BORER-COW(OVER 100.000 BTU) /��{ IO
Minn.? Q
❑Ye, ❑No NEW RISIDEN'DAL MECH. 1
SQ.Fr. AUG — 9 993
1 hove rind Nt hsrnmua rmtcrida raryire ems ludo Ctupter 6.93 of Be /� b /�
Calunmin Ilcmlh&Safety CoJr.SoBum 25505.25513 and n53t, lunleraumd that yll I V� \iVYcn111vV
if Be budding dors not currently have a e,wn,thm 1t u my reap.vibiliiy w notify Ne
occupant of the rcyui—enu which mmt M mm poor w ivumee of o Certificate of
Owner or uutMnral egrnt Pau TOTAL ISSUED BY:
'i M1.L._� ? o � m v � �, � N• 2. m �.2' r�__� � j �a t � - - .�_-i_ __i -.__.=1=L_. __
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