24536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- .0 ICA PFJWITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24536
BUILDING DI VISIUN BUILDING PROJECT'IDPNTHICAI'[ON
BUILDING ADDRESS: SANITARY NO. APFLIIONSUBMIffALDATE
Sao "2 -` UNRN OTI C T
,�-OW SNAME: ,/J PHONE: CONTRA OR'S NAME: LICNO:
S, p�s NIC CONTROL
II CT/PNGINEER: UGi`�'�KO LIC NO ADDRESS
^ lA/ ❑
Yr
CONTACT: PIIONe: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT UMB MECII
PERMIT ISSUANCE 0 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENIAL
p�.lIyZ Thereby affirm pmt l�licrnud under poromws of Chaper9(comnwcing with TOB DESERT ION
y�F CJO full force uvl elfec�wisirm Jnf the Bmiraas um114nfcxvinnnCNc,and mYli«nseis in PANELS n
License Class, Lb.0 UP TO 200 AMPS \ ,\ I,
+n,6'y Dunt Gmtmdnr 201 1001AMT5 �J
FON_ ARCHf1ECTS DECLARATION OVER 1000AMPS SQ.Ff.FLOOR AREA f/SQ.FT.
OZ—p I molerstard my phora shall be uxd as public record.. fS II
SIGNSELECIRICA
6 f.J Li«nscd Pmfcaioml
Q OWNER-BUILDER DECLARATION SPIiC1ALCIRCUIT SC.
pX.
CE F� I hachy.fr roar 1 am coax t from me C..-.Liccrme Lew f«the �
W3LLUj following renorr.(Section 10313,Budoes,and Professiau Code:Anycity ucamty TEMP.METER .
OR 1
which ma,airo a permit to consermH,alter,imp ova, disM1,« our any oniclarc
`t2>5 Priorhr its ianrnrrcc.elsotryu'va 0e cpplic�nt foramen pertain,file amgnedutae
scat POWER DEVICES DA
TO that he is licemmnsN par.to the parvumrm of the Contractus License Law(Cbeper SWIMMING PDOL ELECTRIC
W 9(ona.ring with Sas6M1
17(M).f Dlvlsiuthe r 3 of Business.ml Profai—Code) VALUATION
'4_',� mthat he is enema thaefmm and the Wsis f«the alleged eaempioo.My violation of OUTI.eI'S-SW'RCIIPS-IT
36 Saremn70313 by.ny applicant far•prmil anbjecm the a,flicamor a civil lzrally of
not neac ilwn fisc hundred dollar(560().
C G NEW RESIDIMTAL ELF SQ. STORIES TYPE CONSfRUCIi
❑ I,vowttrrof the PoR^y.«myemdnymwith wages uthdrwlecvmpemetim.
u3— iB&the wmk,and Oa oosome is On mendcd«nffertd f«sdelSec.70,1THusineas
and Oufee,ions Cnde:Tic Conunchr,s heave"w docs rot apply or an owner of
poperty wh,buildsa imprwnprermn,ard worries stadt work himself«threm lb his
ownrnaployaa,pmvidcd that aach imprmvetncnts are nm intended or offered forsale.If, I OCC.DROOP RES.UNITS
however,the building«impuvement is sold within me ycuofeumpletion,the owns- TOTAL:
builder will have the bmdm a proving that he dal not btdd tor improve for puryose of
sale')' QT'Y. PLUMBING PERMIT FEE Fl "N❑ I,vowrterofthe popmY,ata eacluaivelyconuxting with licermedrnnusctaam
contract the pmja7(Ss,.10,14,Business,and Prefnuri.Code:)The Conmamus
Lican¢Isw Jna rani apply lnwow«ruflrrycny who builds«impnrvothcreon.and PERMIT ISSUANCE 0
whomntracu f«suchpojecm wiN.mnmct«(s)liccrum qusuu.Ope Conveor
ct 's
Li.Law. ALTER-DRAM s VFMFR.WAT (FA) FEE SUMMARY
❑-I em eaemp under Sec ,B&P C for this rmron BACK FLOW PROTECT.DEVICE
SANITARY YN
Owrcr Dom RECIJPI'M
CLARA
DRAINS-MOOR,ROOF,AREA,GOND,
WORKMAN COMPENSATION DETION SCHOOL TA% Y N
❑ Istarchy
aR tharI have.namnamar acvniofmruc Tbof(,Seame«am C.)chid FIXTURES PER TRAP RECFHPI'N
Wwken'CmnPcve(em lvumnceoreccrtirN enpy Thereof(,See 3gfMl,lsb CJ which PARK I'fil3 Y N
Or,0ert�tIF RECEIPT N
polls l 3 � r GAS-G.SYSll1.5-1 INC.40If1LETS BUILDING DIVISION FEES
Cotnp'mY ��/Y{� y4f�ir
GAS-EA.SYSTEM-OVfig,4(EA) PLANCIIECK FEE
I ❑ Ccv�icJ copy Ls,hcrtbY ltunWed.
IlkCertired copy is sled with the cityimectiw divuian. GRIASE(NDUSfRLWASTEINTERCEMOR GRADING FEF:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FIT
COMPENSATION INSURANCE
(Thus monreml raw becompletN ifthepermit is fm orehwdrN dollaa(SNX) SEWER-SANITARY-STORM FA,200FT. ENERGY FEE
«Ica,)
I terrify Tied in the performvace ofthe work for which do, ,m,is oaraL l shall WATFR HEATER W/VENT/ELF.CTR
rat rnapby any person in any minister so as to becone aubjxt to the Workers PAID
Comprnsabrxi Lawaof Cdiform.. Date WATTRSYSIFM(TRE,TING Date Reacie0
zQ NOTICE TO APPLICANT:ILaf.maks this Certifinsi Eacmpi«i.you should NEW RESIDENTIAL PI-MB. SQ.FT.
z ng TOTAL:
ry becomeau usapto de Workers Compensation provisionsof theemed!Code.you mw
[anhwith cunply with sucM1 pmvisinns«thls prmut dual(be,deemed!revo0ed. BUILDING FEE
0. (�
CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z Ihcmby.frnnih.t them Is.cmwrsetlon lrnling agerey «
fee permon«
i of
Q she work far which this permit is isssed(Sec.A197.Civ.C.) TOTAL ��,�� ELECTRIC FEE
t<Mera Name
(-L' Lender.Acidic. QTY. MECHANICAL PERMIT FEE PLUMBING FEE
0 V EI I certify that 1 have reed this application trust..arc that the shove imi.im is MECHANICAL FEE
�"' correct. I agree mcontply wlih all city uM amntycohnmom and state laws relating to FERMITISSUANCE
F^ wildingcormtntnbn.and hertebyaam«;ate rtepretenutiateaMthi.cirywwteralron pe
U z above mentioned property for inspection emanates. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree to save,imknu Ty wad keep harmless the City of Cupertino againw
Iiabilitln,Judpnenu,cmtaard e.apensawhieh may In any wayamerue aunt said City AIR HANDLING UNIT(TO 10.000 CFNB
ms,equrnce of the mat. of isprnefl.
a . ` /rao
O AIR IIANDLINGUNff(OVER 10,00(1
mdum of Applican4Conlroct« Data EXIIAUSTHOOD(W/DUC`G PAID
I TAYSRDOUS MATERIALS DISCLOSURE HEATING UNIT G O 100,010 BTU) D. Receipt#
Willihc a,li.lorfuwre tor ilding«cvpant start«hudlc h.menles material RESTING UNIT(OVER 100.00a)BTU) L.
as darned by pe Cupenlno Municipal Code,Cbaper 9.12,and W
the t th and Safety
Code,Savor 23532(0'
Yea ❑ No VENTILATION FAN(SINGLE RESID)
❑
I- Wil theappicammfutare building by the Lay equipment Gush,Management
BOIIRI(-COMP(RHP OR 100.000 BTU) ISSUANCE DATE
hva.dom air cntuamlwta ss defined by the Boy Arae Air Gudiiy Mutegement gOIhER-COMP(OVER I(p,000 BTU)
DianicG
❑Ya ❑No NEW RESIDENTIAL MP.CI I. SQ.FT. P glM ' L)
1 have Lod On harmdotm materials tcquimi tsnua Chapter 6.95 of the yC b 1
California llcalih&Safety taGde,SnTbns 25105,111533 and 25534. I mdeastvrd Oat `Y q�
if the building does t currently have a terucostly th
nt that it is my responsibility to tl e C 6 1(I
«cvpant of tk mq.i.tar which mus be tan prior to iss.of a Cteniftcuc of /.7
ckcupnnq.
1: r
Ownumauthrrriad egrnt Data TOTAL ISSUEDB . Z1 ft
OFFICE