25888 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOU`LDING-KI E UNICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECIIDENTIFICA'f10N 25888
BUIIDING A13 "S: SANITARY NO. APP1LIGXTI.ONSSUFM///f:::ITALDATE
2 T N LOT N L�(/�_q
Lj
NAME: / P}) CON'TRACTOR'S NA LIC NO: 1 `
C/wJ4 NIC CONTROL If
RCIIITEL GINEER: LIC NO: ADDRESS: ❑
ONTACI': PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BI. ELL PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED COMIRACIDR'S DECIARA'HON APPLIANCES-RESIDENTIAL
n0az I hues,Jinn tum l un iku funder ProvisiauofCluper 9(mnmcocingwid, I F
ID00 Seelion]000)of Urisom Sof Ae Beonets and Pmfe.ssi...Code,.N my l'tcrna ie in PANELS
I�
IK W full fume and'fiat.
FFa..ZW Li.fue Gla.. Iic.N UPTO2 AMPS
r6y Dalc Cmtr.mta MI-1gpAMPS
F''z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA USQ.FT.
i_C s— I undcnuM my dans slmll heuscl n public treads. OVER 1000 AMPS
OZ-0
Fy(=W SIGNS ELIiCfRICAL I _ I ere A L E D ' y I
Q�zQ LicrnW Pofnsimnl OWNER-BUILDER DECLARATION SP:CIAI,CIRCUII'/MISC. - tl� 11V
I N,by effum dust I em cacmp from the,Cmv.clor'I Liccme low for the P T b--1
W3LL� follo .(Sa
wi'musur tion]OJIS,flmiocs.nd Pmfnums Code:nay citymmmry TEMP.METER OR POLE INST.
I_u-0g which m9uimso permit le mnnsuet,.Iter. m ,um
,imrowe.deoll.h,or my mmc
5 >2 Pri«,o iu usuerre.afro requiter the applicen,fm such pemdd to ER.aignd.emerrcv POWER DEVICES
=zoo don We,WensmPursumttoJW rxr,iomnftlbeComi tKaLicenvelaw(ChWer DATE 21141 ja e�' 9(.vmmcu:ing will,Su9m70N)of Division 3afAc Bmircvmal Pofnsiuu Gde) SWIMMING POOL ELECTRIC VALU
Of test he is exempt thmefrm red Ae stones fee the.Ikgci eaemptim.Any violation of I
FZY Smetion7031S ba'mty vpplicurn far.permit subject,tWitpplicmn too v.]PaWtyof OUTLETS-SWITCHES-FIDCFURES
TSp Ih.n term hundmldullats NEW RESIDENTIAL Ft FCIR _SQ.FT. STORIES ow.rof Ampopeny.amyemploywwieu w.gumtlsehwle mnpermAm. STORIES TYPE CONSTR CTI N
e. I on the wofk.mtd IW strucnome is mt iotendd«offcod!for wk(S..]014,Buainevs
Ihafnelom Code:The Comos 's License Ww don out apply b on owner of
ny who builds mintpmre t cecon,and wised such work himselfer thorough his
wncmploym.pmvidedthntsmhimpmvetnmu menmimm�dMmufTares f«xJa 1L C. ROUP RFS.UNITS
howcrcr,the W ildinga impmvemrn,Is sold within ore yurofemnVic,ion,the owner
'Id.will h.ve the burden po
of ring term he did n«Wild im
orprove for pupoee M T \
aak,) QTY. PLUMBING PERMIT FEE FL D' Ne APN
❑ I,uowrero(thc l.openy.emeaclusivNyamtr.cuttg with licevedemtr.amto
c.t the Project(Sc.](44,Business unto Pmfevim.Code:)The Coro,',,
Li.nw law does vnapply et tmoweerofpenperry who builds.,imTrnva the.,and PERMIT ISSUANCE
whoconu.cm for much pmjcmw'iffitt.ta(s)Beem,esI punuen,to the Conn.cmt. ALTER VENT-WLTER FA)
license Taw. ( FEE SUMMARY
❑ 1 em nrmp under S.. B&1'C fm Thu reasonI
BACK FLOW PROTECT.DEVICE SANITARY YN
Brrra-
Owner Dude RECEIVI'0
• m URNNS-ILOOR,ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
❑ Ihvcry Jf desl l lvvevcrniioteofewent to xl6inme,ora anificomof FDCFURPS-PER TRAP BEEFIPI'-
Wortev'C«npmmvdim lmurarce or a certified copy thermf(Sec.3800,Lab C.)which PARK FRE YN
m JI employ.'.under this pe min GAS-FA.SYSTEM-1 WC.4 OffILETS RECEIPT Y
Policy♦ r BUILDING DI VISION FGf
Cnrnp"ny GAS-FA.SYSTEM OVER 4(EA) PANC IECK FIE
❑ Crniid mPY is hereby furvNed
❑ Crniied copy is filed with the dty inalecdim division. GREASEpNDUSSI.WASTE INTERCEPTOR GRADINGFEE,
CERTIFICATE OF]X MPTION FROM WORKERS' GREASETRAP SOILS FRE
COMPENSATION INSURANCE
Ontis.uetim nml not Wcmwletmi ifAcperrom is for on,huntdtcd ddlan(5100) SEWER-SANITARY-STORM EA.2WPf. ENERGY FEE
a lea)
I certify tMl in the perRmman.of Ate work for which this crent is issued,I.rlwll WATER HEATER W/VENT/ELLCIR
trot empbY any person many mmme,so m to become subject to the Wakrn'
PAID
Compermtion laws of CJifunia Ihle WATER SYSIEM/IRPATING Date RmipY
z z NOTICE
z � NOTICETOAPotheWoT:ILComm,m ngthPCenBW tof heLtt Coce.you
NEW RFSIDENTALPLMB. SQ.F. GTA
beicomenc rn mO.imubjectm the Worker's Pr Cattpmvm i,povisimsafdhC Labor Cnde,yw muu
forthwith comply with such puviaiov athiv permit shJl be deemed revoked. BUILDING FEE ,
0. Q CONSTRUCTION LENDING AGENCY SEISMICFEE
-) z IWo,by Jf that there is a cnouructim lemling Woe,for th<peJorntmtce of
U O Ac wockfor whkb Nis Fenno,is issued!(Sec.3097,Civ,CJ TOTAL: ELECTRICFEE
L: Lots er' Nome
F o
Iandorn
ces Ads MECHANICAL PERMIT FEE PLUMBING FEE
CJ I emiify duet I heve rted this.,I"uoo end wee test the Jove itdarmatim is
Iagree to«anply with ill city and county«dinmenam seam luwa othomg to PIRMITISSUANCE MECHANICAL FTE
F building cmuvuctiom ud hereby authmvc mpncummllm of doaciry toceraer open Ae CONSTRUCTION TAX
U Z above mentimed property for m,ecdion purpmev ALTER OR ADD TO MSCI I.
(We)agree to save,indemnify m cl keep hmmlesv Ae Cny of Cupenb,ergs ml
IiebiliAn.jWgnmtu,coam mid capevn which mvy in my w.y.cctuv a,mmm raid City AIR HANDLING UNIT(TO IBM CFM)
in cons,,uenee of the groming of this smmlt.
AIR HANDLING UNIT(OVER BL"Clem)
5 Salam of AMI,' iu Cornr¢mr Dye EXI MUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATDJG UNIT(1D 100,000 BTU) Dye R.eip N
Will the applicant or future building occupsot cure orhmdlc hovrdms mmcniJ FffATEJO UNIT(OVER IW,IXp BTU) A
u defter by the Cupertino Municipal Code,Ch.per 9,12,.nd the Huhu and SJmy
Code,�Ij 25532(')]
❑Yo ❑No V ENTILAI'[ON FAN(SINGLE RES1D)
Will thevPpicanturinurcl,uildingccupmdu.ceyuipmentordeviceswhichmit BOILER-COMP(31IPOR IW."BTU) ISSUANCE DATE
h.unh o,in,ceruamirunu u defter by the B.y Avert Air Outlay,Mma,cmem MP P P7 A ' B
• Di+Wct] BOILER-CO (OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. pre
I base rend the hnssNous materiels rcyuiamends under Chap.6.95 of Ate
California lluhh R Sofmy Code,Sectimu 255(05.25533 a of 25!34. Iwdv,dord Nov 9;'a j
If Ae building does nm anrmify este.swat.Ann it B my mup«rsibiluy to taeify Ate Vl�l r
pant of the mquimmenta which mum IN,et prig to issuan.of a Ceriium of
Owno err emMMud'gem � Dune TOTAL: ISSUED BY:
OFFICE