24771 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING- LR RI L PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. /� ^
4
BUILDING DIVISION BUILDING PROIRCT IUENTIRCATION L
771
BUILDINGADDROS l q� i vUCITN _MjSANITARY NO. APNJG"HON SUBMHT2DAT3
OWN NAME: 7}YI HONE V CO CIOR'S NAMEO ��LI �I���
Our+ V O E ONROLN
RC! GINEER: LIC NO: AD G ' tlo- I ❑
CONTACT: PHONE QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
QLDG Ll; PLUMB MECH
%iRMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION AMLIANCFS-RESIDENTIAL
JOB� YIIf
awz I hereby affirm Nat l ane l icer duNuprnvisinn.nfCnapte9(,mtmeoeing with
i �00 Seim'J[q0)afDivivmJofNeBusiness andPmfeasitwCodc.ydmylkanreuln PANELS V
tyU� IWl face anJ cffcci. _/]1
F G IL I.ic.I UP TO 200 AMPS .�
to em Comr.ct« Ir 201-I"AM
,ZOO]. CHDECTS DECLARATION
SQ 17.BOOR AREA S/SQ.17I'.
o:G_q�y 1 umdvsevtd my plmu sJ I be u m public emits OVER 1000 AM
<Y�M IJ,ensal PmfeoiaW SIGNS ELECIR
�'W< OWNER-BUILDER DECLARATION SPECIALCIR 1
KOaO I hueby affirm then I am exempt from the C«umatoes license Law her the
W,"uo following rx,..(S,eiun T031.S,Business oml Pmf.,ions Cock:Any city or county TEMP.M1tETER OR
L: which which"Faves.perrmn to mrutrvct,elt«.ittyewe,dcmolislg or n,ishr my wuclwe
M�7 pn«m its is.w .alsom no,thn Wlketm fa wch pemtiuo Ekasigrod m.nenenl POWER PS
O thou he Is Ikensed p xnt to d+ep isime M the Corn 's Lmm-"law(Chepnr
66X0 9(commencinN with Sa'dm]Oq))o(IJivisinnJoftx Busintm.M Ptofcsim.Ctdc) SWIMMING POOL ELECTRIC _ygLUAT10N
W_rn adw he is exmp theref.amJ the bmu fm dte.lkWel cmptlm.Any viol.tim of OVILEfS-SWITCIIPS-FlKITIRFS /rV`--`—r
t-Ka Sectim 70313 by an,.,!cam fare pc—,..bj"Ore n,pliant to n civil pcnelly of �'
hit mac
than five M1tuWrM donne($300). -4 714
NEW RESIDEMIAI,F,LF.CTR _SQ.FT.
Cmy� ❑ I,mowwrOftx properly.«myemploymwiN welam Ncirroleu+mpcn.m'tm, STORIES TYPE O N
L3- willdoexwon,Codex rbc Com 1.ratleterdMmoRered fm.a.,Sec.]Oan Ruvmtmf
mM P ywh.bs code:Ix Cmtweor'.Cleave Law Joe.taw app1Y In an owner of
pmpny wM1u but hH m Irtprwm Nerean,.rd who JoeuuH+x'ork himxl f«Nmugh his
empb bui]wWhimw ch tip vldwi .renoeinteof moRim.t r k - —GROUP .UNITS
however,elle over e a improvement i..a1J a Mn u+e year nfcontpletim,rhe owne-
sole) will h.ve the buNen M' nhae x dW rw build m' fm f TOT L
prwiny unpovc puryoso
0
❑ I,mtmmrofmxpopmty,.meadusiMyaxNstinywiNlicenacd(9NIKImto QTY. PLUMBING PERMIT FEE FLf D ZONE APN
cmmme be%o*I(Sm.I(IM,B-inoa and Hafwxlau Coded The Ctmemamr'a
Limns low Aoesn«.ppymo.n owrterofpopeny wbobWldsaimprovm llnemt..rd PERMITISSUANCE
who cmuacts for such pmje vn with actmmwhmfa)II¢n"pmxuwuo ex Canw«ufs
ALTER-DRAIN&VENT-WATER(PA)
Liccmc law. FEE SUMMARY
EI I.m e,emM under See. ,B&P C fm this ratwn BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dista RECEIPT♦
DRAINS-FLOOR.ROOF,ARTA.COND.
WORKMAN COM%NSATION DECLARATION SCHOOL TAX YN
❑ cn'CM ff tim[muu crnifcete ufc y coral(-.3 ,UbCfcUwf RECEIPfI
IT%TURPS-PIR TRAP
WmkerwCmmltrn rim lmur.rtee«.emillM copy Nerrof(Sec.1800,tab C.)whicb PARK EEE Y
N-
m di employee i umde Nis petvJl GAS-EA.SYSf ENI-I INC.4 OUTIJ?TS RECEIPT I
PolicyN ' BUILDING DIVISIO FEES
COO1f>°y GAS-EA.SYSTEM-OVER 4(1'A) PLANCHECK FEE
❑ crnifial enpy4xteM rnmialted.
❑ Crnifcd«pyufkd wiN tx clay imupeetlmdlvision. GREASEANDUSfR,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE17AP SOILS FEE
COMPENSATION INSURANCE
eTMa.ttthn stem o0t b,eampleedifex pantie is f««rchurdrNdollrs(SI00) SEWER-SANITARY-n ORM EA.200FT. ENERGY FLEE
o nem)
I cmiry thL in the perfmvmx of doe war for which this pemtil is issuu ,Isbud] WATER HEATER W/VENT/ELECIR
not employ any p in any meaner v+m to become subject m the WctkC PAID
z Comlrnxekmlawrof C.lifmmi.. Deee WATER SYSTEM[RFAT1NG Reecipl
Aliesm
NY
Opp
Q NOTICE 10APPLICANT:If,aftt twking this Cenifime of Excmpion,you sbmJd NEW RFSI DFNIIAL PI.MB, SQ.FT. TOTAL
h bccmmr wbjme In the Workers Compmstim p isinm of the Lubar Cade,you must
forthwith comply with such povisitm.«Ni.permit""be dee revoked. BUILDING FEE II
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hen by dr Nat Net, ck
et,is a ion nB.gm,f«Ne perfomume of
U Q tx work to,which N 30
ia perm..kiss«d(Se, 9],Ci,C.) TOTAL ELECTRIC FEE
LcNcls N.
L) Lode',Addte.ss QTY. MECHANICAL PERMIT FEF:
PLUMBING FU:
O U I unify Nae I have read this application.M rr.t-Nu the.booe htfmrmulim is
L1-) comet Lgrtemaxnply wiN all oly atW caumy oNinCscn enJ awclewa rdeting to PERMIT ISSUANCE MECHANICAL tE
_ builcing cowncmtm,std hereby amhons mepcscnwlvn ofmia<ity mo eruct upon tx
U .1,me-.nni mwn,,eny for int time putposea. ALTER OR ADD TO ME.CIL CONSTRUCIIO TAX
(We).gree to svc,imMenmify and keep hermle•.the City of Cupertino epaiw
14tilinin,jWgmenls,mLrWexpenses which may in any wmy a,crue agarose s.id City AIR HANDLING UNIT ITO 10,(M CFM)
mn.ey mof doe grenein Nisie G
AIR HANDLING UNIT(OVER IO,(pO CIM)
Si,msbo,of Appliv vCorihoswr Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE IHEATING UNIT ITO 100,000 BTU) Dec Remi I#
Will the ap,Ii.1 or futon W iding«euryon wore«handle hatnrdous nommen
Its dcfnal by the Cuprnino Municipal Cade.Chep¢9.12,end the HWN nd Safety UFA']ING UNIT(OVER fl)(),"BTU) L
CoJc,Smlinn 23532(¢)'!
❑Ya ❑No VENTILATION FAN(SINGLE RESID)
Will doe Ibtu«fuWre heJdimtg rccup.nttue BOILER-comp(3HYOR IW,Oq)BTL)
ISSUANC ATE
•PP egoipn,r mdevimwhichnent
hvmdwr stir,mtemiwn4 m JefnW M IM1e 14y Arta Air Quality Menegcmenl
BOILER-COMP OVER 1 W,(Xq BTU) P AID
kvnce?
❑Yes ❑No NEW RESIDENIIAI.MECH. SQ.ET FEB 2
I have read tine hasardaus mam.1.teyuircmrn4 ander Chep x 6,93 of Ix 211993
Celifmia ll alh&Safety Code.S Huss 25303,2S533 end 233]4. l urdmmrd that
if the buiNingdoes not ctmemly have a emun4 then it is my tesposibility to notify Boe
u Cin l:uren
upon¢of the reyuirenwnu which muse x mH prim to imu of a Cenfime of
Occupncy '-� .
Ownoer or.uNaved e,em Owe TOTAL ISSUED BY:
OFFICE