25334 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO NUILIP-r, LT'cI`RICALPERMR NO.
BUILUHNO DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 25334
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'/ /',.,� y/�g SANITARY NO. APRICATIONSUBM17"PALDA'IE
007 Cly-(�fh M(TnO &UNRN LOT
Owl
AMC: � �--II PHONE: CONTRA 'S NAME, LIC NO:
SI a h I L I ✓V�V 9 - O NIC CONTROLI
RCIIIIECgINGINEIiR: LCNO'. ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMR'WFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE El R El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ION DCSCRIPHON
IM17")affirm Watl 3 orh rwdwdor pmvids.i.coie 9leanmemng with
�00 full iorce"of Division Sof db BuumaraM Narruioni Code,aM myldeme is in pAryp�
full forceud effect. ; A
;<
license Clan Lic.X UP T0200 AMPS „
n Qy POte Contractor 201-1000 AMPS
7ONz ARCHITECTS DECLARATION SQ.m MOOR AREAS/SQ,M.
AMPS
O Z-0 I uMenuntl mY plvns shall tr used u public rands. OVER 1000
H C W SIGNS ELECTRICAL
IicervN Professional
Cax Iy6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W 3 LLy1 hocby affimn Nat I am exempt from Ne Conbactovi lLaw for Nc
following rc..,Scrator]WI5,Branca.and Profaaiom Code:Any city my„anty TEMP.MBIER OR POLE INS]',
t�o,ig which requlsnapcord,to I..,.tiller.imgovc,hnmlWt.or repair any nm M. PoW[R DEVI 69
f, }� prior to its isauwcc.also«yuires the amlicani for inch permit to file a signed stmemrnr I �y
K p that he is lianxd gln.•.,.r n Ne gvvidau ofttb Conbamor'a ticaec law(Chago
dcx 9(commennng with Satinn]m0)of gvisimJof theHminyu aM Rofeoimu Code) SWIMMING 4-ELECIitI. 71 F' VALUATION
W o, or Wit M E wisp,therefrom aM rhe train,for Ni,aliew crearptimr.Any rioWion of C
Za Smion'/0313hywyapplicantforapemrir.wbjautheaMlicanttoecivilprn iyaf OUT<.FTS-S a ESeflIf
not start thorn five homind dollen NEW RESIDLNII Q.
C ElI,uowrcrof0hepnpary,mmyrnployaswiNwga esthrirsolccmnpwatim0 gATTpR 1 STORIES TYPE CONSTRUCTION
ywilldo the work,end the stnu7ure is not rucndolocoffo for ule(Sec.71)44,Butiriea. Nv J1'
and Prorevcnu Code:Tia CmlrncroW.Limina law aces m apply m an owns a
proprny whnbuildsmimpmra Wcmm,and whodaca such wort himclfm thmuehhu GROUP RFS. NI
anpbyees ldim,oed Wmwch within
it ane rot imeMm malfved ra We
If,
Mrwovrr,thety,the, origin of rovni heardwithi norbyea ofcompledan,Weooaeor
hrildo will have the burden of proving that he did rd build or Improve for PrrP^+e of TOTAL
role')' TY. PLUMBING PERMIT FEE FLOOD ZONE AM
❑ I.uoworrorthe Sec.7,AW, .sin iv ant!Piradiion,C cte n) T Crourtunw
ymwrvct the kis,"rofcci army.]Of 4, ocs OT vM ywho mina Code:)'De Cnnlra " PERMIT ISSUANCE
,thoselacitfor c to .,. who WiWan' O
aPWY goR^Y vogova thvcan,and
wtwcmtrvsa for sixh proje,u wiN ecrnlncta(a7licenacd punuunt to the Cmtrecrds
Lcemc law.
ALTER-DRAIN&VENT-WATER(EM) FEE SUMMARY
❑ Ian esemq uMa Sec. B&P C fm tM1u reason BACK FLOW PROTECT'.DEVICE. SANITARY Y N
OwxDue RELIiIPf N
DRAINS-FLOOR ROOF.AREA.COND.
WORKMAN COMPIIiSA'f10N DECLARATION SCHOOLTAX Y N
�❑ Thereby a(f tbatlhaveecenif[ste of caurntto relf-inswv,aamtifna of FlX'TURFS-MR TRAP RECITE -
'Wrrwo,Compensatim huuruub m a ccnifid copy tlrn (Sec.3800,Lab C.)which PARK FEE Y N
m all emplryee'I der W I peemit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT X
Poor
Poll,N BUILDING DIVISION FEES
Co,oftanY GAS-EA.SYSfEM-OVFB 4 HQ,) PLANCITECK FEE
❑ Ccoil s is h...by fumishcrl.
❑ Caiflcd copy ufilcd with the city impectim dirisbn. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FF2
COMPENSATION INSURANCE
(lTia sectio reN lra be complel�If Ne pemuti,foratchwdmlddlvs(5100) SEWER-SANITARY-STORM E.A.21XIFf. ENERGY FEE
rel u.)
� lcenify that in lla performmge oftfbwork For which, ' pmmtutssltd.l ax. WATER IIFATFR W/VFM/ELECTR acs✓ -
m ertplol'any puao^ in any matron so ea to a 'e m cokm' PAID
Crmpnuo 1 al iforrin. Dot WATER SYSTEhr/IRFA'DNO Due Receipt♦
O Z• Amlicem�l� n0{ - �' 1�
zO NOTICE TO APPLICANT:If.after crakrtgtNs Cenlfdate of Csemtoon.you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL
a > f hhwilhhc m�Y illWorker'.
och pmCanpcnr,this remit sholl M10 m nrrokN� BUILDING FEE
�] CONSTRUCTION LENDING AGENCY - SEISMICFEE
CLI
rZ I hereby affront RIu dbn u a uauvumion lending acerb,for the pof�or
U p the work for which this prod,is i anted Sec.AH7,Cis.C) TOTAL: �/. ELIECTRICFEE
Iandaa Nems PLUMBING FEE
O F 1e ,Addrtlo QTY. MECHANICAL PERMIT FEE .�
U 1 testify thu 1 have read his application aM Into,Writ the all mresr ion is
correct. legne,to crmtWY wiW all city aoa munry mdiwevs Wsraa lewa rcluing to PERMIT ISSUANCE MECHANICAL FEE
_ NoWing cvnsruytian.and thereby eutharlx rtpresentetiveaof Wil city to row upon Jb _
U Z adrve�mrnuabd gope ty for'in action puRwsee. ALTER OR ADD TO Wal. CONSTRUCTION TAX
(We)ogre,to save,itdemnify aM keep harrolnv the City of Cupertino mit[nm
0ebilitin,jWgmmu,cosst mde.perlsa which may in any way aceoc agmimt rid City AIR HANDLING UNIT(TO 10,110)(1 CFM)
in csaucylnrnce M'the gran ing of this;permit.
AIR HANDLING UNIT(OVER IO,p1l0 CFM)
Si¢n.tunear AppliciarYCamacta Da. EAUAUSTHOOD(W/DUC PAID �� '/
ITAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO 10),000 WITH IX. tteiq N
Will the alglielm or futoe building occupun ntae or hwdle haveNous normal O
as defiml by Nm Cu,rrhon MuNClpal Code,Chapter 9.12,and the Heahh end Set HFA'DNG UNIT(OVER IM."BTU) TOTAL: -�•
CMe,Section 25532(.8
0 Yes 0N VENTILATION PAN(SINGLE RFSID)
ISSUANCE DATE-
Will
ATE
WIIINc licenrm funice lerildicjo ,s ret are BOII.FR-CVMP(3HP OR 100.000 BTU)
erq equirmentmdevlmwM1khonit �F
woic,? aComirau
ir ctanas deficed by tM Area Bay Au Quality`Marulmgccm BOILER-COMP(OVER 100,Oq)BTU) - PAI D
Disrict)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT.
I have read We harardoos nornmals rtq ionto.vMo Chagcr h.95 of the 'JUL 161993
Cnlifmnia Hc;Jlh&Sofuy Cock.Sections 25505.25533 and 25530. I wdeNend that
if he bu k int cines not ootenulr has:a rcrnrit,Nu it is fey rapon.ibility to notify the f C�111`IV
occupant of We oNoiremcnu which mon Mme,prior b issuance or.C Tame of 01"! ur UU
Ottupuay. V — .
Uvrbr m euNoriud agent Due TOTAL: ISSUE
O