25472 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILULNG- LL RI AL PERMIT NO.
PLUMBING
BUILDING DIVISION APPLICATIONIPERMIT BUILDING PRADJKCT IDENOFICkT1ON 25472
BUILDING ADDRESS: I SANITARY NO. APPLICATION SUBMIITAL DATE
G/ I/''etJ V UNIT» LOT»
' SNAME: —1y 'Y L M{ONE.: CONTH
ISSCG /N}:&0. T '/
NIC COMAOLN
• RCH1IEC'OHNGINFER: LIC NO: ADU ,s
El
CONTACT
11: PBONE:ui✓ QTY. ELECTRIC PERMIT FEF: BUILDING PERMIT INFO
S77—S OOw I PPRMIT ISSUANCE ' BLPLUMB 1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENDAL
pyrz Ibecebyaffimdonmlkevd dl aurhpmvisi.of Cb.,mo9(Ionmrnring with JOB DESCRIPTION �N
=o FpSection F f If moil and eRU vlsiun3uf de Bminns al Rofn.ions Code,ad mYlRrn,uin PANELS
<1Z Lian.a Cle Lie � l3 UPTO2MAMI'S �i -
t, a Conu;mc 201-IOW AMPS
/Im ARCUITECTSDE ARATION O IOoOA SQ.FT. REA $/SQ.FT
pZ_,) Imdaslarl my PIw.IWl be usd®pubic recwda.
�yFJ S E ICA
C
'1_1 PPLRcruM Profess eand
aa'MM=< OWNER-BUILDER DECLARATION S ,CIRCU 1
pXxoiF 1 hereby affirm that 1 an exempt fear the Contract(.lictttse I�w fa the 70 %
�
W3�y fdlowiny meso, Section 7031.5,Baer.-al Prof.ions Code:Any city acounry P.M IN
Cv-O<, which mquim a pmmit w rnmtrvct,alcor,impmvc,dewlit,a mlmir anY smwtwe
J� priamiu iswmwe.vim rtquim lM1c yglimm rm sucM1 pemulio filevugrcd'ad i POWIM DEV
�a p
that M u licem�pursuant to the co, donsof the Contract Liems,Lew(Chaµer
�X��0 9(commercing with Sectim7o00)or Divition 3 M the Bu.ir,aa and Profmaimis CMSWIMMING LELECTRIC c) 1 VALUATION
twt,t he kr enemq tereltmn ul d,M.isfa the allegd enemMion.Any vidai,n of 2
I.Z,a Sectimn'l031.5 by any aWlinru for eeubj
a peen sects tMm crW
.ppBcsto civil pty of OUTLETS-SWITCHES-FUTURES
not mom Than fvc hu dm l"Imm($ND).
egF� ❑ Lmowtmr,(tepropnty,amyempla itw .0,6-50 ampemaian. NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRCiCTION
1'3— willd.1he-A.iMBenimn"'it n.i.endmotofr dm,.1e Sec.7 .B.ite.
and Pere,,'.Cook:Thc Comfacwls Lb c mm clam not apply w an mer of
pngctywhnhuildnaimpmvcxtcmm,ad who ws otch,orkbimsefocth -his
own,mployegpmved dta anch wpovunen aerwtduendedoroRetedfam If. C R s P RES.UNITS
howwcr,debuildingmimlnovememinwld thin a,yeerofcanplelia,teo
Wily will have tc drnlco of proving that didtd bdldaimPmve fa purymeo
mle.).
❑ LmowrcrMte pmpcny.ane ivelyccd w,wit nmd mnu.ctaam PLUMBING PERMIT FEE D�oN APN
,semen the pojen(Sec.7060,B aca.W Ptofesums C 1111,Contract , !/
I.ic-1-awduesman' lyman ofprnpurywlMWil v der grid RMIT ISSUANCEt IL
wlmc,h.fusuchpnjec dbsmwcmr(s)lie nmhe Cas acmla ALIY:R-URAINA VP.Yf-WAI1iR(IRA) SUMMARY
IJccno,Low.
❑ 1 am exempt udc P C f BACK R,OW PROTECT.DEICE SANITARY Y N
Dats DRAINS-ITOOR,ROOF,AREA,COND. RLCCIPTN
WORKMAN 'OM A ECIARATI ��� SCIIOOLTAX YN
❑ IFembyaffvmtalltsvea 'R tm.N aamuf of PUCIIJRPS P[R TRAP RF,CT:IPTN
Wurkers'CmnPemmim lmuru,e pyter ( 39W.UbCJ hi,h PARK FEE T N
/ cavrn ell employee's leder W.pmna GAS-PIs.SYSTEM-I INCAOUTLETS RECF,IPTN
Pulicy0 BUILDING DIVISION fFFC
Co Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHIiCK FEE
rad copy i.hemby fuml.hed.
Ir Ccnifid copy i.fled with dm city an dlvtdon GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE �»
CERTIIICATEOFEXEMP-1 MOM WZ ORENSETRAP SOILS FEE
COMPENSATION IN RANCE
('LTi.xn'wnnaJ ax be,uniplmdl(the i.foran $Hp) SEWER-SANrTARY-STORMEA.20DIT. PNFRGY IEEa less.)
Icrnify taint,perfommnaofihc wakfawid,l.w" WATER HEATER WNENOELF,CTR
on crtmplay any Wcrkm' PAID
Z Cmmrpmsou w Cdif via Dote WATER SYSTEMOItEATNG Dare Remy,»
Appli w
Q NfYI'ICT?I CANE:IL etwki n8his Cent fiche M Exemption,yuo duwld NEW RESIDENTIAL.PIM B. SQ.IT. TOTAL:
V1 become.ubjen w the Wockc'c Cmopauadm pr.vWcm of the lab,e Coda"am m,,.
fatwit comMy wit loch provisions a this pemut.hnll bc dccned rtvokd. BUILDING FEE
4 CONSTRUCTION LENDING AGENCY SEISMTCIE,E D
U .2 1 hereby effrm 11 tem u.artsauNan kndinp egecy for the pafomm�a of
O the wmk for which ti.R.mit is issued(Sm.3(97,Civ.C.) / FJ,ECIi11C FEE
Lender'.'Nem,
L ,Addms QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1,miry dud 1 have rend this appli,vaai and awe that Use above infamepoa is
corrin. I w It all cit ad,amt atmomices and one laws rel MECHANICAL FRE
agree emplyw y y • fit PFRh1IT ISSUANCE
UZ abovboliin nfihonat no,em fie,by maeato, srcose,i, auvm of tit aitymentcr tsps the
L) 2 above.znoor,d prq,nyfmimpccum pce,ban. ,U.TERORADD TOMECII. CONSTRUCTION TAX
.- (We)egmm m eve,indemnify and trop hamlets the City of Cuperdro againn
Ilabilidm prmeu,ewvdexpemm which rosy In any way acture sal City AM HANDLING IINff CTO 10,000 CFM)
inc an putting of ti
AIR HANDLING UNIT(OVER 10,000 CFM)
arc of ApplicenUCmmtncmIf G
c MIAUSf HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURIi
HEATING UNI'T(TO 100,)00 BTU) Die RuoipN
Will the applicentor intoM uebu0dingar Cm
no9e2.balk b.mdautmreril HEATING UNIT(OVER 100,000 BTU) 'TOTAL:
es defined!eSec by to 32,.)?m Municipal Calc,Cnepmr 9.12,ul the Health ed safety
Code,Section 25332(a)T
C3 Yes ❑No VENTILATION FAN(SINGLE RF.S1D)
00TH thea coaamaams.belocal by ft awequ Ant Quality
mwhich emn
BOILER-COMP(3HPOR I00,O)OBTU) IS C ARE
4 bvsrddu av rnuanuwnts m dcfmd by to BeY Ata An Qmliry Manegvsnt
DisRin2 BOB"-COMP(OVER 100,000 BN) AUG 23 1993
❑Ya ❑No NEW RESIDENTIAL MMI.—SQ.FT. ,
1 have read to Mvnlws material,rtyuimnrnts undo Chains,6.95 of the CITY Ut 1/UIstn i nu
Celifania 11mdh&Safety Code,S e ate 2 t,5.25.533 ad 25530. 1 undnan if to
Irtchuilditeon,motcurrentlyloveamtlb ,edW IIis myrnpmniofa codify the
cuipm of the rrylmmets shah mats be nte5 prig w Rause,of•Ccnifcue U
oaayan,y.
Owneraamlwrircdnget Data ISSUEDBY: ✓V l 1