25302APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOUB.DING - ELF=ICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL BUILDING PROJECT
'ati"•"2+ I06NTIFICATION�:[�r"
PERMIT NO.
25302
BURDIDING ADDRESS' ^/�J�g(,�)1 -
C P UNIT# _1140_6Ol'
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SANII'ARYN'D.
APPLICATIONSlf1BMill9]'AL DAIS.
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OWN By NAME.' CONTRA O�
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ftCHITECT/LI:GINEER: LIC NO: A9 DRES :
rpt lgipeL C�Ll1t Q2,
CONTACT: PHONE: - r n��. '3,,, r. mwr:t a r F >Lii n t 'w'. .e
QTY v1J ""P� ELECTRIC PBRMIT{9 ei,5�'x y. h T RE
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"BUILDING PERMIT INFO .
BLDG ' .ECT PLUMB MECH
G� N
PERMITISSUANCE /
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LICENSED CONTRACTOR'S DHCLARATION APPLIANCES- RESIDENTIAL
I humbyaffirm But l an licensed underprovisionmfClupier9(commencing wish
Seldom 75MI.1 Division lofshe Business and Precision, Caut and my license is in PANFIS is,c ✓
fullf anile
cnu Clas��/' ic.M oD2� UP TO AMPS ^Ice/ IJ�"
Da¢ Canwnar 20 IgTI MPS k/
IJS DP_SCRIPI']ON
1-
ARCHITECTS DECLARATION OVER 1 AMPS'
I understand on, plans shall he used as public records.
SIGNS ICAL
a SQ. FT. FLOOR AREA
S/SQ. FT.
Licensed Professiwul
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OWNER -BUILDER DECLARATION SPECIAL CISCUI ISC
1 hereby afftmt thus I am aaemps Irma she Camranora License Lew for the
following reason. (Section 7031.5, Business and Professions Code: My city m county TEMP. METER O LE INST.
which mnd. a pemti, w construct, alter, improve, demolish, or repair any ,.,,..
prior in its issuance. alsom ot, theapplicans forwch pmoutto fiheasignedsutemem POWER DEVICES
that he is licensed pmstuns to the provisions of she Common. License Law (Chapter SWIMMING POOL ELECTRIC
9(rot racing with Section B100)ofDivuion Sof the Business and Professions Code)
or that he is eacmpuherefrom and the basis for thcellc8ed exemption. Anyviohtionof
Section 703)3 by anyapplicant for a pr.issubjm. theapplicans toe civil'nal"is' OUTLETS - SWITCHES - FIXTURES
rant more than five hundred dollars ($5W), NEW RESIDENTIAL EIECIR_SQ. FT.
❑ Luawmraf hundred
city,ar($5W),oYceswithwagesuthcirwlecamprmation,
VALUATION
STORIES
TYPE CONSTRUCTION
'3—
will do Nework,and the strucmrc is nos intended oroffered for sale (Sac. 7044, Business
and Professions Code: The Contractors Liceme Lew does not apply on an owner of
prapemwhabuildsm impmvuthetmn,and whodoessuch woH hinucvarthmughhia
employees,providedthatsuchimpmvemcnuarcnosimend maffemdforWe. If,
OCC.GROUP
RES. UNITS
however, the builiingm lmpmvement is sold within one yemofcompletion.sheowner- O ��
builderwill have the LuNm of proving shat he did not build or improve for purpose of
sals-l. {�y 'wAA�nrxi,wlw-n:an„ate •r • �i ¢a f4 i Fi
❑ I.mownmofshepropeny,emeaclusivelymnuactingwithlicenseAcomue'orsto w�.a' k' FS5eP1:I1MBII 4vP,aE•snw. rfd IN, :,`rC.-'�sa t"H,n
IlOOD ZONE
APN
construct the project (Sx. 7614, Bmineu a RofMions Code:) The Conuacmr's PERMIT ISSUANCE
Li erose Lw dm rant apply to w owrm of property who builds m improve Nerew, air W
.hoca.. fmauch projects withemakinuor(s)Iiemaed puuuwsmshe Convenors
Licroselaw. ALTER - DRAIN&VENT. WATER (EA)
h=•sc+ eos ayi;o - --
u.�S VWe FEE,SUMM_ARY;
raj^`.,,,;,•..%_
❑ 1 am esempt wdm Sec. , B & P C for Nis reason BACK FLOW PROTECT. DEV I1
” UT, IT ,
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M .
'•SANTTARY Y N
OwnerDa¢ 'I
"' r' RECEIPT#
SQHO M Y_ N_
ROOFAREA, ND
WORKMAN COMPENSATION DECLARADRAINS-FLOOR, .
TION � 1 I
❑ Ihexby eR Butlhaveattrtifiuu ofcwxntmself-Insure,m ecenificae ofpIXpOgEg PER TRAP
Wa 'Comp timlmurartcemacenlfedmpy Ncmof(Sa.3800.UbC.)which
Pnalcu�lvnploya's under this lsmsik GAS -EA. SYSTEM -1 INC.40IT1. ATE
RECEIPT#
I Y N
RECEIPT N
BUIL GDIVISION PIES
Y
Company GAS - EA. SYSTEM-OVERaE' —'
Clort
❑ Canified copy is hereby furnished.
PLgNCFiECK FEE
GRADING FEE
❑ Cenified mpy is fled with the city impection divisim. GREASE/INrUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This ammru need not be completed Rule permit is forone Imumaddollara(SEX) SEWER - SANITARY - STORM EA. 2W17—
orless.)
I certify thuinthe prrformanceofthe workforwhich Nis pemuris issued, I shall WATER THEATER W/VENT/ELECTR
not employ any person in any manner so as in become subject to the Worked
PAID
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Campensmionl-awsof California. Dam WATER SYSTEMO"REATING
Dole Receipt#
TOTAL:
Applicant
NOTICE TO APPLICANT: If, after making no, Certificate of Exemption. you should NEW RESIDENTIAL PLMB. SQ. FT.
p]
became wbjxpo the Worker's Compensation provisions of she Labor Code, you muss
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE O
'
CONSTRUCTION LENDING AGENCY
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1 hereby affirm Jur Nem is a construction lending agency for the Performance of
the work for is hich this permit is issued(Sm. W. Ci, C.) TOTAL:
Lenders Nomeay.
ELECTRIC FEE
PLUMBING FEE
Lenders Address QTY § -air JMHCHAMCAL PERMIT f, gt't z, µFEE .
I cemk that 1 have mad this application and sum that the above information,,
e nee'.Iagreemeompivwuhallciyandcoun.y ordinances and curt laws reletingt. PERMIT ISSUANCE
building communion. and hereby authorim representatives of this city to enter upon the
aboee-mentimed properrc for im,mu,u purposes. ALTER OR ADD TO h/F.Cl1.
MECHANICAL. FEE
COFSTBUC ION TAX
Me, ,mem save, mutuality and keep hannlca the Cu, of Cupertino against
habilities,judgme mss and expenses which may in any way accrue against said City AIR HANDLING UNIT (TO IRWO CFSD
in mmuquence t granting of noir.
AIR HANDLING UNIT (OVER 10Sgq CFMI
PAID
gnature of Ap aammcs me EXHAUST HOOD IWMUCT
HAZSRDOUS MATERIALS DISCLOSURE HEATING UNIT ( TO 161000 BTU)
Date Receipt h
'A
Will the applicant or future building occupant store or handle havrdous material
asdefned by the Cu,ammo Municipal Code, Chapter 9.13, and the Health and Safety HEATING UNIT(OVER IM.WO BTU)
Cade, Section 25533(e)? VENTILATION PAN (SINGLE MID)
❑ Yes ❑ No
ISSUANC E DATE
-
•thismisO
Will Neappliunmrfutux huildingocmpnd useequiptmntordeviceswhichimit BOILER -M. MP(3HPOR 100.000BTU)
ronunts u dented by NAte e Bey Air Quality Management
stir ntim
'Dlsvict? BOILER - COMP (OVER 100,000 BTU)
❑ Ya ❑ No NEW RESIDENTIAL MECH. SQ. FT.
/T D
P 3'
1 base read she haaardous rmmish, mqumenu iraunder Chapter 6.95 of the
.
CaliforniahbulHulthm nil Code.Sections
ase. m23SD5at it is woe 35534. 1uhdnrsudf the
if the building diamond cunwJY have • tame, that it is my nuancPlausibility the
-- 8
JUL
ernotity
rceupwt of the mquucmmu which most be met prim w issuance of a Certificate of
OccuPwcY
ISSUED BY:
Owner or authodr4d agent Data TOTAL:
OFFICE