25938 .'w^-nrruur.n r'a v Herm nervmm�a rvn'a
CITY OF CUPERTINO •sass...rr� rr. TRICAL PERMITNO.
RUILDINO DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL D 25938
BUILDING DESS: SANITARYNO. APPLICATIOONSSUU'9BMOTALDATE
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WNEi�jIAM :� PHONE CONIAACfOR:S JJAME: LIC ND:S keV1 N/C ' CrONIROLx
[NEER LIC NO:s A 'S3r
�� rvrncr: Pxorve--..11 r gNS: ,.''ire'!«r'"�`}.. WLDRIO.P `EkMIT tPrto"tifC�r':fir?
-- /1 PERMrf ISSUANCE �
LICENSED CTOR'S DECLARATION APPLIANCES-RESIDENTIA IOB DESCRIPTION
KZ IWrtM1y ef{mthat Lou licensed uderprovldons of Chsplm9(commencing with
�00 $ecllpn]UCO)of Dlvi,loo3eftheBudneaaertd Profeulone Cede,mdmylicenxlsin PANELS 9
{{RR full force and effect.
IQu LlcmseOeu LI[.N UPT01 PS
yco Dem Cm0acmr 201.Il SQ.FT,FI,ppRA 5/SQ.FT.
ZS„b AR010EC um DECLARATION Qyp,R —
0 Z_C1 I undmmd my plms.hell W used u publie records.
FyF. SIG EL AL
lEpSy LA
Licensed Prvreulonel
OWNERBUILDER DECORATION S 0 CIRCUIT/MISC.
O FFF 1 hereby aTfim IMI 1 sum esumyt from the Contractor's Licenew Lew for the
3%A following..(Section 703 I.S.Bueineu and P ofeuimu Cade:Any city m county TEMP.METER OR POLE INST.
e]y which no,do a a pemth m construct,alts.Improve,demol0b,or repair my structure
N� primm its istuame,also requiresfie.plicmt for such permit to file asignd statement POWER DEVICES
dust he b ihemed pm
ursut to the provieima of the Conbanma r License Lew(Chept«
VALUATION
p�
4. 9(cmtntemingwllh SeSectionSection]IXIO)of DlvOinn 7 of Ne Businessand Rofusione Cade) SWIMMING POOL ELECTRIC
o ordustheisexempttherefromadthebutsfmtheallegedexemprion.Anyv Immo pypyRpg-SWITCIiFS-Fl%TURES l r
SttBm]03L5bymygglimtfmaP itsubjewt eppllesnt 0 vii prnWY of _ JJJ 111
tet come dun five hudred dollars(5500).
p EW RESIDFN TIAL ELECTR _SQ.PI'. STO ICS TYPE CONSIR CfIO
❑ Lmowreraftlee someoe1,req loyenaiNwegd soeifce.713 npemuim,
will doth,work.anelW mucmreis ortineded«aRrredfm rsle(Sm.706a,Bminor
ana Roreaimu code:rW emu.cml.seam.Taw dm.nm.1rolr m.n awmr or
own enywhabuiMo«impmvnchereon,edwW donouchwmk Mnsselfor Ouough his OCC.GROUP RFS.MN
IM
that su
chimpmvmmntsseene Intendedmoffvd forrole.er,
however.Neavehebuilding mimprfinovitlsant he didn Wild.Improar roedm,@eow«r-
raleI
bidder have he burden or proving that W did ort Wlld m Improve fm purpoa of
le.)., { � FLOOD 2ONE. APN
❑ prrofrsee edconnnm w
construct the aJect(Sec.70414.Business and ProliniuestCod.)The cm0PEISSUANCE
Licmselawdmnm apply m mowrrerofpapeny whoWildsmlmpmvutunroo.and M
ro
pu
LWemrsfwaneh project,with.mnhsctm(s)littrued num0odecmtrmmr's
LiLt..lamecw. ALTER-DRAIN&VENT-WATER(EA) ' 'i.� l���.H PB9,5_UMMARYYr;,z�.y,'kJy(JN�:r
❑ I un nempt udm Sec. .B R P C fm Ihh recon BACK FLAW PROTECT.DEVICE
SANITARY Y N
Owner Dam RECEIPra
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, OOP,AREA,COND. SCOWL TAX Y N
' ❑ IhcmbyaRimthemlhav<aceni0cate ofcrosenm m,clf.lnmre,meanl�om of FI%TURES-PER AP RLCEII"1'N
Wmkm.'Campenatino lmurancemettnifid copy mMreof lSec.J800,Lob C.)wM1ich PARK FEE N
r:CElrrx
J <ovendlemploycc'sundcrthhpemdt. GAS-EA.SYSTE ETSB )I IONFEI'
Polley N
Company OAS-EA.SYSTEM-OVFJ! PONCHF,CK iZill
❑ Ccnified ropy i,hereby fumishd.
JW
❑ Cmtifrod copy ie fill wlN Oe city inspection divi.im. GREASFJINDUSTRL WAS I CF. GRADIN r
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEvk S I:I..
.(ha COMPENSATION INSURANCE
(lhb and not becompleted ifthe permit is for oro hundrddollm(SI00) SEWER-SANITAR - MO.2 ENERGY FEE I^
orless)
I cerify that in the pedmmameof the work r«which this peonh i,lured.I shell WATER HEATER WNEW
not
employ my perean in any summer an u to become subject to the Workers' PAID gaw`
Compmuties"..orcelifamie. Dam WATERSyMMfrREAnNO Dam p
Oz Applicator
O NOTICE TO APPLICANT:IL sfton making Nia Cerdfiu¢of E.emytlon,yon rhould NEW RESIDENTIAL P. TOTAL:
ta" US became subject to the Worker.Cam
npeulm Provisions of the labor Cade.You most BUILDING FEE
I k[2) fonhwllu comply with such provision,or this peredt dWl be domed rooked.
p, (� CONSTRUCDON LENDING AGENCY SEISMIC PER
t-� z 1 hereby of on then there is.construction lading agency ren rhe perfmmma of �w ELECTRIC FEE
ltJ' O the work for which this Permit Is issued(Sec.3097,Civ.C.)
LL. Loonl 's Nome .�uu%%.. �rX;.:(�ti:' `')'^ 5 PLUMBING FEE
h' Lendeie Addrea ,J._ gaa y
I
06 1 mni(Y Out 1 have read'his application and cute IMI Nee ole infommum 6 MECHANICAL.FEE
W
correct.Igre<m nrplY with dl city ad county odimrmcsednuelewemletingm PERMIT ISSUANCE
Wilding coowcrim,and hereby malvrire repm
renmOva of this city to enter upon IW ALTER OR ADD TO MECiI. C'ONSIRUCTION TAX
property inspection Purposes.r
store-mmtimd
(We)agree m seas Idenmi(y W keep humlue the Ciry of Cuiautim egdna ant O
IlebillOn.Jdgmcnu.msu Wexpemea which mayin any wayamuegelml aid City AIR HANDLING UNIT(TO 10.000 CFM) f.
iner, con Ith t gal mhi permit.
f ^z ./ AIR IIANDLINO UNIT(OVCR 10,0011 CFM)
ffB?
F Si a pplicm4Cmomtm ` Dam 7 EXHAUST HOOD(W/DUC17 PAID
6 HEATING UNIT(TO 100.000 BTU) Date Raciptg
IJAZARDOUS MATERIALS DISCI.OSURP.
Will the applicant m future Wilding occupanutme m handle hazardous materiel LIGATING UNIT(OVER 100,000 BTU) TAL:
t u deRrrcd by the Cupertino Municipal Code,Chapter 9.12,sed the Health and Safety
Cade,Section 255324)T VENTILATION FAN(SINGLE RMID)
❑Ye 11 No ISSUANCE DATE
Will 11w.,icaor future buildi.S.pantuaequipmentmdevimswhichemit BOILER.COMP(311P OR 100.000 BTU)
ns
haaudau air contaminant,a de0nul by the Bay Area Air Quality Management BOILER-COMP(OVER I00A00BTU) P q U
%.WCIT
❑Yn ❑Na NEW RESIDeNT1AL MCCH. SQ.FT.
i. I have read IW haaNm,materiels requirement under Chapter 1 q
Chapter 6.93 of the 19940
[aliform,lledth d Safety Com de,Seelio25505,25533 and 25334.1 udcrotmd Out C�jY
If the Wilding does Int currently hove.mount.tMm It B my"Possibility to undifY the Ut
occupanr,of Ne requiremmu which most Is con prim to luuumtt of•CmiOute of UUY[
FOccupancy.
r Owner or.uthoriecd agent Date A ISSUED BY:
i OFFICE
r .�