25388 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN OErr.NLY vItRMTr NO.
25388 CITY OF CUPESION PLUMBING-MF.CIIANICAL
BUILDING DIVISION APPLICATION/PERMIT r24aF+li'w' L.BUILDWGPROJECTIDFNTIFlCATION-
SANITARY NO. APPLICATION SUBMITTAL UAIIi
BUI DING ARS: Rl
3 'e IIWW// UNIT LOT `rl" /S
�
O E N E PHONE: C R'S NAME: LIC Nr// NAC CONTKOLx
�RCIIITECT(BNGINEEK: LIC NO: A D ` ,C r/Ix ❑
' wEsLaE•-CT'R,nIC ti s -xL sa.e ts«Jl,CL
..•-- o . tN.�" BUILDING PERMIT INFO
I ; EE MECH
-
PERM
ECHONTACf: PHONE: BLDG ELECT PQm .
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESCRIPTION
]L'2
thereby affirm Nan l am licensed underpovisians OICnapur9(carnmencing with 4
0 F0F.. Section 7").f Division 3 of dre Business and Pmfessi...Crate.aced my licmx is in PANELS 2 OCT/ s V V a a
YZW In and Ltc.N 75 IIP TO 200 AMPS
,<A- Data / Cont
ncwr 201-1000 AMPS SQ.Ff.FLOOR AREA MO.FL
0y ARCHITECTS DECLARATION OVER 1000 AM
:gip1 undetstmd my Plans aM1JI be used as public records. I
nF'uq SIGNS ELECTRICAL
dCQLicensed Professional OWNER-BUILDER DECLARATION SPECIALCIRCUIT(M C`- II
J6 U I hereby affirm slut 1 an exempt Iron the Contractor's License Lew for Ne TEMP.METER OR POLE]NST.
=0y following mason.(Section 7031.5,Basin.and Professions Code:MYeiry acaunty
which requires s Permit w'can—L Jur,improve,demolish,or repair my mucture POWER DEVIC �A I C
3}� pimtoiu ixuance.ewrtquims Neappllantfaamhpmnitso Bleaaigmd wemmt
yp0C
dust he is lianred pursuant to Ne pmviuoru of NeContncmr'e LicmxlaW(Crtvpur SWIMMINGPOOLELECTRIC VALUATION
eLL 9(cammencingwiN Smtion 70001of Diviaion3afNe BuainassmdPwfessimu Cade)
y_y mthat he is eaemq Nertflmm andthe basis(or Ne Jleged caernpuon.Myvidadon of OUTLETS.SWITCHES-FD=RFS
.Z} Smdon 7031.5 by my applWnn fore prmitmlascu the app)iesnrwa civil pendry of -
L C n t more Nm five hundred dollars 5500). NEWRFSIDENIIALELECTR —SQ.FT. STORIES TYPE CONSTRUCf10N
`4 ❑ I.0owrurofNepropeny,ormy=PloyaawiNwagesu Ncirsolemmpm uon.
i3— willdothe Wark,mdmeavuctumisnmmimdedmaffexdfmwe(S .70I4.Busineas
and prefexiom Code:The Convectors License law does nm apply to an owner of
pmpeny wh.Wildsorimpwvesinereon,ardw1a.does mchwork himxlfmduoughhis OCC GROUP RES.UNITS
owncmployoue,provided Nmmchimpovemenuarera inncMedoroffertd(or We.if,
however,thebuildhtg or impmvemmt).mild withinaneyeer.fcompledan,the owner TOTAL:
Wilder will have the burden of proving that he did not build or improve for Purpose of _ .,,, "Yayscc
ode.). % "`�kI,ea..;4PLUMBBJG PERMITfY}r.ti'�;l�kµ•< jr FEE FLOOD LANE APN
❑ Lmawnaroftheptopeny,mr,mlitimlyourromorgwith isxnsedmnmcbnm s%:a :.::i'_"•• IE`.�+I+^`•^n1"1
construct the Prow(Sec.704al,Business and Pwfessimu Code:)no Conmmor's PERMIT ISSUANCE
Lianx law doesnotapplymmowrurofpoperrywhobuildsor impmveathermtt,and Y ,-_
whoconvecsfmaxh projects wiNacourecwr(a)Bansd puneantwNnoAI
ecanvela ALTER-DRN@VENT-WATER(EA) FEE SUMMARYp-iy_•',..i•:a;-
t.
License taw. .le Or.
❑ 1 am exempt underSec. ,B R P C fa this remon BACK FLOW PROTECT.DEVICE SANITARY Y—N
RECEIPT N
Owner Data DRAMS-FLOOR ROOF,AREA,COND. SCHOOL TAX Y N
WORKMAN COMPENSATION DECLARATION RECEIPT is
hereby efum Naz L have a cenifare of consent to self-insure.maaru0uneof FIXTURES-PER TRAP PARK FEE Y_N
en Compaunon Inwrartce a aanifid copy therm((Sm.lg00,Lab CJ which RECEIPT x
*-- rovers Jl mderABs9etmit. GAS-EA SYSTEM-1 INC.40UfLETS BUILDING DIVISION FEES
Policy x J ra
Ga,,,pny GAS-P.A.SYSTEMAVER 4 TEA) PLANCHECK FEE
❑ 9"'t ed copy is hereby furnished.
MJ 'Ccrtifed copy is fled with Ne city inspection division. GRFASEANUUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION RJSURANCE
(This xmion need notbeonmpleted ifthe permit is for one hundred dollen(51001 SEWER.SANITARY-STORM EA.200FT. ENERGY FEE
mIc certify
erdfY Nm in the perfotmmce of the work for which Nis permit is isaued.I shell WATER HEATER WNENT/ELECTR U
PAID
nm employ my person in my mumer w as to became subject to she Walken NATER SYSTEMjTREATING Date RaciPnx
Compensation Lewao(CJifomia. Data Z Applicmi NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Q y NOTICETOAPPLICANT:H,Cimp'ningthu Cmlfiwe of Exmpdan,youuld
become subject mthe Worpev
kers omadprovisions ovisions of Ne Leber Cade.youu must BUILDING FEE
forthwith comply with such provisions or this Permit"I he shamed rooked.
SEISMIC FEE
A CONSTRUCTION LENDING AGENCY
Z I hereby affirm Net there is a construction lending agency for the prfennmce of TOTAL: ELECTRIC FEE
the work for which this unit is issued(Sec.3097.Civ.C.)
Lender's Name pe y"Jas- .•','.i..•. f-y',y!`? ,c PLUMBING FEE
�+ lenders Add — Q'fY.::y' 7-MECHANICAUTERMITs„ 1 et: > ':-.
_ 1.I Agl that I have rad this application and sure that the above aws losing udon is tv, - MECHANICAL FEE
6. corrmt.Iagta to cam Ply with Jlciryardc,,niinuojunces ansh auv bwtrupom PERMITISSUANCE
rA buildingcotuwcdon.and amhorirt rtprtsenutiveso(thiariry memcrupen the CONSTRUCTION TAX
Z above.mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap hennless the City of C- On against
r Imbilum,pilgmens,toes ardexpensesw h mayinmywayaccmeage' Iend CityAIR HANDLING UNIT(7010.000 Cl
one J/WitP /JI I / AIR HANDLING UNIT(OVER 10,000 CFM)
Signa use of A,fcmXcmrxt r U Dau EXHAUST HOOD(W/DUCry PAID
HEATING UNIT(TO 10(1,000 BTU] —Date Receipt
{(n tofro OUS MATERIALS DISCLOSURE L
Will the the Cupertino Municipal Code.
C u.Chapemrea.hatdlie Health and
HEATING UNIT IOVER 100.000 BTlll TOTAL:
m def ted by the Cupertino Municipal Cadc.Chapter 9.12,and the Health and Sefery _
Code,Section 25532([)1 VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No ISSUANCE DATE
BOILER-COMP(3HP OR 100,000 BT11)
Will Neapplicmtafuumb[fired by the Bay Alan Ailt Quality
nl pp
A11111161hmurdous Jr conumians m deDned by the Bey Arta Air Queliry Mmagemem BOILER-COMP(OVER 100.000 BN)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ FT , t083
1 have rad she hmallo e,mamilla 5505.25533 sed 25 Chapter 6.95 of the Nov o
California buil Health Safety Cak.Saco ana25505in it is and25534.1ilyto bond Net
ifthebuilding tiesnor cunivew have sealer,Nato is myreaponsiof. elmdfythe r
recurrent of she requirements which must be ma prior to issuma of a CeniOum of
Occupmcy.
Owner c r m bodxd agem Dan TOTAL: ISSUED BY:
OFFICE