26033 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING—P.'E PERMITNO ^^O
APPLICATION/PERMIT PLUMBING .MECHANICAL Lb
BUILDING DIVISION BUILDING PROJECT IDF.NTINICATION
BUILDING ADDRESS SANITARY NO. APPIiCATION SUBMDIAL DATE
�/� UNIT" LOT �./ M 9
OW iRS NAME: r PHONE.: CO ACT R'S NAME: LIC NO'.
NUC CONIROLN
SRCIMECr/FNGINF.ER: WC NO: ADEIRJ�: ^ ^� ❑
COM'ACI': PHONE° QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
l n RBLDG FlF,Cf PLUMB MECH
A
4wsl PERMLSSUANCE ❑ ❑ IGj ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENI'1AL JOB DESCRIPTION�y I hereby affirm that l am licewM UMo-pnwisiorrsofClrept«9(cmnnencing with
00 Seen.].1000)ofDfo,ion3ofthe Business stW Pmfeciaru Cade,aro[my lk,enz u in PANPiS
SUEfull rar¢ust effect. i
I2y4 Beate Chu, Iic.N 7 UPT0200AMPS .
y 6 yDace
y0 - Contnctm 201-1000 AMPS
to J�/7�7dkCHfIF,CTS DF, ,A ATION OVER 10(a 1P5 SQ.PI'.FLOOR AREA S/SU�F-f.
oyto_M Iundcrsuust my plans shill be tiedu public record+. R II1���
F vtF; SIGNS ELECTRICAL i� Ia.. E D I Y V
Limned Profs.iorW .. - 1ql T OF.�..N
u�3 Elik DECLARATION SPECIAL CIRCUTTIMPSC.
C y following rev«a.(Secti O 03I.5pN 1iui0rcv arst Pmfeaiaru Cale:Ary ciry a county TEMP.MISTER OR POLE INST. v'J t,J 1 i
V hereby
ff that I am m—,I torn the Co..,',nLicense Law for the
�i',5 which requbeu.pcmrittom.covet,shm,imlvove,deoolbb,orrepair any
.wemre
CMQ7 prior to its issuance,than rea,u the applicant farial part to fileaai® d
eaba., PoWFR DEVICES
E,1<o that b,is liccmNlmou.m to the Provisions.f the Comr.cml.Lienee law(Ceuptm DATE
a ECI9(cnmmercing with Section 1000)of Divrimmr 3ofthe Businss aro[Pmf¢rimu Code) SWU4dRG POOL ELECTRIC VALUATION
y�_,, or that he keaempttherefmn mst the luau rartbe.11eltivJ e*mrrhtion.Anyvlolulmof OUTLETS.SWITCHES-PLXIURES
Cy>- Section 703 L3 by any.pplirant for a Permit subject five applicant to e civil penalty of
ort naw thin five hum!ida1W.($500). NEW RFSIDENIIAL ELECIR _SQ.FT.
l.uoO r ofth[
K�� ❑ propenty,or,nano oym withw.gnu Nelree.7W.rnntlm, ORIFS CONSTRUCTION
y3_ will dadew«k,iiad Coll:: he Comcoure iat",INcdaraifirnal wclece nen appec.1614,owner
ess
est erty wh on.Cudc:The Contnctm'.I .Iso dos oar reply to an ow gh is
pmpcMyww bwldsmimptorsthcrwr.Mwhodrcuuch w.h him.Nfarthmuyh hu .GR P RFS.
UNTIS
ownemploye builds need mprovcmenuve nen lmeohdarofraeA thecom
If,
bawem,thebue ftlunimprovementn ofis at withinaneyamorcmroveifortheowrcr-
builJerwill have the buNen ofpmving diet be did not build m improve for puryou of TOTAL
sole.).
E-) I.uowrcrofthc lvopenty,em eaclmivcly corn vng with lianscimrm.cmnto QTY. PLUMBING PERMIT FEE FLOOD Zo "N
,anteroom the project ISec.10,14.Business stud Protusion.Code:)The Cmtvrra'c
liamcl�wdoa mtePplymanowrcr.f property who ddMsminBmmaJcmt,.nd PERMIT ISSUANCE }�
whocomrucesforsuchprojzU with atontrectar(s)liccnudpuuuantDo theCmuxto/.
Lion.Law, ALTERS (EA)) FEESUMMARY
❑ 1 am e.aemPt un er Sec. ,B&P C fm thi.reuoo BACK FLOW PROTECT.DEVICE E FffT
SANITARY Y N
Owner ail DRAWS-FLOOR,ROOF,AREA,COND. RECFi"N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereny.IBrtn thotlh.ve acatiBann of um.ent D..elf-inwre,maanifirue of RECEIPTM
Wakes'Carnprnsetion Irvruuc<m a¢nlBed c
POSTURES-PER TRAP
spythenwf(Sec.Jg00,lab C.7 which PARK FFE V N
RrlwyNl toy Sullen thu permit. GAS-FA.SYSTEM-I WCAOUTt£ i BUILDING DIVISION ETES
0 Centred. /6- � GAS-FA.SYSTEM-OVER 4(EA) PI-a NCHFCK FEE
ceopr to ler rftnfeea.
'141Cenifieil copy is filed with Jia dry lnspectim divlsim. GREASHaNDUSTRL WASTE INT'ERCEPT'OR GRADING FTE
CERTIFICATE OP E%EMPIION FROM WORKERS GREASETRAP SOBS FEE
COMPENSATION INSURANCE
(Thio,action need not he competed hire petmi,is roroe hunduel dollar 1$1 Wo SEWER SANITARY-STORM EA 2U0ET. ENERGY FEE
or lm)
Itertify NUlndupcform.rceofthewarkfmwhichdti.pc thlvuN,l.h.0 WATER III:STFR W[VE/fJRCIR S
oar a*,any peinrm In any m.mtee an u w become.object no the Wand. PAID
O z ^.mpenmtion l-aw.of Cabr ml.. D.4 WATER SYSTEM/TREATING Dote Receipt N ,
z O NOTICE TO APPLICANT:9.after meting this Cenil"v¢of Eent,mon,you.FouM NEW RJESI DENTIAL PIMB. SQ.FT. TOTAL:
CC_ became subject to the Worker's Carnpenvtiort Provision d the Tabor Code,you most
forthwith comply with such provision or this pmNt shall he deenoM revoked. BUILDING FTF
W MNSTRUCIION LENDING AGFNF,
CY SEISMIC FEE.
5 I hereby affirm Dust dere is.conviction IUWinp saltine,for the Pvftxmuee of
V O the wart for which Dhh pmndt u unbent(Sec.309'1,Ci,C.) TOTAL S ELECTRIC PEE
t-. 1<rdel.Nm
O [(-,• I '.Addro. QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I ccnify Jut 1 barn and this a,,licmion end Nate that the above uformentirm is
nal.. cartel, inane to comply worth sill city rust runty coinerces®o[. .laws relatingPERMIT ISSUANCE MECHANICAL FEE
_ (� buibirnyamnmction.est hereby autMiee rtpe.entb4rn of thin city torntvupon the
I..) z above mcmiebol propmry,for inspection purpms. ALTERORADDTOMF,CH. CONSfRUCIIONTAX
(We)atone to save,irW Inify.M keep lurmleu the City of Cupertino against
liabilitis,judgmems,emu end e.,ma,%vehicb may in any way accmeagairo mid City AIR HANDLING UNIT(I 010,000 CFM)
in faNrtuyucrcc af therite of tui.pamia
AIR HANDLING UNIT(OVER IO,DkTO CFM)
are arA icam/Cooreanrc Dote [IXIAUSTHOOD(W/DUCT)
PAID
I IA]ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Caere Reecipt N
Will the applicant orfum,belldin6 oavpeat More or hstdle h.audwu mntvul HEATING UNIT(OVER 100,000 BTU) TOTAL [-T
u dcfinul by Dhe CupertinoMmdcilrth Cade.Chapter 9.12,std lie Irs1th W Safery J v
Cak.Sttti 255J2p)1
11Ys 1:1 No M'IVELATION PAN(SINGLE RESIDI
❑ 1
W illthe BOILER-COMP(]HP OR 100.000 BTU) �)N45;i ANCE DATE
apPlicamwflmrrtbuiWing«cupmn uucqunpmem mdcvica anidei emit Y' AN
h anbywictl e'er cau.rtdnaeu u itfvd by the Bay Am Air Quality M.n.germu BOILER-COMP(OVER"00'"BTU) r_JBBN 19
'(60
o ❑Ys 0 N NEIYRESIDENTIALMECIL SQ.FT. 4 IJv�4
1 have msl the haaaNau materials bNer rcnu tMer Ch.pm 6.93 a Je C�Ty
C.Iifamia Health&Safety Code,Sections 255115,25533.nA 25534. 1 mdensbno[that
if the bui ldinS does ort currently have a terwD,that it is mymltwiMliry to notify the, - I' vI✓r �
arupem of the rnquircmcnu wuicM1 mut be nun prim to iaueme nfe Crnifico¢of f{I/'eN/
attpaney.
bwrcra.uthorird egrnt Dire TOTAL ISSUED BY:7!�