24790 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY VF CUPERTINO
BUILDING RLAI. PERMIT NO �� ��O
V APPLICATION/PERMIT PLUMBING
BUILDING DIVISION tlUll.11lNG PROJECT DUE.\TIFICATIOF
BUILDING ADDRESS: SANU'ARYNO. APFIACATION SUBMITTAL DATE
/0'7.5-0 Fy2R �lb.U� nor # IAT# 3—a"93
OWN' AME: PHONI^ CO RS NAME LIC NO:
14rQ 2 f. I / R2 n S V Ai �y NIC CONTROL#
ARCHITECIIENGINNEEER: !/l LIC NO: ADDJj' ��BTI/C}� /'G ❑
COND ALT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
flL -5TPLUMB MECII
PERMIT ISSUANCE, ❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION APPILNCES-RESIDENTIAL
OmZ IhvOson ebyaffimut Iliermtsm under pmvision.ofCTJOB DESCNI ON
opect(commrnring with /nn•�' �ON
{+100 Scnlon7")ofDivimum3 flhdBuamcv'undPmfwnionsCode.andmylicense isin PANELS
'1FyQ..d"G<UUuy full home,
_1,". a
UP T03W A�'m 0s � M
FIECTS AJQ,/ ?(11.1000 AMPS
ZOrE'it'� ARCIIITIiLTSDECLARedmit, OVER IgM1AMP5 SQ.1-76 FL(F)R AREA SrsO FI'.
O-L—r, I unJcmYaN my plans dull be used n publk mused+.
� SIGNS FL:CIRICAL I' �Pmfcssiwul
u' OWNER-BUILDER DECLARATION SPECIALCIRCUUJMISC.
KO V 1 hcmby afMn Sm I sou stem.)Iron d4 Comuanor',License Law for 0a
(y3LLy fdloving re,son.(SectIm 70313.Busirccs and ltofcssiomu Coe:Any city or county TEMP.ME'ER OR POLE INS.).
F u-0 which requires o permit or,calm,,,dtcr,improve,demolish,or mpair any vronom
S'w Q'7 u
Prior to its lsrunce,ul.u)ne,uimu ppl the aicant for such peromi to file a sigrcd te
swment POWER DEVICES'M4,0 Thu he,is licemssm pum.uant to the provisiau of the Con.or's U.Isw(Ch.pter
asC o❑=myQ y( ncingwith Section
0Division JgBtsieProfsionsSWIMMING POOL :tECOU
or that he is mnb for eslidmexempt,
.on.Ap taxam
VALUATON
ctimJO31.5bynynWliaifmuaiisub*mlroaoM® tmusnvilatyof OUT.E -SWTCUS-F RFS //Q O.
O
WF not moue Own five hmdred Mi.($510).
CC ❑ I,mownrrofthc prgcny,am #FIV RFSIDEVTALE SQ.FT.
ycmployea with wag fcr.1eirsn,.7 n, nsetion, L7—STORIESTYPEC NSfItU ON
R3— will Prmewak,ende five
Commodors La ,,raw clefasale(Sl,.to an sue,of .(t\1)
and liorea,imNu cne:'Il<caumn«,uart,e Law en.appy to m nwn<r tar
{Nopertywhta W idea imlvwn thercm,srd wrodaasuch work himselfa through nu
ownempiny«.,pmoviammat x,Knimpr^vemonl..�mmwintendmaorfema rm..we.H,
C.GROUP RES.UNITS
Mmwever,rate huildingomlmpovcmcnt is mlJ within orate ycm ofcampinion,the Dann- /
Inullderwill hove the burden ofproving than he did dud Wldm bn for TOTAL
pove purpose.of
❑ I,mowner of mM1eprupmy,vne.aclueivdyconv.ctingwnhlkensed cronmmemun to Qom' PLUMBING PERMIT FEE F DZONIi APN
aonua am project(Sec.9141,Hudncv.M Roh scrods CmeO The Concom or's
LiceaeluwbemtyglY to mmowwof popmywrobuiltlsalmpmvea ticmon.vd
PERMED"ISSUANCE
who.as fomsech projects wilh.mnersorer(s)beenrm Pusu.m to me Cmmb.etor'.
Lieser,Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 ran c..nrpt under Sec. ,B R P C faxthi.mum HACK F'LO PROTECT.DEVICE OUTSIDEFEJES
SANITARY Y N
tam D,eDRAINS-Fi R,R(IOF,AREA. RECEIPT#
WORKMAN COMPENSATION DECLARATION . S UOOLTAX Y N
�}I[�' Ihereby uR tread l have•esrtifcae ofecment to self-hours,ora certifieale d FIXTURES PER P RECEIPT#
x rem Contpvmution lmuonduzmaanifcdco,y tMmf(Sc.J .Lomb C.)which PARK FEE T N
mvcrs mi employees wrier mhi.pc " . / _sO GAS-FA. -SYSTEMNC.40VELETS REL1iI1TN
Polq:yN b f�C BUILDING DrvISION FT.ES
Caty's^y - GAS-EA.SYSDEM-OV 4(EA) PVaNCHECK HE
❑ Certified copy is herby fwnirhm.
Cenifzd apt'is fired with the city inspection division. GRE ASEONDUSTRL WA 'INHiRC OR GRADING FEE
CERTIFICATE OF[DEAfPDON FROM WORKERS GRFASETRAP SOILS FEE
COMPENSATION INSURANCE.
('Unix sectio nem not he completed ifthe P-nnit is for one mralmm dullarv(SIM) SEWER-SANITARY-STORM I' MI. ENERGY HE
or less.)
I ttniry tlw in tic per(avurmcx oftle work for which mhispmnir is harassed,I"I WATER HEATER WNENT >LTR
not employ any person In stay m—r so as to become subject to mh<Womkeri PAID
Caa,PdmitinnlswwfCnlifomia. Date WATER SYSIIi EAG Dae Receipt#
Awl.Q z A .
z2 NOTICE TO APPLICANT:If.•fter nuking this Cerufete of Esemgion,you s1muld NEW RESIDFN L .MB. SQ)177. TOTAL:
FQO hcume subject to the Workers emmpecosmion pmvinum ufthe,1..1»r Gds,you most
a hrnbwimM1 amply with mach Pmv,,kami rt his Perma,lall IN,Jecmm reva4cd Bou LDINGHE rLh
00. CONSBUCTION LENDING AGENCY SEISMIC HE
z) Z I hereby affirm that there is a cowracmim lending agent'for the pvfomuoe of TOTAL' ELECTRIC FEE
U O Ilia w^h for which E i.lramit is issued(Sec.309],Civ,C)
Lender's Name
U PLUMBING PL'Ii
Lender'.Archness QTY. MECHANICAL PERMIT FEE
U D certify Trod)have mad this spplimtiun mad sour mhal the above infuntumion is
correct, I Mode to comply with all city umd county adiaoa and stale laws reading to PER M IT ISSUANCE MECHANICAL FEE
Fy buidingv.tion.and hseebyaadvarom"nssurrous esof mhuci,m ever upon the CbNSDRUCI'ION TAX
U Z Ywvc-mrnuaed property for inspection pur{.aER a. ALTOR AI UTO MSCI{,
(We)agree to suave,inJmnnify and kern harmlem:.the City of Cupertino Maimw
Ilubilitin,jmgments.c-I.and expenacs which may in any way secdue agtirut said Gty ADR HANDLING ff(TO low LTM)
in mnse9mmemwT M the gmaxi,of this perrrdt.
AIR HANDLING (OVER D0.(p0 41
Signvumof ApplicnUCmu.nm Date EXUAUSTIIOOD(W UCf)
PAID
FIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I AMBTU) Dote ReceiN
Will the N+plicvmt or future building occupant came or hvdle hazardous material
u dcfnm by the Cupcnino Municlpd Code.Chaper 9.13,srtl the Deal W Ssdfs, HEATING UNIT(OVER[W-4.B TOTAL:
Cade,Section25532(.)9
❑ye, ❑No VENILATION FAN(SINGLE A,ID)
Willthc Tatum buildineoceu�mmtuse BOILER-COh1P(JIIPORD ,000
ISSUANCE DATE
aPPlb^tm cquipmmtomdevicdwhichcmit
hexurdaua air mnumhunma n defied by the Hay Arse Air Gaul M.oaparent BOILER-COME,(OVIIt 10,U10 BTU) PA / 4
Dlstnn9 � p..
N
❑Yu EINIT
No NEW RESIDEAL F.CH. FT. !F'1�1
I have rem!the hvmc1drx cents red,urmem,ander Chapin 6.95 of the •POI„� �519g3
Calll'omia I IwIN R Sa(emy Coq Sccyiomu 35515.2553)aced 255J4. I unemWnJ thal L V W
if the building Jou wtcurrmdy bvea mrtt.thatite to
pmtsiHBtymrmaify me I Cur
upans of rte requimntcvs h muse be met prim m irsumue of. w mif de of a
1
mat .gent Dste TOTAL ISSUED BY:
OFFICE /