25919 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
APPLICATION/PERMIT P`UMBI NG-MECHASICAl, 25919
BUILDING DIVISION BUIDI
LNGPROJECTIDENTF7 TIEN
BUll.f)ING(�Ill)0.1'.$i QST SPQI •� �- SANU'ARY NO, AP%JCATIONSURMfI.1-ALDATE
UNIT# LOT♦ �---(
OWNERS NAME PIIONB: CONTRACT OR'S NAME: I .UCNO.
K45c/J Sro— 73--S31G LY�(L7TlwEs 673 S "A `bl•'Dc°`«
RCHf1ECTlENGINEER: WC NO: ADDRESS: ❑
CONTACT: PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
n BLDG ELECT PLUMB MECH
PERMR ISSUANCE 1C ❑ M. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPTJANCES-RESIDENTIAL
OZZ IM1aeby affirm this l am lic—,l utdc pm vJ,omofCh.pc9(caausmaing vith JOB DESCRIPTION
�U00 Saton7")of Divuian I of the Buavcs.wd Pmfeuiona Cade,.rd my llceue u N PANELg
<zw full rK� O sae.# 673446 uPTxW AMPS
N—a&b_Z cantr.mm b t x01.l I%10 ArtPs �•
FON Z ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA S,(SQ.FT.
p0�_ nI!
I mdcnand my plum shall be usad u public m m N. OVER 1000 AMPS
aN5'� IJcrn�Rofmiwel SIGNS EIEC UCAL ^ �� n LED® ! N
oYaa OWNER-BUIIJ)FR DECLARATION SPECIALCIRCVITIMISC. - OV
qxOaUCM. I ` rI,
I r,ra .(Sc tint 1 e1,cxcnia from da Cmv.0 Co L' Lew for ,y 4kJ Y�
W 3 LL ran which ng recon.(Section"l031.5, afar.improve,
ve,darmd G on,Any my th<otmry 'TEMP.METER OR POLE INST. u
F`-�M Pontt itsuimne,sli bmmthcostal
pplicimprove,Jpmrdtt Erepay wysvunae
f'�Y� pithbiuivrovadpahortywrn tM applianeftlb uCoperrmi ..uc.ugred Ruemad POWER DEVICES
K p that Ae is licrnad puamN ro the provisiau of the Co...!tease Uw(Cheper
a Y cnntmcncin SWIMMING POOL ELECTRIC
FoL, ( gwith Scaion]11W)of Division doDhe Buslnmaaaf Pwfesiam Cad e) _ VALUA
t_�y ththu ba is exampa byancafromudda b.defaljacut o,swmpdon.Any Yblulanof
F-< Section by any epplloa fa.pmnit wbjaa the eppliewt baeivil pceWry a( -�S'SWITCIIES-Fl%TVRES
rx#mme then Bvehumdred ddl.n(53001. NEW RESIDENTIAL El-ECTR _SQ.FT. STORIES WPECONsTRUCTTOR
CEL ❑ Luawr#rofthc pr�pcny.amY unployaswith wage mthnrsdecmopweuan,
ywill da the wak,aM thcwrvnurc is mtinandcdoroffertdfasak(Sec.]034,Buslna.
and Pmfout.Code:The Comrclas Liana I'w doa td apply b w ownv of
pvprny who but Ids a i mpov a thcaan,and who dm au rh work hinucl f m through hu
awn emplgm,povideJ this sucM1 impmvenrnsert not inteMMoroffertd fade.
If. OCC GROUP RES.UNITS
however,the huildiny or improvement is-to within ow,yaar.frnmplaron,Jrc owoc- TOTAL:
builder wJl have the budw of proving this he did.boi)d or impmva fm FotPoa of
vlu).
❑ I,e.awrrrofthcprtgcrty,em cxclaivcly cawaning with lirnscd cmivrtmto Qom' PLUMBING PERMIT FEE Flt]OD' APlJ
comuuct the pajes(Sc,.7014,Buunev sad Pmfessiom Chep The Contractor's
Llama Law a4v a#apply ben owncnfpopanywMtuilJsaimpruvu thmmn,ud PERMIT ISSUANCE
wtoconoxufa such projecr.with.eanV.cta(a)licwaed puauwUathe Cawclrs
Llama U., ALTER-DRAINA VENT-WATER(EA) FEE SUMMARY
❑ 1 am caemp uMn Sec. ,B A P C far Chia ream BACK FLOW PROTECT.DEVICE, SANITARY Y N
Owrcr Date RECIi1PT#
co DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COAIPFcana of ONDI:aLARATION SCHOOL TAX Y N
❑ Irs'Con Rrmthml,.aortificucoJ co,tlmaof( JIM,1aniEacof RF.CIAPt'#
or a Fl%TRJRFS-PER TRAP
Workct%C�mrpuueuan lnsurutcethaanifrd rnpy thetmf(Sx 3800.Lab C.)which PARK FEE T N
Hell ccnpbya's under to.pmnh. GAS-RA.SYSIEM-I INC.4 OUTLETS RE RPT.
PNiry# BUILDING DIVISION FEES
Comp'^y GAS-EA SYSTEM-0VER 4(EA) PLANCIIECK FFR
❑ Ccnificd capyu M1caby fumishul.
❑ CcniBcJ copy is fled with tha city impccuon Jlvl.lon. GREASF%INDUSTRI.WASTE INTERCEI'1'OFI GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GIiPASGIRAP SOILS FEE
COMPENSATION INSURANCE
(Thisscctiannmint lccompletad ifthepermit is forone hurdroldaller,(5100) SEWER-SANITARY-STORM EA.300FT. ENERGY FBE
or I..)
I CWfy that or the parf.n ofthc work for which dbi,permit is issued.I steal WATER HEATER W/VENT]EJ_Cpt
nor employ any Pa.on in any nvnr.m w b/ c,, b tha Wot PAID
CmnpenwlartlIppw.of Cdifmu sae WATER WATER SYSIF-A1/IREATiNG Daae Receipt
U Z
Apphcenl� /
z NOTOAPPLICANT:If,9=meting this Ccnif le of Exception,you sboub NEW RESIDENTIAL PLMB. SQ.FT, TOTAL
V_] boot subject b the Workc's CanpvtvJoo provhian tithe Labor Code,you rtast
R' > forthwith comply with such provisions or this pmon,"I be domed mated BUILDING FEE
M1W. Q CONSTRUCTION LENDING AGENCY SEISMICFFE
D Z I lrreby affirm that Nae is.cadbuctlon IeMing agaby,for Nc pccf.M
U G do work for which thispermit is issued(Sac 3097.Civ.C.) TOTAL ELECTRIC FEE az
Trader'.Nems
W F Irrdar.AdJa QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I mfify Jut 1 hate rod thi. wic.tion wd.ua toot the.bove Informadan is
U.1 umrocL I agroe to comply with all chy.rd comfy adimmcu sod state 4"al.titgb PERMIT ISSUANCE MECHANICALFEE
f^ buibing canrmcimr,.nJ hereby,wtMriu repreaenwiva of this city b amsm upon the
U Z awe-mentiorcP'n J porcrry for impaction PotALTERORADDTOMECE. CONSTRUCTION TAX
M
(We)agra to va,indemnify end kap hennlas the City of Cvpctitn agaimt T
liebintiajudgnctm,cons,audexpcn¢s whichrw
may in any way crue.gaisaki •�
iCity AM UANDIJNG UNIT to."CFM) 7:S_41
in o�nse9uceve of the grwtingo�f/thuperroiL AIR HANDLING UNIT(OVER 10,000 CFM)
///A !' i/ EXIIAUSTHOOD(W/DUCft
St—gret u�E�Applimn/Conmwtm Due PAID
HAZARDOUS Mbuilding
ocIAIS DISCLOSURE
HEATING UNIT(TO Pal BTU) Due Receipt#
Will the a,ldo,Coentmfawe bupJingaapwtsbath"th baraddle hevNo ct anal Sa Tial HEATING UNIT(OVER IW,I##)BTU) TOTAL ZS
u Jeftad by the Cupertino Municipal Cade,Clwper 9.12 and the Health erd Safety
Calc.$orlon 25332(.)?
El Ya ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR I W.(M BTU) ISSUANCE DATE
Will lac eOrnmraiafs n huilJing by data Bay AoaaAcnt ualityawhicM1emit PAID' D
he artai? air rnnaminwu u dearth by the Bey Ara Air tZtWiry Manugrnunt BOILER-COMP(OVER 1 W,000 BT) T M
D odor!
❑Ye ❑No New R151DENTAL MECIi. SQ.FT.
I h.ve aad the M1vardaua noom.l.roNWancnte order Ch.pc 6.95 of the FEB 14 1994
CdifarJa IIW th h S.fcY code Scmiom 23305,25331 sad]3334.I uMeruund that
if do building dors nm coat Mve a amnd,that uta my re"onwbility to notify the (rill Y Ur ,urrh i INN
(acupwt of the requirements which at be Torr prior m i...a orf.Cent Eam of
k ,mrcy.
Owns a audwriad egmt Daa TOTALISSUED BY: I.
-OFFICE-
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