S 0252 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELecrafaM, PE�^IT No
BUILDING DIVISION APPLICATIONMERMIT PLumBING-MECHANICAL. J 0252
BUILDING PROJECT IDENTIFICATION
BUI[I]I
NO D RISS: SANITARY NO. APPLICATION SUBMITTAL DA117
CO AllN
NIC CONI'ROLN
�A III'MCfEN'INI313R: I,IC NO: Al RISS: ❑
C PHONE BUILDING PERMIT INFO
NJAIm ❑ Constiltent Fees Paid by Applicant(Initial) BLDG; ELI! PLUMB MECH
m, al _6A0El ❑
1 hcrchy. trtn
CENSEU CkNOIRA17OR:S DECLARATION QTY ELECTRIC PERMIT FEE R DENCRIPTION
tMt I dam M pmvinitms of CTmpter 9 Icmmtrncing _
O afZ wim Section]all anon 3.nne sad . D,ur i .c o dmYliceveis R UID NTIAL'
W O PERMIT ISSUANCE
W in full force end d 0 ❑smwh ❑KITCHEN REMOOIH,
sic CleanseC Lw.41W
pPPL1ANCPS-RESIDENTIAL ❑ADDFUGN ❑PI.UMBING REPIPF
rn< Dau Ctw ❑MULD.UNIT ❑STRUCTURAL
ANCHI'fECTS Z l u Y Man•shag N,used s PANELS MODIFICATION
OZ�—'W '1 - QI'l(1300 AM PS El INTERIOR 11 CHIMNEY REPAIR
FN�W Licarei lYo(essitxml 201-10MAMPS LMPROVESlliNT C]SWIMMING POOLS
< �,J
OWNER-BUILDER DECLARATION
Q I hereby atEnn slut I dam exempt fmm the Conluxtlr's Licrn.a law for the OVER Ia d AMPS El BALL]RF,MOUEI/REPAIR UIih10LfIlON
xd O a U follmabeg reason.(,Stttitn]11315.Business end Profassoro,Code:Arlt'city m county SIGNS FLECIRICAL C]OTHER
which aquiae.lerdhit to cumlNer,clear.improve,deeeloth.or reW1r wY arced rt
0 priorto its issuance.also requires the opplifant for such permitin Hk a signed.ueamcnl SPECIAL CIRCUITlMISC.
f r�). thvl he is licen•N puuare to the Pro,is.of she Gn.rYln(s tic.16w(r,YWpl t9 OM�ERCIAL.
�1'p0 Icommeneine with Secttun]agl)of Division Juf me BusiIXu and Prnfecsirms CnleltxTEMP.METER OR POI.F.INST.
tL y o That he is la Ihaefmm unsl the tui.Rv Ole WIegN e.crl�tiun.Any viulvion of ❑N17W BLECuADDITION ❑DEMOLiTION
uXl 1i• Smim]OII.SM1ytoy opplicent for Mrmil suh}cts the applicant luacivil
Fecal of PON'I:N DBVICCS 0TENANI' ❑FOODSERVICE
F-Z> est than five hundred dollars S500). Ih1 PROVF1v1F1sT
< Ql,e.wnero(thc pnyeny,mmYcmplrryreuwithwa8ea a.tMirmlefnrycmatam, SWIMMING POOL ELECTRIC ❑OTHER
3C wield.the work,aadUes.Lic is not intcwld oroffmed finealc(Sce.YMd.Business
F sed Prefessiuun Cade:TM1e Common./.Liana Law docs rw apply to an owner M OIITIETS-SWITCHES-FI%TURFS
prupfny who builds.,intpmvcr Item..,and Woo does such work himw[f m through
his arson employtas.Thai Thu such imlmwrnoR not t WeirWeirdest m loffered for NEW RESIDFIAL ELEC R SQ FT.
side.IL howuxc the buildinetrimpmvemcln is add wimintnayec,ofvnpIrliu,ire SQ.FP.FLOOR AREA LSQ.Er
..chlor will lune the header.M pmvine the he did to build or impmse far pur- P ,
intent ],.) A p
I,u was ofthe pmem Pcr e.sheively rnw.cling wilt IicCrtad rnntrvnars les 'f0T'AL:
ted.the ppojcn(Sm.7641.Business ad Professions Cade:)The Convumrs Li-
cave law des rvul.pply low owrerofpmpcny who builds or improves diocese.sed QTY. PLUMBING PERMIT I - FEE +oC
win n.m.cu for such M),cis with a ctmtractmlO Jcevd pursuant to the Conduit f�
Liana law. PERMIT ISSUANCE /1.- (�
Ise e.cmp uNa Sm .B&PCtnnhis avtc
ALTER-DRAIN.@ V ENT-WATER(EA) NDUAT1ON
Owner Data
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT,DEVICE
1 hcrtbyillirm sederpcnehy auofIfollowing
im:
�IM1arc vtd willtmintwn vCmifruh,ofConianttoalff-incorelitrWorkerh
Cnmpero DRAINS-FLOOR.RWEAHhA,COND. STORIES TYI'ECONSTRUCfION
satire,
wuhhr p chthis
thi sIp«cmTrytit 5i«iswund3][IO of the Iahm Code,fa the perfsrmarce of Jae
FIXTURES-PEN TRAP
I M1arc,,nd
will ode.fon he P rfu.Cone of the s Inaor which
ss aquird by Section '
39x1 of mclaMe Code.for the perfnm eMthe witrk Lx whiaM1 thio permit isitmed. GAS-FA.SYSTI3M-I INC.d OUTLfOS (ICC.ORQDP AYN
My Worker's Congevyimt huuraIX'e mcvric Beat Polisy number sec:
Cooke Policy Na,: GAS-IA.SYSTIALOVER d(G)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRL WA5Tl!INTERCEPTOR
COMPENSATION INSURANCE , BUILDING DIVISION ICES
The, nod rw be cmrytWWifde nn
tei,i.!arcane hundred dnlLva(Slip) GREASETRAP
it Iw)('IPLANCHIiCK FEE
I amity that in lbs peforratw oDbc work for which do parent is o tail.I JWI SEWER-SANITARY-STORM EA.200 FL
not employ any person in enY menrer m v to barna subject to the Weaken*Corafen- ENERGY FEE -
oZ wInm Lawx of Califomu.Data WATER HEATER WNINT/CIECTR
CO APplicW ) GRADING IEE
NO CE Til APPLICANT:II:ager nuking this Coniometer of Hxen doom,you should WAT13R SYSTEM,7REATING SOILS TCC
hefvtc subject to the Worknr's Cotnleotion apmvisiwn of the Isbor Coffee,you must
forthwith comply wilt such pcoemn tx this permit(Wl he dtswvl revoked. WATER SERVICE
aQ
Z RTNSTRUCI'ION LENDING AGENCY NEW RESIDENT[A].Iai.fB, SQ.IT PAID Dye Recei N
1 M1ertby.ICrm motacre lisfol 307.Civ C.) Yfm the peRormaIXe of A
0
'be work fm which this permit is iuued[S<x'�9lro],Civ,C.1 TOTAL'
O F' L<MeR None
W Isdcrs AJJrc�s 'f(lTAL:
a. 1 cenifY that e
I have cel this oppriaenei
lifan d ne that tte.bove intmrcdon is BUILDING IEE
Com. to couccl.l egacm comply whit,all city end cnuruy onfinarco mud are law.mleing to QTY. MECHANICAL PERMIT FEE
V Z hudding cnnsucliunid hereby vuRwiie al). ht ivee of this city to entme the
SEISMIC IIiE
u
above-mentinned P ti eny fa inspection pu Fro cs. IYRMIT ISSIJANCE
(We)egme w wve,inkmnity aril keep harmlcs.the City of Cupertino against 11HCHi1C FEE
'ebili ajtvJ,_ha Is.dexce.,tichntaYininywayacccheirlinwwid Cay, ALTLRORADDTYIMHCH.
to gacrne of g. 'ng of this it. PLUMBING ELI!
A'PLI 'A UNI AS DS AN ELI C NP WITHA�V(. )TNI' AIR HANDLING UNIT TO III,IXkT CPM) 6111
$ OR !RI ULA I 5. T MECHANICAL THE
AIR HANDLING UNIT(OVlOt Io,l10f1 CFM) CONSTRUCTION TAX
Sig V uaof ApPlic I/C ¢ EXHAUST HOOD IW'IOUCO HOUSING MITIGATION FEE.
1 4S MAT RIAI S DISCI, SI1R F,
Winflevpplicentmfte but gomfaruulw handle materiel HEATING UNIT ITO 10)(LO lBTU)
as dclio d M1y the Cupcnino Mcu cipal Code,Chapter 9.12,end the Hulth and Solely
Code.Section 25532n)? HEATING UNIT(OVER 103.000 BTU)
Yes Ej Nn
VENTILATION PAN(SINGLE RES ID) I'AIU Dec Receipt
Will the.,lifanl or future huilding tccupanl too cquipmcnt or illy ice which
emit becanbn,yr ctrtmmiranLea,contrast by the Bay Arta AG Quinn,Merulecard BOIW3R-COMP(3HPOR HARM HTU)
Diurict4 TOTAL
❑Yes ❑No IIOILI3R-COMP II1111M10 HI'U)
IM1.ve mad the hwenkws matcials rcquimrcnts muter Cltutxer 695 of the Gl i- AIR CONDITIONER 1 CE DA
forme Health 1 Sefpy Code.Section,25505,:3533 ed 25511.1 t nkrgvtd that if ale
NEW RESItlIiNfIAL MECll. SQ.IT
boildie8 doesm curfently huve o Ienvv,that It is mY aspxea M1ility eu unify the tnaupant
d the u.,.irertNwx which maw be mn prier to issu.nee ofe Crnifvu d(keupvtey.
(Timer a.mtton.d ogee Dmc TVfAL: ISSUEDBY:
OFFICE