25424 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' . BUILDrolti-VaLMMICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.IBB /�5 /I 4/�t
_ UUMINOFROJECEIDP.N1'B1QGA77ONj{ -t"S�'Bi J L
BURRING ADDRESS: G#�af� • �p SANITARY NO. APPLICATION SUBMITTAL DAT
/OD rrL /I /20 IfbIIT# IRT# S ..
OWNERS NAME: Pt[ONE: —21-6— CO CTO ' NAME: LIC NO:
S SIC 2u .0 \ NIC CONTROL#
G ~JCI II'" ILNGINEER: LIC NO: #DDR S
❑
NTALT: PHONE: '. r,
- L '% ')—BUILDING PERMIT INFO..st^�\
Y9ELECfR1CP A '11 a FEEFy,t
/c t�! /rsbo PERMIT ISSUANCE ELECT PLUMB MECH -
❑ ❑ ❑
s LICENSED CONTRACTOR DECLARATION APPLIANC -R I ENTIAL 108 DESCRIPTION
—_` Iheodo affirm that l amlianeedmderprovlalomof Chapter 0(cnmmencing with
_ Scnion iW)I.f Division 3 of the Bu.inn.mJ Professions Cale.loss ar,license is in
PANELS
x�—
full fomc and dicot.
eVU
�y�/�/5 1
. Z•.., Lacnx UP TO Class Lic.# A
g,JB/'es`O
1�y Date C.mramnr OV I(M PS
7C Z s shall TECT5 DECLARATION OV IAAIPS SQ,FT.FLOOR AREA SISQ.FT.
O Z-7 l understand my plum shall theueJ m public recuts.
SI LECIRIC L
6 -_ Licensed Pmfcssiond
^_< OWNER BUILDER DECLARATION ECTAL CIRCU S .
1 heteby ffu a that I ten ex<mpt from Ne Conuvemr's License Law for the
'd—_•a�C' following....(Section 7011.5.Business and Professions Cade:Any ciryar county' MP.METER A PO EINST.
,A which requires o Permit to camnuct,alter,improve,demolish,or repair any
W
swcmrt
, }m poor 1.its ismance,a6.requires teeapplicam for euchpamitm fileuig.adsummem POWER DEVICES
m C C ma
p that he is licensed Poon .the provisions of the Cooumr s zcLicenu taw(Chapter SWIMMING POOL ELE
a X�� 9(roun
(commencing with Section 700010(Division lofNe Business and Professions Code) VALJ�r�6jJ
W—y or that he is exempt therefrom and the bar.far rhe allegedexcmptim.Anyviotemnawf OUTLETS-SWITCHES-FIXTURES
L.ZY Section 0011.5 by any applicant for u permit subjects the applicant a civil penalty of
< not more than five handed dollars($50(3).
=PQ ❑ I,mown<rofJde Y P Y 8 pemation. NEW RESIDENTIALELECB _SQ,FT.
properry,orm cm m eeswidffo esus all(Sal.cam TORIES TYPE CONSTRUCTION
will dothe
esaims Code he cture Ciouisnoninxnense Lawcovfineale(Sey 7614,Business
and Rofessiam Code:The Convectors License law docs Trot apply m m.carter of
property who buildsorhanrovn then.n,andwhodoassuch work himelfortmoughhis OGROUP RES.UNITS
ownemployces.provided thauuch impmvcmenuarttotintendW oroRertd Torula.U,
however,the building orimpmvemem is sold within oneyeeraf canplctiom,theownn- TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
sale.). ,y c' /, S,r;a-j��.,a- .. sy N:�ny Y`�;?.:_ccs
❑ I,us.wneraf the pmpenYemexclusivelY convattin6 with lic,nxdconmcmnm QN'.}-"�?-.f,
PLUMBING PERtrB•f [.L„sY ��• _,-p{ FLOODZONE APN
.nsran the project(Sec.7614,Business and Professim.Cade:,The Contrecmrs
License Law doesionapply loan ownerofpro,my whobuildsmimpmves Nereco.and PERMIT ISSUANCE
who coalfasuch projects with.contmctorod licensed pursuant to the Contrum's ALTER EA t"+'•' �r
License Law. FEE SUW(MARYfjg�»�t:d
❑ 1 lure exempt under Sec. ,B @ P C for this rtnon BACK FLOW PROTECT'.DEVICE SANITARY Y N'
Owner Dare DRAINS-FL . RCE
OOR.ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm Jutlhav<.cndfiate of<otuatt self-imue.na mdficatc of RECEIPT#
srken Component..lmureneeora cenifted copy thereof(Scc.3800.Lab C.)which -PER TRAP PARKFEE Y N_
roves till armlaloe a under Nis permix OAS.EA.SYSTEM-I INC.4 OIIDETS RECETFr#
Policy# BUILDING DIVISIgaFEES
CoCmifi,d copy is hereby fumiahed.
Clany
GAS-EA.SYSTEMAVE (E
R 4A) PLANCHECK FEE
nn
❑ Cmified copy is Bled wiN the city impaction division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTISCATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundeddoll.n(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cently dust in the performance aide,work for which this Permit is issued,l shall WATER HEATER WIVF.NTIELECM
out employ any person in any mvacr m es to become subject to the Workers PAID
Z Compensation Lawsof California. Date WATER SYSTESVBEATING Data Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If.after making Nis C,nificese of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
` V] become subject m the Workers Compensation provisions of be Latin Code,you must
x D forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE �#
0- CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby art=that there is a cansuoction leading agency for the performance of TOTAL ELECTRIC FEE
V O the work for which Nmit is peris issued(Sec.3097,Civ.C.)
r, Lender s Name •-. ?($vy.»"" ^'�`°"."• .- ..- i.•:J.;'ii -yF"Y¢..?: PLUMBING FEE
Lender's Address Q7-Y.k •rs a MECHANICAL:PERMIT'.'' ,tFEE"i ;`
} 1 certify Jut 1 have mad Nis application and sum toot the above information is
comet. lagreemcomplywidhalleiryntic...tyoaaad
mmomnaxbwrrelatingm PERMIT ISSUANCE MECHANICAL FEE
building ematruni.a.and heeby mabrixc ep ssenutives of ilimcq ua enter upon the CONSTRUCTION TAX
V Z abrvcdncmi.ned p.,oy for inspection purposes. ALTER OR ADD TO MECH.
(\Vet agree m sa e,indemnify keep harmless dee C' of Cupcnino against
IWbilidia.judgmenn ns and cup, es M1ich nay in any cmeagtinat miss City AIR HANDLING UNIT(TO IO.OIX)CFM)
ianxque�e old greening eR, Pe it.
S p AIR HANDLING UNIT(OVER Mods)CFMI
r 7
Signal A .Dae EXHAUST HOOD(WIDUCTI PAID
Hr \R fo15 MATERIAL LOSURE HEATING UNIT(TO 100.0011 BTL) Dae Racipt#
Will the Inatome
lure building aecupam stemm hamfle ha>:udous material
HEATING UNIT(OVER 100.008 BTU) TO
n Jelined by the Cupertino Municipal Cak.Chapter 9.12,and the Hcahh and Salcey
Code.Section 25512(a)?
❑Vie, ❑No DVENL\TION FAN(SINGLE RESID)
ISSUANCE ATE
Will thea licumor funic buildin ecce BOILER-COMP(JHP OR 100,01)(I
Op 8 Pana usecquipmemar Devices which emit
Laaurdnus air emnarinums as Jelined by the Bay Area Air Quality,Mmagcmem BOILER-COMP(OVER! 0 pTL) n A
100,00s /AT
hmvdo
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. r D
have read the us materials n titicmemrs under Chapter 6.95 of the
110"'mcialding
ilin.l Health@Safety Cod,.Sections 23505.25533 and'_5534. 1 tndersamdtoot docs not currently base a tenant.that it is my responsibility to notify the AUG —
Ieu F nix Yf the requirements which must be met prior to time,.1 a CmiOate
thea a
()%ntor aathuoi cd agent Dam TO TAI.: ISSUED H'.
OFFICE