25451 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' TMs- 'FuCHANIC PERMIT"°.
BUILDING DIVISION APPLICATIOWERMIT PLUM ROJEC7 IDEN7HFIC 25451
/I C 1
BUILDING PRUJF.CT IIIRYTIFICATION JL�J
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMOTALDATE
tO OO r UNIT♦ LOT# ���
OWNERS NAME: PHOb6CNE' JC NO:
S / El �L�
%R /ENGINEER: O. LIC N(]: ADDRESS: ❑
GQ Cr. PHONE QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�V�V /v{o,V �' PERAffTISSUANCE BLDG Fl. PLUMB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES RES L ❑
in ca Iheeby alf Jw l un lianerd uMapovoiauof Chepef 9(anvoalcio{wilb LOB DESCRPIION
WOO Sstion]000)of Division 3 oft Bwinen and Pmfesaimma Cock,and my lice is P ' V
�y_ fun f«ce aM eRst.
Fzct Date Clue ueY To i
y7N am li vsD - M1f5
ZE-NK ARbodl Fusedf PubficRATION IOOOAMPS SQ.17.FLOOR AREA S/SQ.FT.
OZ— IwMnsuM my place;ehJl b<u.Cdu Pudic recatda.
P.0
Lipmsmd Professiowl SIGNS FIECI1tICAL
. < OWNER-BUILDER DECLSRATIO S CU
XO�U 1 hereby aff t Nu 1 em asemp fmm the Cmev#c La the
:L3mN following Ramon.(Sccai«t]0113,Bwlrca aM Dofevimu e o 'ry muny, FOIE WST.
t,LLONQ which requirss a pemut to a mrl,aloar,improve,dcrnalish,« ammturt
J. m prion.iia luuvce.0sotequias Ncit"Aicran f«such Pcmtilm file signM autentw D VICES
W <O slot he is li .n pun.mnt to the Provl.Ion.m(nba Comranmh Lia Law(CTupte
dXom� 9(<vrmCncing wiN SeNdt llp0)nf Divieian Sof nhCBwinW etM ofneiwv Code) GPOOL CIRIC VALU ON
or that he in exerrifi therefrom and the bads for the alleged exemption.Any vidatimoof S-S LTIPS-FT%'NRFS , , /
FZ� Seetion]0315 by any applicant f«a Pmol subjects the applicant to a civil family of
t F—+yo
not momthan fivehunNcd dollars 1150tp. w FNIAL P,EC1R _SQ.PT STORIES TYPECONSTRUCIION
1 ��� ❑ Lwuwrcrond t Pmpny,«myrntpnded orNwagnuNe(Sac dnPemuion,
d3� will8nhc w«k,wdnhcswaurummimm�JCJ«affucd for isle(Sec.]p44,flwirtcu
ants anrnaiorK coem:'Inm cdttmmt�a Liana law dos not aPpr m rn owrcf or
pmlrenrwno W ilda tR impntvca tr�rrm.una w W NK.ercn wort himml«nnmagnnia
owncmployccn,Pro,sda,nnnsuch imPmvcmentaem nm intcnlM nrrtffertJ fa ode.If, OCC.GROUP RFS.UNITS
be—vir,,the loilding nr Impovement u sold wiNin one ycuofrnmpdion,the owsar-
builder will hsve the humen of Pmv ing diet he did nut Wild or Impmva for pupm of '
sale).
❑ I,uwrcrmfNc pmpny.um udwivdy convening with licaON contredonm QTY. PLUMBING PERMIT FEE > L APN
rnmnact Na Projxt(See.7IH4,Bwlneu aM Prefessidts Code.)The Co .,
Liansc Lervil..m apply no en owtterofpmprry whobuildraimpmvn dCrton,arM PERMIT ISSUANCE
.ho..for,och Prof"witheconwaap)Ilceneeci punuunt to the Convacm/e
Liana Law. ALTER-DRAIN&VENT-WATER(EA) { FEE SUMMARY
❑ 1 am esemp miler Sea. ,B&P C f«Nie rtamn BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner D.te s RF.CE.IPTY
WORKMANCOMPFNSATIONDECLARATION DRAWS-FLOOR, ,RRBk,- 4 Kl1.TAK Y N
❑ Ihcmby affirm Nulhaveacetifiratc of cement to ael(.inuve,«aratc of FTKtlIRFS PER - RECEIPT♦
Wa mC INumncanacetCfC ythecof(S .38W., C)whicibr - PEE Y N
all cmpbyra a urtden Nu peA ronf. GAS SYSITAf `.4 OUTLETS. RBCE VISII Y
Pom PolicyE16 BUILDING DIVISI '
Comnsoy GAS-FA.SY -0V ( ANair. FEE❑ Cmif�mpyi.lreebyfumiehed
❑ Cerifielmpy is file!with the city impactiondivislan. GREASE/IND WASTE INEBCFFTUdi GRA
CERTIFICATE OF EK1JIMPf10N FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(Thu action rtsi not W mnNktM ff the pumitof«orc bwAad ddlan/SIW) SEWER-SANITARY-STORM EA.200FT, ENERGY FEE ssassassr
«leu.)
I certify that in tk pafaanotce ofthe work for which this Parrett is iuued,I shell WATER HEATER W/VENT/ELEC7IR
oil ploy any Pvemt u any.an u to became sub)at to toe Workea' PAID
Z Compnuuien lawn of Califomu. Du /IRFA
Due WATER SYSTEMTING Date RaccipIt
zO NOTICE TO APPLICANT:IL aRe making this Calfleateor Esempian,rou all NEW RiEsm ]IAL PLMB. SQ.FT. TOTAL:
F` Us) Saccanne mbjm to the Wotka'.Comianruim pavislau N the labor Code,You mosso
foMwiN comply whir such povisiotu or this permit ahall be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SP,ISMIC FEY. Ns
1 heresy#ffmm that them ui&anmtruction landing agency fa the p.f.a of
UOTOTAL If ItCTRIC FEE
the work for which Nu permit is iauCd(Sec.3!19],Gv.CJ
Cr^ Lerwar'a Namur
u' Irndcr's Addau QTY. MECHANICAL PERMIT FEE PLUMBING IIF
O W 1 certify Net 1 have read Nis application and uete that the above Inlorm.um is
nmor:L I ogme to campy with all city and coumy«dinmtes erM nue lows rtleting no PERMIT ISSUANCE MF.CHANICALPECj) E
p" buil,hogconstruction,und thereby aulloom7c aprexntativeaof Nieciymmnterapoo the
CONSTRUCTIONTA%
U abw(Wentioned pmPny cdcom«bunk lbns. ALTER OR ADD TO MECTi.
(We)egra m xove.indemnify arA lee p hannin Ne City of Clrpenmo id Cry
Iiubil itin,juJ mCrna.cMn dnPen.c.0 ch may In any way«rnmegaimt vid Cry AIR HANDLING UNIT(TO 10,(10!)CFM)
in c«ucys c cgr.ntin AIRHANDLING UNIT(OVER I0."CFM)
Sfoaerra.fA iunloComact« EXHAUST GOOD(W/DULT)
PAID
BAZAR TERIAIS DISCLOSURE HEATING UNIT(TO I diff"BTU) W. Rcaip#
Will the epplicam orfuae building rcculemt atone wb.,v4 hamrdoes ntahmid HEATING UNIT(OVER 100,000 BTU) TOTAL:
m defiml by tk Cupetlrw Municil l Code.Cluper 9.13,and Ne l lealtb and Safety
Code,Section 25533(v)]
❑yeas ❑ No VENTILATION FAN(SINGLE RESID)
ISSUAJiC(
Will Ne applicant«futurt building«cvpant uC cgeilmCN a devkn whichemit
BOILER-COW(3HP OR IW.O BTU) 3 D&TE
milhanrdwu mit cvnantinants n defirtW by the Bey Arm An Quality Maugcmcnt BOILER-COMP(OVER 100,000 BTU)
°`a"°] SEP - 9 1993
❑Ya ❑No NEW RESIDENTIAL MECH. SQ.FT.
I Neve(esti Na huaNaa matcrula raccith is under Cbepa 6.95 of floc
California flea1N&Sarery Code,Sccfvu 25505,25573 and 2553x.1 uMruatmd that CI I Y Ur ..,.,rcn L mu
if Jx buimin don rot correctly have a noun.that it u my respm.Ibility to tCtify JC aYr(
Onvpaot of FIC tcquiamcnts ena which must ba mIin isatant
tcc of a Cetifiae of —9&
r0l�j
Occvpvtcy. ' ��\\►►/���!!�//'�S
OwraaeuNaiud egrnt Due ISSUED BY
O
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