25017 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BmID PF:RMITNO. 25017
I`�I^ ^ O 1 7
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDPMIFICATION
BUILDING SANITARY NO.
SADDRESS: ' ' n` r, UNRI LOT A[PrP/IJCAlTIO7N S-U'BM�I/jITAL DATE
-con
WN NAME; /' � PHONE COMRACTOR'S NAME LIC NO:
et'gW K Wrl T. 12 NIC CONTROL♦
R I CT/FNGINEER: LWIC NO: ADDRESS:
o S. V e .
• CONTACT: PHONE BUILDING PERMIT INFO
i t 1 O al QTY. ELECTRIC PERMIT / BLDG ELECT PLUMB MfCH
S 1 f�/ �lf G ��3 PERMIT ISSUANCE O/ ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDPMIAL
p.Z Ihneb"flim that l am liccnsdtmder povihorsofChWer9(.wmlmcing with JOB DESCRIPTION
µg00[ Section TIXG)of Divisiin 3 ath,Business W Professions Code,and my Batu u tit PA rz U full force sed erten.
c,-t E License Lic.x UP 200 PS
rnjy Date Cmtrxta 20 1000 FT.FLOOR AREA SaQ.FT.
ZOinZ ARCHITECTS DECLARATION O PS SQ'
ZO, Imdmwd my plw swlbcu 1nplNic lcmNa.
<y� Licensed Profusimul 510 F.IF.CfRI \ •"J O�
o �y6 OWNER-BUILDER DECLARATION S L CU (•
KOk!tJ I thereby so)irm Thu 1 ao exernp from the,Cmtr &.Uceruc Law Inc the
W3 u v.¢ fullowing reawn.(S«lion 70313,Bue'uea W Pmfeuiwu Code:Any city a county TEMP METER 0 INST.
E' OJ which res uires a ornit to ccr mlct,ether.improv,,Juhholish. sr reoar any.wcnuc
Y� siorloitsirsuucc,nlwraluresrhespPlicenlforaahpernotho rileasigndsdtemenl s POWER DE VICES 3
�p thin M is kccn.scd punaninl w the,provisions of the Coso ors License Low(CLap¢r
ddxo� 96,anmeocingwith5ectim7W(1)ofDivision3.f ft Buirces ad Nofexi.Coo) SWIMMING urECTRIC VALUATION
W_rn or lowhcisexenToiherefmntant]the b sfor the alegdex,mptim.Any violation of O SWITCHES
FZY Section](131.5 by any applicantpermit for a t subjects the alo cma pen
to.civil a - -
lly of t
not more than five humhd dolhors 0). NEW RESIDF1lGAL FJECfIt SO.FT. IES TYPECONSIRUCIION
W � C3I.nowterufthepoper9y.«mY,mPloyaswlth wg<authdraokcaotpertutim.
d will do the wark,rurd the suucture is notineMdoroReadf«aek(See.'1p46.Buuw
aM Profesaru Cade:The Cmmanafs uaeme lsw does rot ruPpY a sec o
prgcnywhodnlds«inpro.v Jncm.ard whoakhea such wart hirmclf ghhu
awnemPbyea.povided llutvshimpovnrheau sre notion- ,-,and fior, B, OCC GROUP .UNITS
however,the,buiWinga impmyerant iswld within rote yeuofcempleuan,tleowrer-
TOTAL
Twill love the budm ofproviry Jw he did rw iwiWainynave fa puryme of
ssle, A
sok.}
❑ : m
TYPLUMBING PERMIT FEE APN
coscrosuct
ths,Myen(S .70 ,Bossiness and Professions CuJe)The Costmruct«a
Iiaoselaw
Axa mlapply loan ownanfpropeny who bulMHaimprova tbetem,ad PERMITISSUANCE
who c nlructs for such projects with a conbadar(a)li�Purwent to Ne Cmtrenora -
LianreUw. ALTER-DRAIN&VEST-WATER(EA) FEE SUMMARY
❑ I an,c.entpt under Sec. B&PCG.Thi,i tlACK ILDW PROTECT DEVICE 1 SANITARY Y N
Owner True RECEIPTN
�' DRAINS'-t -R,ROO�.ARE,CO DI
WORKMAN COMPENSATION DEMRATION 1 - n SCHWLTA% Y N
• ❑ Thereby nfflrm lhrutlluveruanifirue ofcmxnt to self-inwre.mrumufiruc of ., rFlX'IVNFSt ._RAP II �� �� RECEIPT'♦
WarkttiCmmpcyynulian lrcwaccaaatifi[[M<vpythv�^m�f(Spa.JBW,Ieb G.)WblCh PARK FEE Y N
Folicy Nlc-s �'LN �eP1AtlIi 1 `4'AS-E.S I 'C.A BUILDING DIVISION FEES
C«rytsny
❑ CrnifW fwnisMd. •'•— PLANCHECK SFE O`
coPY is heats
'Cenifhed copy is fid with the city inspection division. SE/WD INITRCEPTOR GRADING FEE r
CERTIFlCATEOFEXEMP110NFROMWORKERS' GRGSE SOILS FEE.
COMPENSATION INSURANCE
This section reel rnlhcmoplctcdiftlhe Aconin is fmmrchurdreddollsn(5100) SEWER-SANITARY-STORM EA.2(X)FT. ENERGY ME �s00
orlaa)
I certify llw in the perforrrurce ofthe work ha which this prnnh u blest Ishd) WAIERI EATER W/VENf/ELECfR
twat rntpWy any perm in any roamer so as to become subject to tM Workers PAID
Cnmlrnetion lrws of Celifomu Due WATER SYSIEM(fRETINO v Racip0
Q Z Applicant
Z 0 NOTICE TO APPWCANf:If,.IIsi msking lois CauOmlc of Pacmpuon,you shhoW NEW RESIDENTIAL TIME, SO.Ff. TOTAL 04
0) bew Ie.subjxt to tie Wakes Canpensatianpovisiom of Nc labor Code,you must
� > forthwith cmtply with such la wrath.or oris pende Mmmd,shall brevoked. BUILDING FEE 63
C Q CONSTRUCTION LENDING AGENCY SEISMIC FFE
1
U O I busby aHhm Jut thereu•caesvutian lading agency f«Jre peef.d TOTAL: ELECTRIC FEE
the war),for which this pernu ut iuodSec J(191,Cly.C)
leder'.N.
0 F Ic,o .Addren QTY. MECHANICAL PERMIT FE PLUMBING ME
O CJ 1 cerJfy wt I h. a mm s
.e re. is.pp cotitd strut,th.t Ina abase infmmaean is
fJ-1 , . I agree to comply with all my sed cuumy«dinrunv soul laws re Wing m PERMIT ISSUANCE MECHANICAL FEE
building conwnction.ere twrebY authorise repreuntulves of this my to ernerspm the
U Z eMwe-rllentiorld property fa inspectim purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)nigra to savq indcmnif,and kap IurmlGv the City of Cupenioh rugslmt
liabilhics,judgrrcnt,cwt.and esp which may in noy way a,ruerugeina sire Cu, AIR HANDLING UNG'CTO W."CFM)
to unmyuvac at Ju gmnung of Thu Aconin,
AIR HANDLING UNIT(OVER 10,0.10 CFM)
Sigrulurc of AMlicanl/Conotclor Dmc EXIIAUSTH(X)D(WMUCD PAID � 3
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,1X0 BTU) Recertt
Will the applicsnt sir fulure building acuprunt some a bsodle bvardoua materiel it IIFATING UNIT(OVER 100.000 BTU) TOl'AL 3.S
m deft ed by the Cupertino Mmicipal Code,C3npa 9.12,altl the Health std Safay
Cole'Sarno°25532(.)] VENTILATION I-AN(SINGLE RFSID)
❑yes, T�Wo
ISSUANCE DATE
Will thcrupplic-wutmfuwubuildingoceupw useequlpncnt mdcvim whicheroh
BOILER-COMP(3HP OR IOO,000BN) � � � D
hamnfous sir conuminants m defend by the Bay Aro Air Quality Mrunagmrnt BOILER-COME(OVER 100,000 BTU)
Distrin?
❑Yes NEW RESIDENTIAL MECFi SQ.FT. SPR �7 1993
1 hot rover the hwutduus mucrieln rWuinTl,ltls uMn Chaps 6.95 of the
Cullfnmi lahh&Safety Cdc,Satims25505,25531 od 25514. 1 undcnurd thet
inhc. ge«.not,anrntiy nate a mnmt,that it is my resWnslbihty to notify the C1 I! Ut'WUISGTi 1114sa
MYapM t 11Y`M1Yui ,n15 w/hKh must bt mel In iF{nnMC"In C,Nf Cate n(
Ike f / 44��-9
Ow rmaulh«i rugrnt Due TOTAL ISSUEDB . via