24654 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPPV OF CUPERTINO BUILUIN.-ELECE'RICA L PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 2-//' 6 A
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 4 6 R
BUILDINGADDRESS: 056, SANITARY NO. APPLICATION DATE
DATE
UNITO "i IDT N I L S
OWNERS NAME .PHONE CONTRACTOR'S NAMEto LIC NO:
NIC CONTROL N
RCIIITECP/FNGINF LIC N : ADDRESS: El
CODNI'As CI' PHONE,
QTY. ELECTRIC PERMIT FEE BUILDING PERMI9INFO
M �p_, �s R7V � -/ BLUO Ill(! 1 UMB
MECH
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El ❑ V, ❑
LICEISm=ON A4DEC
ARA )N APPLIANCES-RESIDENTIAL
[01`x7 Iberebyriff rm Nrolam liarvN uof 9( th JOB DBSC 1 ON
�OE u llfaee]erld)effeDyiIsW��n�73�ameBlrsirc 'avC .avd mYlic�in UP PANELS SWAMPS
QZUUtu V Claa+��CL Lic.g
i,<c. Du 6 j�Con' 0 201-I(I(IO AMPS FT.FLOOR AREA E/SQ.FT.
�,aZ ARCHITECTS O OVER TWOAMPS SO.
OZ`—'m I mailenNM my plain"I be munrds.
r h F W SIGNS ELECTRICAL
QY�j Ilccmcd Pmfcsiotul
KK
K�Q OWNER-BUILDER DECIARA'fION SPECIAL CIRCUEDMISC.
06U I nmeby n.(S, hit 1 31 cxrntq from the Gmvun Co e:Anyc Lew ro tlr
Iii 3 LLy lidlowing mown.(Scdim]0313,euainem W 1'ndecitm..Code:Any city«cowry 'OiMI'.ME'11iR UK IDLE INET.
which rcyuim n .it,c c«svu,I alter,improve,dcmalieh,or repent ony strucome
2WY� min i.raua«c.ala thea tfa.wch 'imfilea aircJsutemrnt POWER DEVICES
KKK prim tryuirts vikiom Putni g
LLK00C Nat he is lirxnxrl putwmltm0te pmvisions of the Commanot law(Chaplin SWIMMING POOL.FIF.CIRIC
ai LL 9(Foltmrntnvocro S efmrmrmd me ,forJof filo Bminru mlJ P M,vora Cade) VALUATION
� ,� «thatllc 31.5 tyrRnefrrmartl the Permit
wbj dkgedexemption Anyviolroion of
�ZG Stttion]OJI.36y any applwmlt fmapermit wbjttH dte ePPlicant toacivil Penalty of OUTLETS-SWITCHES-Fl%Tl1RE5
tw owe dlan Evc harNd douto,(5500).
C � ❑ I,mowrcrofthcpmpmry.amycmWoYemwithaagnmtharsdemmpemuion. NEW RESIDENTIAL ELECTR SQ.FL - STORMS PE N
a3� and Prf.i.Cort The,Cmeieta Ln L,.Uifncdfaot ,ly I.am.ameee4
mrd Pmfemimv Cao:The Canuenata Lierue W w Jon not apply to rn owns a!
,rut who builds mimprovcs tllneun,arnJ wlwdae much work Wtnstifor ituoughhls
wn emPloycm.pmvidcdthsntehimprovcmmuere ttq intenJeJaoRerMf«.role.IL OCC. k P PGS.UNITS
howevm,the WildingmimlrmvmcntaaidwiNinarcyrarofmmpletian,theow - TOTAL
builder will have the buden of prying tnat he did rat build ur impnve fm putpee of
sale.).
❑ Ln.awtternnnefnapcny,em newaivetyeunrasvrgwhn nernae conwaorsm QfY. PLUMBING PERMIT FEE lit DZONE AIN
nromct the pntjttt(Sec.7W.Drum—oral Prof,-,CIA.)T m Comm"I"A
Liana Lawd«anm apply to an ownnofpmpcny whohuildsaimprovcs thaenn,and PERMIT ISSUANCE
who comr s faauch luojecn with a comm lm(s)Eicen i ptrtmor to the Ctruutar's
[it.IrW ALTER-DRAIN&VP-WATER(I:E) FEE SUMMARY
❑ 1 m eaemPt under Sec. ,B&P C fm urns t®m OUPSiDISFEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner —Tom—WORKMACOMINSATIONDECLARATON DRAINS-FLOOR.ROOP,AREA.GOND. SCHOOLTAX YECEPI'F
NN
err•e
❑ar- I heaby vffmm Jw 1 hove•cvrifcue of cotarnt to zlGitvurt,as¢niftcue of / RECEIPT
km'Canpenwim lnsmarw mifiM copy metnsf(See,38(1 Erb C)which FIXTURES TRAP PARKFEE Y N
coven all employee's uMer OIu pcmtit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPI'I
Pol it,0 BUILDING DIVISION FEES
Caney GAS-EA.SYSTEM-0VER 4(EA) PANCHECK FEE
❑ CenifMcopyishem,byfumisMi
1L r'mlfieJ cyry is Illed with tlrt city inspcctim divicinn. G L1!I�UgIR�1'ATE 'R �OR I GRADING FEE
T CERTIFICATE OF EXEMPTION FROM WORKERSGR' SIi9RAP s dl it SOILS IRE
COMPENSATION INSURANCE?
(Thi.action neN rot be completed if the pemtit is fm vrc Hundred dolWa(S100) SI: }illi-SANITARYSISTC)R G I ENERGY FEE
or Ecu)
I cenify slut in the perf«ronce oftlte w«k for which this Perrot u issued.l mhill WATF, W/V L
not employ any pert or on,nomm av lir becmrc subject to the,Wmkvs' PMD
Z
Com,mouimlaw mf Califunir. Dare w TFR SYSIRM(IRFATING- -- — Date RadptIt
ZO NOCE TO APPLICANT:If.after making this Ce iffier f Exemptiorg you shaoW NEW RESIDENTIAL PLMB. SQ.FT. TOTAL
(/J become wbjeel m dtc Worker's Compatwioo provW.aft labs Code,You Hans
a >- Rxtltwith comply with vseh pmvisims«this Permit shell be deemed invoked. BUILDING FEF.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm dun them u a construction lending agency for the per(omlrotce of
the work for which this permit is ilmted(See.3(1 Civ.C.) 7 ELECTRIC Fl:E
U Isndcr'e Natty
Lerdcr'e Addres QTY. MECHANICAL PERMIT FEE. PLUMBING IEE
W 1 eer ify that 1 Hnve tend this a,,liceem and elute that IM above mind mon is MECFLWICAL RE
mlmt. lugmc to comply with ell city nor!coadinutce anti ete¢laws rtnlingm PRMITf ISSUANCE
b,ildingcommotiml,endherebyamh'aereprtantroivnofmiscoy m emer.pon the
U Z imme mentlo«d ropmy for itupectinn Patti ALIER OR ADD TO MEC11 CONSTRUCTION TAX
(Wc)agrtt m save,trdcnmify road keep hmordi the City of Cupertino egilmt
IieMlitie,jWgmctu..comm andnpmtam which Huy In rosy way rmue aPinro said City AIR I IANDLING UNIT G70 I It,"CFM)
In caueyuctla of the grwin8 0l tMa Permit.
AIR❑ANDLING UNIT(OVER 10.000 CFM)
SLpuwrt MApplicentraCanuacta D„• FAHAUSTHOOD(W/DUCU
PAID
HAZARDOUS MATERIALS DISCLOSURE L IEA'n NO UNIT(To 100,000 BTU) De. Rncipt
Will tFc appliomorfututebuildin,..,cot dnremlwndkhamrdauamroeriil HEATING UNIT(OVER 100,000 BTU)
L:
m dcfncd by the Cupertino Municipal Calc,Chapter 9.13,not the Hciltli and Sofay
Can.Section 25532(a)P ,/ o VIWI'RA'I'ION FAN(SINGLERESID)
❑Yn pr0.w,i
ISSUANCE DATE
Willthcapplicant«ruturtbuilding«cvpanluaryuipnmtmdevi«s whichcmit BOIII;R-COMP(JHP OR IW,IXp BTU)
L4:- �
ir con..na ms defined Hy the Bey Am Air QuOily Mmugement BOILER-COMP(OVER 100,000 BTU)
NF,WRESIDFNIALMEC11 SQ.FT.dr trlummi b r Rd B maer Chapter&95 M tk&Safny ode,Sectiav 503, 3JJrod 255]4.don int heveetrn L t it i.my tcspavOtlity to n�fY tle ,^^3
which rIm prig to i.suartce of•CerriBe-,.M J" f zed egmt Date TOTAL ISSUED BY: �.IIa ... t Gf11 EIYU
OFFICE