24859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUBAIIN(i El
' CAL PERmrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL J� O
BUILDING DIVISION BUILDING PROJECT IDWIPIRCAT10\' 4 o C J
BUILDING ADDRESS: O AIS" p SANITARY NO. APN,ICATIIONSUBMITALDATE
/ –////1 UNIT♦ LOTH
'MrNAME: PHONE CONTRACTOR'S NAME, LIC NO:
L fLV rr o r 40If//n6- S'P£CIA Lll l)r e, NC coN ROLN
\RCHITECT/FN'GINEE R LIC NO: ADDRESS:
y22 5a-xa7 )Ga tee . El
CONTACT: PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
U la,vt y-C O nI` B % ELECT PLUMB MECN
T G sJ- PERh1R ISSUANCE R
LICENSW CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LLl` IDH DESCRIPTIONpcZ I hvebyvffiren flat l unlicrn uMcr poW.urnsnfChPler9(curvnmcingwiN
roc Salim 7(Y0)af Dwision34 the Buircu uW Pmfeaaiov Code.and my Iwai%ism PANELS �� T/ �� �,/��I
W d u full fame
an"'Eal // �h /P
�Zul Licca% lav+—�-,—Iic.N_ e 4 UP'1'02W AMP5 /-
'^¢°' �e 3—J��J—Conlrennr 2(11-IULOAMPS
FyZ ARC11111;C1'SDECLARATION OVER I(0f1AMP5 V '� A "Q1 IT,
Z O,z IutdenienJ nl shall be uaM as blit mcords.
OZ�O YPun. pan
Fh GJ SIGNS ELECTRICAL
Qy IJcrnud NofrniauJ is
rysz� OWNER-BUILDI?R DH(.1ARATION SPECIAL CIRCUIT/MISC.
X4 W 1V. 1 hereby ulTml Nal I um excri from Ole Conwaera Licrnw Law for the l
Wit+-fn fall—in,oo,on.(Seaeion70315,Bae,m unnJ Prufeuiunn Code:Any city arcounty TEMP.MIi 1T;R OR POIH INSI'.
which re9uitn a Pmniuo cvmnmet,.Ileq improve,detmllsb,or«peir any s.I— POWER DEVICES
Priorto its ivwumx.illw olnv Ill.apPlieart for.,hper it la filenslgrcJ aulemrnt
,,CQO Thal he ix liavW purewni to the envisions of the Contracto(s Licaise Law(Chaffer
aYpyy 9(cmlmtricingwhh Section 7100)ufDivisionJMthe Bnsi.rand Pror.e.Calle) SWIMMING FOOL ELECTRIC VALUATION
x N IBM he ix exempllhesefmmal N
arehvla forthealbri exen,aicm.Anyviolim of el
WF_ZY Section 70313 by any applicant fur.Permit subject,the applicant to a civil Nasty or OUTLETS IT
-SWCHESFIXTURES
XTURES yJ ,,VALUATION
l'
Q mt nano than five hulWral doll. S!lX).
E p
opc� 0 NEW RFSIDEENTIALELI:CIR SQ,FT.
SIURItS TYPE CONSTRUCTION
y3� will Polk woer;ararl Cotlte he Corche iLec rcJ aw Law
frost e(Smapply 0 an owner
et
of
anal Pmf¢swm Cale:Tte CW Relti•titan,Ina doe Ilol apply b N owar O(
property whobuildsurimpowes thamn."whadoesuch wank him%Ifmthmugh hu OC ROUP R ITS
empbyas,eavided th.t.uch impmvrnrnta uc rrot intended«offal fm a.lc.If.
Iwwcer.Nc Euildingor Irrspmvemcm u roll within are yam of mmpksio.t We owar-
buildttwill M1.se the bwden of coving"he did nor buik a improve fan por ca,of TOTAL:
uIl
❑ I.uowrteraf Ncl•merty.annexclusivclyconlrurirtgWmUcrn%dmwxtmlo QTY-1
TYPLUMBING PERMIT FEE FLOOD ZONE AM
corenucl the pri(Sec.7644.Bulinus anal Proresairics Code:)The Cmu.cmis
uarue law Manat aPPlY tomawlw.oleaPaty wtnbuild.orimeovn thaemtual PERMIT ISSUANCE
wAocmnecuforsuch projects with.conlraareaci Iicerud pmsuon".the Cana.tlm's ALTER (E1)
Iicnlse I�w. FEE SUMMARY
❑ 1.rn enemPt under Sec. ,B A P C fm Nis resao BACK FLOW marl LT.DEVICE
OUTSIDEMMS
SANITARY Y N
Ci PTN
WORKMAN COMPENSATION DECLARATION DRAINS-Fl.00H,RWF,AREA,COND. SCHOOLTAX Y- N
4❑ Iherchy affirm lhatlhuve ecmirimleafconwnmowlf-in%te,mac ifiuteof FIXTURES-PIER TRAP RECEIPT0
rWmkm'Cornenvalion huurancenracmiricdcapythrm (Sa.38O ,UbC.)wluch PARK FTH Y N
1
SIC if
cmployce'e terrier this permit. REOEWTN
5v 6 PolicyM GAS�IA.SYSII?M-I INC 40UIIJ3rS BUILDING DIVISION PEEKS
T V
D Ccn 7-�L GAS-IA.SYSI'13M/IVHR4(IA) PLANC111?CK FILE
❑ CcnlfeJ copy in hcrehy lumirkJ,
�Cenif¢J ropy BhleJ wilM1 Ne city inapenion divisim. GREASEVINUU.STRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATEOF EXFMPI'IONFROM WORKERSGREASETRAP SOILS FF,H
COMPENSATION INSURANCE
(This rection neva not IN,completer!if Jc permit is for one hural ddUrs(S 100) SEWER-SANITARY-STORM EA.MFT. FNERGYFEE
or Irv.)
I certify thal in the perfurnwree ofrhe work for which this permit itivatetL 1.hall WATER HEATER W/VENT/F,LELTR
wt employ any Pei in any nresmer se u to beton,ub)ect to the Workm' PAID
Canpensuimiswsar CWifierri Date WATER SYSH:M/IREATING D.le fteccieN
z 0 NOTICE TO APPLICANf:If,rho making this Cenifave of EacrRndon.you rlbould NEW RESI DENTIAL PIJIIB. SQ.FT.
(/J TOTAL
becoe subject to Oe Worker.Compay.tine
s avisu iaof Lahore IAbCaduste,you must
foMwiN comply with such pmvisiwe or this parent shall Be deemed mvokaf. BUILDING PEE pJ
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby.lTrm that Ih r,u.c.,ion Irnding agency fm the p cf.e of
V O the wmkfor whichlhis yntnit is ivaued(Sec.3o97,Civ.C.) TOTAL ELECTRIC FEE
LL V IrMrta N.
O Inaler's Addax. QTY. MECIIA LAICAL PER M IT FEE PLUMBING FEE
I certify IMI I have mad hat,ep'Ecaum anal slate dna Pat above infomution is
>- Eliaarca 1arand MECHAMCALIEE
agrecctomNyh with
ystityn county«dinmea faircn lel cohm.,,relatev, to PERMITISSUANCE
U Z rboae-buftog rrticrmli o,anJhereby.c,16an emprewnlnlivu of Niaciry to rnitt upon Be
(, Z ebw(We)timal Pnpcnyfur inapaain Purpxa. ALTER OR ADD TO MECH. CONS'IRUCIION TAX
(We)agree lis,ave,IndemmfY and kap nay
a yina the City of Cupertino ad City
liebl'nia,juJgmemvcmu.nJexpen.wv which mryinmywnY¢aaeegelnslsud City AIR HANDLING UNIT TO I0,(1U(1 CFMI
an" n fit,grmungm Nis Peiin AIR HANDLING UNIT(OVIR lll,lpll Cl T1)
Signal r dApplicani/Contrn.rnr Date P.XHAUtiI'HOOD(Wp)UC9D �7,2 ��'
PAID '
IAZARDOUS MATIRIAI S DISCLOSURE HFA'1'ING UNI'lf UO 01,00 6 BTU) Me- Remipl N 3J
Will the appl'nvnt or futurt buildirr,.apanl amre or hvralle huarduux rest l (
HEATING UNII'
u derinal by the Cupcnino MunicilAl Code,Chapter 9.13,and the Health and Safety HEATING ILYI,IIfIOBTU) T'OfAL.
CoJc,Satim 25512(0)^
Yu Na
VENTILATION FAN(SINGLE RESID)
❑ ❑
Will Oe litxntorfuhuchuild'mga¢ BOLLER-COMP(JIIP OR 100,000 BTU)
ISSUANCE DATE
app upvu use ryuiemmtmdevias whi<hrnut
humdou4 air rnnlamimnu u defireJ by the Bey Area A'v Quality Muugammt
Devin° HOILFR-COMP(OVER 100,000 BTU) PAID
ElYes ❑No NEW RESIDENTIAL MECII. SQ.FT. • ^ ' D
I have reel the huasbws IlNlertifla rryuireranu uMer Chapter 6.95 of the
California Health A Safely Code,Sarwri 35505,25533 and 25534. 1 usderrai Ih.t MAR 12 1993
if the building docs nor cvri hve.lcrwt.than or,u revspons3iEty an ratify the
oavpuu of 1 eyulrenrmn which neon Ie ri prior to has ana,of.Centafficare of
OCcupNMy.
Owner m. r4.grn1 Due TOTAL ISSIJEU BY
OFFICE