25673 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOimDI��-E"EW RICA. PERMIT NO. 25673
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEN'I'IDCAI'ION
B UILDING ADDRESS: SANITARY NO. APPITCA'IIONSUBMfITALDAIE
19 ,75-1 make 0't UNIT* LOT*
OWNERS NAMF_' a PHONE: CONTRACTOR'S NAME: �j �yW(C�NO'.
—A-..r4 w$ 6 ��0 &1111 L A4f� ! /30 NC CONTROL
RCHITECf/FNGWEER: LIC NO: ADDRESS:
2614 S' 4�ti a /�S ❑
:ONTACT: PHONE
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INTO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑ �r
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
POZ Ihmehy ofDivihetl emlimt�underpol iaimunf Ci Code. mmrcaing wish
JOB DMCRIP ION
Pte Secron]D00)of Divi.ion Joftk Burirev and Prnfesaiom Code..rd mylicxnmuin p,WpjS 1 -
muJ fulllma era cif UP T0300 AMPS /rv'—nYv/.1`Y 111
. Q�w tocrnu Clav ab Lie*��7 'dOL
�Q y DueECTS m • 301-1000 AMPS
ZOh= IlECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.ET.
O Z I mcnnd
d my plans ad l be u. as public noon di. OVER 1000 AMPS
a� u� lduIdcmssl pouf aul SIGNS F�CIRICAL
OWNER-HUILDER DECLARATION SPECIAL CIRCUEDMISC
aU 1 hereby.Rrm Jul 1.m e.mtp Tran the Canoed&,Ucemc Lew for the
ul3 O Q following team.(S>rim]031 S,Btvvnews mtl Pmfmbm Code:My city orwony TEMP.METER OR POLE NST, u u ® 8 `
C _I which rtyulrt.a permit w c«vuuct Ml .improve,Mro Wi w rcpir my suucrure ppwER DEVICES
..ee of pri«toita iamercc,elsoo,m,.the.,,A cant for such l+mmitm file a Mimed staten,mt
�_00 that k Is linrue l pursuant to Je provision of the Come. "licrnm taw(Chapter �11 u V rs
da y mrmercln SWIMMING IDOL FT rMIC
xo� ( Bwith Sectim]000)WUivi.ionJofthe Breiriess smdZmmu Coo) V DATION
W=so sorbet he inexempt therefrom end lM1e Muix for Jrc elkgd excmpim.MyvlWWonof OUTLETS-SWECHES-FlXTVRPS
tzQ SecJon]03136y anum,ced"Itins $5001, tubjreuth eppliano toaevilpwtyW
not more h-"Gm hueW W dollva($500}
❑ I,aowrcrnf thepmlary.mmyemployues wiU w.geav Dcuwkcompmuimi. NEW RESIDENTIAL EItCfR SQ.FI'. TOR TYP CO. UCIION
e wi0 In de woe],,and the ttruauee ia.mon,ded croffered for sale(Sce.]044,Bucieev
.d Fofeicac s Code:The Cmmuctor's Lianm law does not apply to an Dara of
p,,erywMhuilrla«impnvw rh«am,ed vNid.,v.hwort blmmlfurilvou�lt hu
ownmtployx.povidedtlur anch impmrrn o.tren«imvldd mMfered f«sale.If, OCC.GROUP RES.UNITS
M1owever,the building or imprwcmmt it sold within orc yea of campktion,thcowna-
buiWerwill hnve the burden of poving khat le did nor build x impove far puryote of TOTAL
We.).
❑ I.uowrcr Wthc poppy,uncxcJusivNYmnuacingwithliunW mritr.nmw QTY. PLUMBING PERMIT FEE F1_ D70W APN
c«uwm the project(Sec.]Ufa,Buslaeit and Pmftion.Code:)'ILe Cimhectnr'a
I.ittnsc Lawdowmelgly tom owmm�fpupenywMhuildt rximpmves thaam,anJ PERMIT ISSUANCE
who mmacn for aucb pmjccu with.cmtracwr(a)licmrd pvsusnt to De Conoxmr.
Liccue law. ALTER-DRAIN&VENT-WATER(IA) FEE SUMMARY
❑ 1 sari eaemp under Scc. ,B A P C fm this rtason BACK FLOW PROTECT.DEVICE
OUISMF MES
SANITARY YN
pwrcr n.'• DRAINS-H.GOR,ROOF.AREA,COND. RECEIPT'*
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihecby afBnn thatl havc.¢nificuc Mcanmtto mlNlmue.mattnifrate of RECEIPI'M
N'udrm'Cunpe+rsatirm Wumera«acmifdcopy Nermf(Sec.3500,Lab C.)which D%IVRES-PER TRAP PARK IEE Y
Wen,Al cnpFfl Ts,r8L4 � RECEIPTI
Pulivy11 / GAS-EA.SYSL -1WC.40VLEIS
BUIfDWO DIVISION FEES
GAS-EA.SVS AF OVER 4 EA) PUNCHECK tot
❑ Ccnifid cWYis hccby fumithd'�
❑ Cmifed capyu Bid wiN Ne city lnspcJon division. GRFASEdNDUSIRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
Tllua.s Job c!.be cooTkred ifthepmni,is faraee hundred dollara(SIM) SEWER-SANITARY-STORM FA.20)(IFT. ENERGY FEE
«I..)
Icertiry dot in the perl«manceofthe wah for which do.permit ismued.l shell WATER HEATER W/VENT/ELWM
not.*y any pvmn in any.so as to became subject to the Wmlo PAID
Canipnvtian laws of Gil Tomes Dare WATER SYSTEMOREITINO
O z Applicant 04te RncipM
z0 NOTICE TO APPLICANT:If.after mating this Cerifimte of Eaemaim you thuuld NEW RPSIDEMIAL Pl SQ FT. TOTAU
(n become 4ubjm m the Woher'a CmnpenvM1w pm vivem of the Taber Code,you vru9
C4 forthwith comply with such pvvisiau or that pemut that be deemdrevake6 BUILDING FEE
GQ CONSTRUCTION LFNDWG AGFNCY SEISMICFEE
I heeby.ff that Dae ata cmWuctino lending agency(«die performance of
U O Ne wortfor xbich Jru pemut is ia.ued(Sw.3090,Civ.C.) TOTAL: ELECTRICFEE
I .N.me
O F latder'eAdIntso QTY. MECHANICAL PERMIT FEE PLUMBING EFT:
U 1 mfifY Dw 1 have read thi.it'hiotion artl roue wt Dre above infmmtion it
commb 1 MECHANICAL IEE �•
egnz bcomlJY with Wciry sold cauuY wdlnutces aM swel.m rel.Dngw PERMIT
building cornwction,.rd hcmby emhorirc rtpcmnwives of Nu city to mutt upon rhe CONSTRUCTION TAX
U above-mrotimcd Mali For in.pa'tion mi ALTER OR ADD TO MECIL
(we).pee to nave.idnmih and keep ha mleu IN,City of Cupiri.g.iw
Ii.hilitiex,jodpncnu,awu and cxpnxs which mayor any way amus ag.inm said City AIR HANDLING UNIT(TO 10,000 CFM))
In coruego-xe W the p anting M thin lamii.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigvmrcof Applimnt/Crmtmm Detc EXIIAUSTHOOD(W/DUC17
PAID
I IA2ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1110,000 BTU) D e Receipt x
Will the,,Ii.,oi(None Wilding cccupmt nnre m hurdle hie us material HEATING UNIT(OVER 10J,000 BLV) TOTAL:
ca Aefind by ole Cupertino Municipal Coda,Chaper 9.12,and the Ileslth and S.duy
Code.Section 255J2(ap
❑yt,!55 C3 No VENTILATION FAN(SINGLE RESID)
Will the applrantarfuurt buildin Deco BOILER-COMP ORIP OR 10)(10 0 BTU) ISSUANCE DATE
8 �weWwpmcntudevimwhichawt
t in,cmitmnivmt as deBnd by Fe,Bay Aro Air Qu hty Mavgenrnt
BOILER-COMP l0 VER 100.000 RN7
) District] 11 Y.
Yu ❑No NEW RESIDENTIAL MECI I. r
SQ.FT. A D
I Iuve rad the hermdout nuomal,o,wenatt..n Chogn 6.95 of Je
Caliomi.Health A Safety Cale,Smimu 25505.25537 and 35534. I mldevod Nu
ifthel+uildin inol currently have anent.Jwitismyrespauibilitytonoufytlm OCT 25
nernputt a".iene m he met prior to� mime.of a Certif®e of - 19 3
Cl/ IV
.gem Daoc T ISSUED BY:
f
OFFICE