25274 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO
BUILDING-FUT I PERMIT o'
BUILDING DIVISION APPIACATION/PERMIT PING FROG CMf IDEAN'ICAL 25274
BUILDING PROJECT IUENTIFICATIrp' '
BUILDING ADDRESS: / SANITARY NO. APfl.ICATIONSUBMHTALDATE
WN17 AMP.: PHONE CO _ OMS NAME:Pr
O:
(! /J NIC NIROL N
RCf111ECrpNGINP LIC NO: ADD R' ❑
COM'ACr: _ PIONC: BUILDING PERMIT INFO
Ql'Y. ELECPRIC PERMIT FEE
PFRMfr ISSUANCE BLDG El ELECT UMB MEI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDPNML JOB DFSCRIPfION
1 hereby affirm Net I em IicrnsM unJ revisions M Cluplam
9(cmncncing with
Poo Sectitm 7")of Divishm 3 ofthe Bleu a ud Pmfndau Code,end my license is In PANELS
fullf cRaL
pQ„Zu1Li -Cl. I.ic.N UP TO 2W AMPS Rr�
tiQo, ate Conlmru 201-1000AMPS
Z FONZ ARCHHE(=S DECLARATION SQ.FT.POOR AREA S/Q.I.T.
O —
shall k uscJ n Pudic«cards. OVER 1000 AMPS
Z
F y SIGNS EL[CBICAL
Sys 1' W
C� Q OWNER BUILDERDECLARATIONSPECIALCIRCUIT/A11SC.
KO�U hrrtbY nfErtn that 1 was csmanplPt fnnn the Contractors License Lew for Ile
W: fdlcoin6 rcasouSection 703L5,Buslrcn snl Pretwimu Code:Any city or county TEMP.METER OR POLE INST.
t°-o hi
g wch rtgn no'n •P t 10 Construct.shot,Improve, dl
demsh,or rrysb my atruclme
oo
y!�a$ poor it)its i ance,elm)rcyuirts NL applicant for wchpronit to file a uyocd aleremrrn POWER DEVICES
y O Nu k Is IL.vunl pununnt to dr pmvruolu of the Cmtru+u'.Lia.ue taw(qupta
�6x❑�' olloaU xi.e.,1 genion umlth.bio,for the 1LBusims end Pmlaimu Cod c)
SWIMMING POOL EIF.CfRIC VALUATION
W m nrthar703L,cmptth,pficam mr.bmisfarbjtulkN,spImptuusrnyl pcnaton of
tZQ Sation]031S byanY epplinnl fm.prnrJt subjav Nc.pplicent to•civilprneltY of OITfLETS-SWITCHES-FIX'IIIRFS
Mnot more Nm Bve hmldred dollars
;Jy ❑
❑ 1,usnwncrnfthc prnrcny,mmycmpinycn wiN w.gowlhciraokcmtMnsuim. NEWRESIDF,NTIALELF.CPI _SQ.IT. STORIES IYPECYINSTR Crl
will Mthe w'orA,Cock srry Cortiato intrrdes,Law edf nuts Sec.]0an ro ,,...
artl Plvfcsvmu Code:TM1c Contractor's Liml.¢law does not apply to ao awmw-r of
pmrcny wMM1uildsmimPmvn IFtrem,uml whuJms such wart M1imvelfm NrwyM1 hie
anploym.leovidW Nusuch impovemenuuerotitucodcdmaRertd(mule
If. OCC.GROUP kES.UNLTS
Mwra,de building m impovurl n is sold within ane yrarofcanpinion,drowllc- TOTAL;
builder will hove Ile bunko of pnMr,dntt he did cal bmld m improve for,mPusc of
wt.).
❑ I,nowlerMBr propety.vaseatluslvelycmtmitlg wiN lived comr.ctaato QTY' PLUMBING PERMIT FEE IL DZONE APN
enrntruct the project(Sec.]OW,Businexs and I4ofdsi Code:)'Ihc Counroor's PERMIT ISSUANCE
Lit.Irw dcs
ormc.pply to.n ax .fproputewhobuiW.mien,ovea Iheeam.W
who mums fusuch la,jvcB with accmuuwr(s)Nursed ptnsu um to the CenuectNs
Licert Eaw., ALTER-GRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 ant cscmpt orldm Scc ,B&P C fm Nu realm BACK FLOW PI CITCr.DEVICE SANITARY Y N
OwocT Dere RI:CF:IPf N
DRAINS-FLOOR,ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX y
❑ Irs,Cum frsmimm Imuveamurrweolmvy then sal!-Eume,mamrrifinte of R=RES-PIERTRAP RECEIPT
Worken'Compenxotim lnsurenm oremti0ed copy Nermr(Sec.JPW,Iab CJ which PARK FEE Y N
coven ell cmployee'a urdcr Nispmnil GAS-EA.SYSTEM-I INC 4 O S RECEIPT#
Policy 4 BUMMING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(II) PLANCIIIiCK FEE
❑ cmirtm copy is lweny fvmiar.ca.
❑ CenifiMC»pyu BkluiN tk city iruprclbldHiaien. GRFASMNDUSI'RL WASTE INIERCEPrOR
GRADING FEE
CERTIFICATE OF EXEMPHON FROM WORKERS GREASE TRAP SOILS FEE
COMPFNSATION INSURANCE
([hlssalion need rxe 4camplekd ilthc pemtil isfm otw hundltt�AlluM(SI00J^ �EW S ARY SrWRJI E 2WI7. ENERGY ITE
mks.)
Icmy tine u lk in
any cchackwork farwcmm,iub,,,'t/llis lYVB .WATF�l w .E
nm employ any Irrso^ in my manner so es to becorre subjM I� PAID
z Cumpeneuian laws of Celifomia Rut— wAn Y Due RueiptM
Ali t ntTT
SQ. f.NOTCTOAPPCA :lf,.lmroingtNilfintcof�xmp1 D TOTAL:p
hcsubjaituNeWoe'sCompnimpovuiaofte� Cd.Youmu
7 fmNwiN mnply wiN vschlmviaiovmNu pcmutYWl be hrnN rtvokd. BUILDING FEE
W 2 CONSTRUCTION LEbiDING AGENCY SEISMIC FEE
5 I Meby.ffrm Nu trace is s onto a o Iotlint.gotcy for Nc pv and xc of TNU, E,EC RIC EFF.
U O the wodlm which Nis lctmit is iauts]Oca 3041,Civ.CJ
LC. ].t is Num
O F" IaMch Adds QTY. MECHANICAL PERMIT EEE PLUMBING FEE
U I certify IM1w I love rtad this a,,liceliml W awe IMI Ne.Wve Information is
'_v Le rte In comply—m ell city erd county mtionocn and sm.l.w rtleting to PERMIT ISSUANCE MEC11ANICAL FL'E
I""' bei 'arL and Meby authmve r<porNa4vn Of Nis Citymrnrcr ulsm dr
U e-rnrntimW t.'erty for inapu'don purpose ALTER OR ADD TO MECH. CONSIRU(7I'ION TAX
v(We)egr indemnify end keep M1arms lcNe City of Conlno. uiv
pegr
huldilitie.ju svc,uadt.p which may' any ysaxte.e' said City AIR HANDLING UNrr(TO 10,1100CFM)
in caecal pmnit.
AIR HANDLING UNIT(OVER 10,00s)CTM)
pelican m Dare EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('rO IM."BTU) Date Remo 0
Will tine alglicantm for=building occupant sum or budle hvardaui msruiel IIEATINO UNff(OVER W,Bfgl BTU) TA
v def d by tine Copmtoo Municipal Code,Chapter 9.12,end Ibe IksIN and S.fety
Cale,Section 25331(.)' VPNLILATON FAN(SINGLE RUM) —�
❑Ye ❑No
BOILER-COMP CHP OR 1 W.(IW BTU) ISSUANCE DATE
Will the yglicuumfuturt boildiM by ttb vBsy Anes Air and ity MsebicM1wit P I D
III Dkun nl�a air cmtardtlmis u defines by the Bay Asn Air Qwliry Maveemrnt BOILER-COMP(OVER I W.BBB BTU)
Uislriat
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
I hove Iced the lmratdoos mwleriels r,r,monnen.unJcr Cba"t,6.95 or the rNY 29 1993
Cu ilemu Health&Sufcry Code,Sctioru 21505.21533 12.5534. 1 undkoamn that _
if bui"ngdocs runt rnromIlyb.reateresm.dust itismyren ornsibilitytonotifyNe CII Y Ur VU
�
cMrnpnnl nr me rmwirtntenla wnien mull Ic met crit.too varve pr e er.,;r tear
«cvp.rcy.
(ywnomuuNori'ud egrnl Date TOTAL: ISSUED BY:
OFFICE