25555 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIlls i— PERMITNO.
BUILDING.DIVISION APPLICATIONIPERMIT PLUMBING-.MECHANICAL 25555
BUILDING PROJECT ID&NTHICATIUN
BUILDING ADDRESS: SANITARY NO, APRJGTIONSUBMITTALDATE
2-1/053 UNITY IAT N L�3
O Nf' SNAME: ""ON I_ CATIl NAMC' LIC NO:
!� 1 N0C CONTROI.N
CERARCIIITECfENGINCNO: ADDR ESS:
r 0
CONTACT: PHONE: BUILDING PERMIT INFO
TY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFMLIL
owz Ihxby al chid l sm liam,d ardor ProvisicrosofChy+la 9(commmcmg with 108 DESCRIPTION
1400 un
Sttlmn )of Divisinn3ofthc Nusins.cand Rnv urenx V
ofaoCode, d my pANpS �
full fora erd cRcs.
Qyy Liave Cl.—LAY UP TD 200AMPS
Gil
Contractor 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER IODO AKIPS SQ.EL FLOOR AREA $/SQ.bT.
OZ
—O IUMasuM my plaru slue b<u.cdu Wblic raartv �...
Opo,Fw SIGNS ELECTRICAL
4cenacdPm mut — t�
OWNER-BUILDER DECLARATION, SPECIAL CIRCUTT/MISC. _
yx OaU I hcrtby if,.Nu 1 son ocmpt Iran Ne Cantrama's Licerae Law fa Ne
c+l , nSec
followingrtan.( tim7031Z,Buineu and Pianissimi,sim,Code:Any city orcoTEMP.METER OR POLE INST.
pJ
00a whl,h n,c a Permit m Cm4ma.al impove,dmnnliN,or aper any strixtwe 5
Ym]aor prito not nsto.,acro rcyuim Us,applicant fm m
such Pculm Gleed mdl stvencnt POWER DEVICES
_DO NY he is lice d punuom to the lxm,inmsof du Co ., Uw(Ch unr E
aaa� 9(cmmcmcing with Smnion 7")of Division J ofdte Bottom and Pont..Cocs) SWIMMING POOL ELECTRIC VALUATION
_,,, or that he is exempt Ncrtfromind dm buu fm the JkW exanpdam My violation of
�ZQ S ion 70315 by ury.ppllontfas.pnmit subjeem do imu
g0d to.ridW
l pary of OIITI.Et'S-SWI'fCHPS FIX'11JRFS
C m more Nm Ove hurxhed MJso,(S50(E NEW RESBJFNMLELECfR S FT.
Wa ❑ I,uowosofdc rot nY,mmYa p10 mw Nw.goudcr okcamtpmuon. Q' STORIES TYPE U ON
a3— willJothe wmk.mcd the smumureiandinuMMaoffetW fm Me(Sec.]O4G,Bu0cv
and Pmfnnions Code:The Concmor's Licmt c law docs not apply to.n owns of
Progeny whobuildsa m,oc,,Ilcmah and whodassuch wort himselfostnmugh his
cmpbyax.povided tEu ouch imPmvcmrnts art nut lntsded ma(feralfa We.
If. OC IR UP RFS.UNITS
however.Nc building or irn rvvcmcnt is sold wlNin ore yam ofcanplction,dcowmr-
bth
uiM will live e burden N"iny dot he did m build or im(vove fa puryve of TOTAL:
sok.). TY. PLUMBING PERMIT FEE H. "If
ElI,uowrraof Nepropeny,vncxcltnivelY cmtr.siog wiN littnse0 roemrsasm
(ms 1 the ll(See.7044,Bulinus and Profedtms Code:)The Conuacta'a
Berne Lew domino apply to.owrcrofTeopeny who bmid.aimpmva Nerwh and PERMIT ISSUANCE
who comm for such pmjau with.tsntr.rm(J licensed Iwnu.nt to th Conwau(s
Lkon.e law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt wrda Sec. B&P C fa dde reason BACK FLOW PROTECT.DEVICE
SANITARY Y N
U.vmr Di,, DRAINS- RECE-, T.
FLOOR,ROOT.ARBA.CVND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX T N
/ ❑ m'Conaffirminstlm vcistt aintcof cauotm.clf-insurt.a.astif uof RECEIPI'N
Waten'C PIXTURFS-PER TRAP
mrWerssuion lvnnrre a.artifid aspY Naof(Sa.IBOD.Ieb C.)whirh PARK FEE T N
coven Jl anpbyce's alma Nu pmni, GAS-PA.SYSIFAJ-1 INC40lIDE1S RECEIPT♦
Iblicy Y BUILDING DIVISION FEES
ComisnY GAS-FJ SYSTEM-OVER 4(EA) / PLANCHECK FEF.
❑ Catificd apY is haebY famished.
❑ CmifiMm is Elcd with di ary mspecum divi.lon. GREASMSIDUSTRL WASTE,LNTERCETOR GRADING EEE
CERTIMCATEOE E- EMPIIONFROMWORKERF _ GREASETRAP SOILS MT..
COMPENSATION INSURANCE
(This ss don read sot W comPthd lfinepermit is fu one hmcdoM dollar.(SIOO) SEWER-SANITARY-STORMPA.2DOEf. ENERGY FEE
or lea)
I fy that w IN,pvfmnmtaofthe.vrk fa which his permit 1.iuved,I"I WATER HEATER W/VESD`1E.ECLR
not anplay.nY Pmrson in tiny m.uc a m
u to bsn object to the Woc1m PAID
Camprnvtion lewa of CJifaNe. Dam WATER SYFIEM/IREATING Disse Rc tfs0
0 Z Appli,nrn
Z 0 NOTCETO APPLICANT:If,.ham.ldng Wis Cerdficue of Exemption,you should NEW RESIDENTIAL PVAB. SQ,Ff, TOTAL:
b csnn, b*l m du Wmta'.Cmnpmrsis nprovivau of Ne Lebo,Codc.you must
a forthwith comply with rush ,situ a Nu permit sial l be dccmcd rtvotal. BUILDING FEY:
W Ia CONSTRUCTION LENDING AGENCY SEISMIC Ml
I hereby aff dm acre u a c,amn mim lading egacy fa Ne psfommtm of TOA ELECTRIC FIE
V O Ne wort for whicb Wis permit is iuucd(Sm.J097.Civ.C)
I ,Nmoe PLUMBING IFR
O F 1<MI o mfy Ss QTY. MECHANICAL PERMIT FEE
T..) I ardfy tlW I hare rod Ni..ppliuim and m..dot do.hove hdaoution i.
Ill Cmmdin lonsotioamP'y hmby auifforim y tdtof Chid isuu lwa Nisdngm PERMITISSUANCE MECHANICAL IFR
UU ill mi,mcsmodioopso fie bns olonss repesenutivn oflhHmybents upon Be CONSTRUCIONTAX
abov(Wc,)amxd pmpatyhN lnnify"ktr bn. AL'ITJt OR ADD TO MF.CH.
(Wc)al m savq indemnify tied keep may in
dr City of Cupertino agmvt
Iiabmsunl jWgmrnu,arsuiand oftbi% . it tmyinany way warm eg.imtsJd City AIR HANDLING UNIT(TO IO,ODD CFM)
In amuequena oft egnnting of Na psmit
AIR HANDLING UNR(OVER ID,DDD CFM)
Signuurt pplicantlCmtrxT Due EXHAUSTHOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO U)).000 BTU) Doe Radp Y
Will Nc.pplimnt a fulurt building mutant mmc a h.rdle h.vNmu m.tmisi
n deEnal by Ne Contortion MunkipJ Code.CTaga 9.12,and Ne ILnhhand Safety HEATING UNIT(OVER IOO,OOD BTU; TOTAL:
Cork,Sation 25532(x)7
Y5 11 No NTVEILATION FAN(SINGLE RCSID)
❑
Will the aWlicantar fumm buildingBOILER-COMP(311P OR 100,000 BTI)
ISSUANCE DA
by his, u.ac.Air
which emit
Disis�dou.air caaumirerw u defined by Ne B.Y Arn A4 ptWiry Maru/eercN BORFA-Comp(OVER 100.000 BTU)
Dixtdet2
❑Yn ❑No NEW RESIDENTIAL MECIL SQ.PT.
I have read the havrd,m.m tomad.nNUiR'rmn1.soda Ch.pla 6.95 of Ne PA 1 D
CJif Wilding
n.fetyomle,Se un 25505.25533 mcd2553n. lundcnsud Nu
if Nebuilding donnm cunenclshaveao bic .,iitis mytaon,,of. mnotify Ne A
OVos,,.Imn,W of Ne tequirrncnts which must be ma Poor m inuuna of a Cmifwte of r
I><arancy.
dlV
OwnamauNoneul agent Due TOTAL ISSUED BY: