24621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO yduit,ytNO-P.LELOUCAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL (� A /�/1
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L 4 F6 L
BUILDING DDR{'SS: SANITARYNO, JAPPLICATONSUBMMALDATE
-J,•1r1 UNITN LOT#
OW S HAMA:_y t' �. pE �� CONTRACTOR'S NAME: WC NO:
YVIUNF�-/ w `/P NIC COY'OL#
•ARCHITECT NGINEFA: LIC NO: ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pa% I hcrclry.ffi—that l am licemos cr pwo iommo,fCh.,t,,r9(camorcing with JOB DESCRIPTION
[+100❑ Seaian)LYIO)a iv 3 of the Bmineu'o mrd my Izcnx is in PANIiLS
a�U tullf c I
Fjty tic I.ic.M UP 102 AMPS
m"C LLrn Dve Cmv.cD 201-IOOOAMPS
ZOyL ARCHITP.CTS DE OVER Io00 AMPS SQ.IT.FLOOR AREA S/SQ.FT.
O%_Q Ittrx4r.tnal my PWnalmll be nacd v Wblue rmxds.
I:.m SIGNS ELECTRICAL
UpI,iccnudP ofn lon.l
X OWNER-UUIIDER DECLARATION SYGCIAL CIRCUIT/MISC.
1+130¢ following reayon.(Smian)031S.Bsuslrcv trod Rofrnasvn Cade Any ciy m mmuy TENIP.METER OR POLE INST.
,n J which rearuim a Imarm to annm[L.ITR.improve,demdi.h,we repair my i..
}� Prior to 1.asu.nce,aluo require theePrlicent for mob permit w file.ni d.ratement POWER DEVICES
tyY�p Natk is mW licepanumt to the pavvisimu a be,Cmtramon"[it.Law lCh.pter
1j1,�K 9(conutencing with Secrion)OOOIof Division 3 of the Buainessnd Pmfe.ions Code) SWIMMINO POOL ELECTRIC I N'UA ON
XW�y -that he rcxnnpt thncfmmnm111w koro forthc elle s]c.crosion.Myvic,mi,m f ED I
} Sevion)0315M1 (cant For. ermi...b' to the OMLE-SWITCI IIS-FIXTURES
C%¢ by eppi yc .pplitamt to acivil pctmhy of ,r'•,
nn more Bun rise hmdrtd dollars IS500).
�FO ❑ I.eowrcrofde propmy,«mYempioymwith w.geuBevsokcanpensation. NEW RESIDENTIAL ELECIR .Rf./' 1 i1 r T TYPEC NSTRUCTION
a3� willdoftnusi Cdtle.uuConara m`i Lidaue Law el fs.apcc.)Oan B of
atd nareva,r code:Tne eanttamota LJcense Lew doe ria apply to m owner ar
parlay who Wild.minamanoethermn,andwhod arbwork hitnselforthmughhis D TE
own unpLryeapr
, ovided that.ach Impmvemenlsure Int inentluloroffeml fmsale.If, G RES.uHnS
however,Ne hailding crimprovement la sold within one yew ofcampielon,brown, aa
milkle,
heownrr-
builder will br,c Ile burdm of proving bm he did m W IM ce improve for P+rPose of I OTAL
❑ I,nwrcro(the property.atneaclu.ivelyaxmxtinewit liaeaai comrrtaam QTY. PLUMBING PERMIT FEE FLOODZONE APN
enrutrun do project(Sec.YDW,Bush .M Profenaiau Cod J The Cantr.etor'.
I.iceve Lawdna Iry apply to.n owm ofproputywM Wildsaimprovn Uerem,md PERMIT ISSUANCE
wFncontranoi formch projects withnnwtiren,v(a)licensed puroamr,me Cunlnaur's
Gcmmlyw. AhUN-DAN&VI]J'1'-WATER(G
) FEE SUMMARY
❑ 1 un eacmp order Sec. tl&P C fm this rtnnn PACK FLOW PROTI=DEVICE ID :1
SANITARY Y N
Owner RECEIPT♦
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPIJSATION DECLARATION SCHOOLTAX VN
❑ Ihneby affirm tMrihevcacmimcue ofrovent maelmimurt.ma anif roof FIXTURES-PER TRAP RECEIPT'#
WmiuiCompematitmiruur.rm nificalcq tRmeof(.See.3M,Led,C.)which PARK FEE Y N
corm ell rnt rstpt�1 �y �+7 R13CEIJ`T Y
11-7M� �Vlv�✓ 1 L/ GAS-EA.SYSIEM-I INC. OVI'LEIS
BUILDING DIVISION FEES
CornpenY 14:1/
GAS-FA SYSTEM-0VT:R 4(E)) PIANCHECK FEE
❑ CmifeO copy s yfmni.lnd.
?/Cmifed copy i,film wiN the 6,impcction dividon. GREASFANDUSTRL WASTE I CEPTOR
GRADING FFE
CERTIFICATE Of'IXINPTION FROM WORKERS GREASE TRAP SOILS FEB
COMPENSATION INSURANCE
(Thi,scction ncttinot becomplcted if Ne,crrnit infcrate haad ldallaa($100) SE 17 -SANITARY-STORMEA.2110PI'. ENERGY FEL'
or t.)
I racily,dart in the'Monose or the work for which Chia pemdtuiarvcd,Is hall WATER HEATER W/VENf/FEECTR
tot employ my pamn in my armorer oro w w borne.ubjeet to the,Workers' PAID
Q z A�
Zpcnwlon Lbws of Cdifani.. Ilse WATER SYSTEM/rRPATNO Dee Rcttipll
O NOTICE TO APPLICANT:If,after making this C rif m of Exemption,you.naad NEW RESIDENTIAL PLMB, SQ.IT. TOTAL:
1~- /J becmoc-bprOmtheWorker'sCm,,,a,otionpmviaionsof the Labor Cale,yoo mon
� > fmhomh comply with nrh provini,mn or thl,pemut"I be dcemW revoked. BUILDING FEE
1 D CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z IhmebY.fmrm that dote u.caunuction lending agent,for the pu(arrtwee of
the work fcc which this pemdt i.itncd(Sa.3097,Civ.C.) TOTAL ELECTRIC FIJ?
Lk. l<akh Name
I.cnd n QTY. MECHANICAL PERMIT FEE PLUMBING THE
I r certifyfy ma Nat 1 have trued tai,ity and
coa and atue IMI the shove Infoa tm a MECHANICAL FEE
>" evreet.lagrtt to amply with oil city and ettmryordirtmua errd uee law.rtlatingw PERMIT ISSUANCE:
� building mnmmmiat,.rrd hersbyaivthnd ercPeentebve ofthis city weterupm tK CONSTRUCTION TAX
V .hove-,torX��
y for iruPecrmn Prrpwea. ALTER OR ADD TO MECLI.
(Wes ,11=mmly and keep a Ile City a Cupradno.gainer
liabilidem mdcxse nmyw.yaccrvc.,mm tald Gy AIR HANDLING UNIT OM I(L"CFM)
consry AIR I IANDLING UNIT(OVER I0,W)CPM)
Sigmuue .nt/Contrarnr pare EXHAUST HOOD(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Due ReasiI.#
Will the applicant or future Wilding trculwnt store or h o dle h.aardmo mucrinl
es defined by Inc Cupertino Municipal Ctdq Chap 9,12,and Ore Health and Safety HEATING UNIT(OVER 10.0X1)BTU) TOTAL:
CMc.Scmioo ,, (n)'f C3 No
❑Y5. VENTILATION PAN(SINGLE RPSID)
WBlde.pplienlmfuttrrt Wildingocculmttuucquipmmtadcvi�whlch emit BOILIA-COMP(3HPORIO.000BTU) ISSnUUANppCE DATE
Dirmonus yr mntmrdrtmu v deftred by the Bay Arta Air Quality Matugemmr r M
Distrim9 BOII.IJi-COMP(OVER I(p,(00 BTU)
Cl year ❑No NEW RESIDENTIAL MECIL SQ.IT. FEB y 1993
1 have real the hik:vumm.marnmrequirement's untie,Co ter 6.95 of the
COils mia Health h S.fc y Cade,Scniom 255(15,25533 and 25534. 1 urdctuand t1a, �/
it the building doe.era currently have a.,that it is my reipacubiliry w notify Ore CITY car (yU(Ct1 muoccupant of tho rtyuhemcou which,torr W con prim w i.auare of.ce rime of
Oavpmey
Owner or emhorivcd sgcmDoe TOTAL ISSUED BY:
OFFICE