27946 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Cn'Y OF CUPERTINO RUILDT\T-EEVCM PERMITNQ. 27946
APPLICATIONIPERMIT PLUMBING-MECIIASICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBIMITALDATE
A* G !� UNITY LOT# /1
O NER NA P,: IONP.: CONTRACTOR NAME: LIC NO
-
N1 CONTROL# w
RC UTE /ENG NEER: LIC NO: ADDRESS y El'21R
CONTACT: j D e PHONE:d f QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
N/ y?/7 BLDG ELECT PLUMB MECH
PCRMIT ISSUANCE
LICENSED CONTRACI ORS DECLARATION APPLIANCES-RESIDENTIAL
mwz Ihcrehyaflml that l am liccnsd uMo poviaiomof CTaptv9lcotmrcei+igwitls JOB DESCRIPTION
+tSatinn'IIMXrInf Dvialon3ufthe Burinras rodPrufemimx Coo.amd my license i.i^ PANELS
FcE&
Tau r««arra art t.
F,ZW u«nse Class- C 4 lIP T02fNIAMPS
r"<c, Daac Contractor 2ll-Iqp AMPS
1-ri�r Z ARCHITECT'S DECLARATION SQ.ET'.FLOOR AREA 5/SQ.ET.
°`?- I undersand my plain shrill be used upuNk rervNs OVER R 1AMPS
e
ern SIGNS ELECTRICAL
<YProfessional!d Professional!
W'rec< OWNER-BUILDER DECLARATION SPF,CIALCIRCUIT/MISC.
E0 W, I hereby affm that I am eacmpt form the Contractor's License Law for the
talitr-err following rtaaarr.Section M31.5,Busi.aM Wesson.,Code:Any thy or caunty TEMP.METER OR PoIt INST.
O�a which mymres a permit m construct,alter,omprove,drololiah,or rtpeu any structure
fnYs prior to iu itewamx,also rest the applicant for such permeot to file a signdawvrcm POWER DEVICTS
Kpp than is liccuM puawult m de ravisium ofoldie,Cetracmis Lime Law(Cower SWIMMING POOL ELECI'ftlC
4 xdheo�d 9(nmmmancing with Avam 2(la)pd MvisimlJof the Bueirxx era Pmf¢sioresCode) VALUATION
y)_y «t11al he u"MN themfr«n and the bmufor the alk;ed exempion.Any violation of
I-•ZY Section 7031.5 by any a*cent for.erinit rubjeeta the eppliant to a civi l proaRyof OUTLETS-SWITCHES-MIXTURES
f Sp< nW inure than five hundml dollars($300). NEW RESIDENTIAL FIECIA _SQ.FT.
a3� C3I.mvwnerofthepoNaty,«mymmployeerwithwageutleirmlecomlernation, GS TYPtCONSTRUCTION
willdo Nework.and tlnswctum is nm Intended«uffetW f«axle ]04<.13cmraa
and Itofess'wm Code:The Contmcto(a Liccmr Law does rd apply to an owner of
paPerrYwW ddldsaimposer thereon and whodoes such workhinuelforthrough hie
own employers.provided that xuch impmvcnems arenot inicudM proffered forrale.IL OCC.GROUP RPS.UNITS
however,the building«unpmvmtent u sold within nate yevofcumpletion,theowner-
Fl.Wilde will hevrtk burden or proving than he did ml Wild«bnprov<f«puepx of TOTAL:
❑ 1,mmr« m
rofthe m,eny,aexclnaivelycontracum with Haiti caonaam to QT T' PLUMBING PERMIT FEE FLOOD ZONE APN
"mom",
the Noj;ct(Sec.264ki,But.and Profemies Code:)The Cantmnmrs PERMIT ISSUANCE
Ilccnsc law dues nm apply m un owoarofpmperty w W W ilds m Improves thb
ereon.a
w W cantrana for such pmgrcts with amntnact«(s)lianaed puaswnt m tie Cowacmta
Cost Law. ALTER-DRAIN R VENT-WATER(EA) FEE SUMMARY
❑ I am exempt uMrm Sec. ,B A P C for Nis move BACK FLOW PROTECT.DEVICE
SANITARY Y N
• Owner mDa"O, , pRAWg-Fl.OGR.EDGE. CON0. RLCE,IPY
WORKMAN COMPENSATION UICARAT SCHOOLTAX Y
N
❑ FIXTURES-PER TRAP RFCFIPY
Wuke
PARK FEE Y N
covrrsall rlyFctrader�th flt�u GAS-EA.SYSTEM-I INC.S OUTLETS RP,CEIPTY
POIiyN / BUILDING DIVISION FEES
C3GAS-EA.SYSTM
herebyfumishotl. ifBA) PLINCHECK FEE
Certified copy is
❑ CertifM onPY is tiled with thr city imprrtian Division. GREASFANDUSELW IM'ERC1i17OR GRADINGF117
CERTIFICATE OF EXEMPHONFROMWORKERS GRPASETRAP / SOILS EEE
CDNIPENSATION INSURANC17
(Thu suction need rot be emoPetcd ifthe permit is for ore hwrdreddollara(5100) S �S Y.STORM Perk.2(10FT. ENERGY FE£
orlrm.)
I acud'that in the performance of 0,c wrxk f«which than Perak is named,l shellWA ATER W/VENT/ELECI'R
int employ any Person in any mover so u b become ri m lir Waakeri PAID
ConoMmeriunlawsufGifsmia Date WATER SYSfEM/IRFATING Dare ReceiNY
C z Applicant
z0 NOTICE.TO APPLICANT:IL after ranking this Ceriltote N Exemption.you should NEW RESIDENTIAL PI B. SQ.FT. TOTAL
r�r heconewbjectlathe Worker'aCampeawtiun povisirre of the laMrt COdc.you muV
> himhosth comply with such provisions or tits Permit thaR be deemed rtvokd. BUILDING FEE
W [� CONSTRUCTION LENDING AGENCY SEISMICFEE
z 1 hctcby affirm mat dorm its comirunion kMNg agercy for the pecfmrwr«M
U (D the work for which this perrnim is i.rd!(Sre.3097,C.,C.) TOTAL: ELECTRIC FRE
Idef' Noun.e Noun.
O F 1rnr'a AJNm QTY. MECHANICAL PERMIT FEE PLUMBING FFE
CJ 1 certify mor I have mead this eppliwrion aM state that the shrive informuion is
r>" Lk1 coma. PERMIT ISSUANCE MECHANICALFEE
Wilding mnumuctim,amd hereby authorime ncpcscmulvaof thiols city to ether upon tie CONSTRUCTION TAX
U abavcmentimneJ po,cu,for inspection WNau'es. ALTER OR ADD TO MECII.
(We)agree toave.indemnify aM keep lunmlem the City of Cupeiom agvnu
IialilitimiuAgmenu.conn and exposer which may in any way arvueugaimt mid City ATR HANDLING UNIT ITO 10.000 CFM)
in c«ueyuexc of tic gmming of ibiu pcmlil.
TAI �C�Y�N
AIR HANDLING UNIT(OVER E OAOO CTM)
Signa mor Appliant/Contrut« pare E%IIAUST JIOOD(W/DUCO
PAM
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) ! Date Raei,#
Will tlrenpplicarot or future Wilding orcunam,tnre or haaodlr hexandous muerial HEATING UNIT(OVER 100,000 BTU) TOTAL:
as def«.d by the Cupeninlo Mlmicipal Code,Cheper 9.12,and the Health W We,,
CWc.Sortie 25532(a)P
❑Yea A''IJo VFNI'ILA (S W
'TION FAN GIR RESID)
ISSU^NCE DATE
Will the aigllanturPommhuildingoccupant use equipnrenl«d<vica wM1lchanil BOILER,COMP(JIiP OR 100.000 BTU) # I�
• hdS'srdious air contaminants as definN by the Bay Ams Air Quality Mulagenent BOILER-COME(OVFR Rat"BTM
istrinDECD
i 11a A41�,�(
Y1 NEW RESIDENTIAL MECII. SQ.FT. 28
1995
Calif—iiiHih&Solely Cade.Suntinn255516.u513a�1Z.5533a.airrand6wnntwo Gl!Y(firUVrrk1IN
if Ne thudding does rot commonly have a tencent,dw R Is my muponsiodity to notify the U
axxupant of the r«luiromcir tx which mum M met prim 1n moor ce of.a Coni rate of
Owrcr Jr uu1-n'rNapent 1 Dn�i -r- TOTAL ISSUED BY:
OFFICE