27022 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILIyING-RER?7rR1,A. PERMIT NO. O
APPLICATION/PERMIT PLUMBING.MECHANICAL
22
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
HUILDING AOQD.RPSS: � SANITARY NO. APPLICATION SUBMITTAL DATE
cgL—
�/V • UNIT♦ LOTH LU _�j _q q
Oyy9TFR$NAMF IG} PHONE: CO ACIOR'SN LIC NO:
g4(l��Jl 1IVV 11`` 0 93 NIC CONTROL#
`• RCHITECT/FNGINEER: LIC NO: ADDRES .
o69 Ll 5. 01lt�u paL. ❑
CONTACT: NIONG
? QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
C)&,I�' PFFtMIT ISSUANCE BLDG F1ECT PLUMB MECH
❑ ❑ $? ❑
UC'FNSED CONTRACTOR'S DECLARATION APPLIANCM-RESIDENTIAL
pwz, Ihereby affirm that l un lleented orderpwvitumu MChapterl) ntennngwirh JOB DESCRIPTION
[UOFStOwn 7000)effCoition 3nf,he Businos end Rofwriau Code,end my licerwe is in PANELS
it
FZu1
U.Clews Lie.# UTT0200AMPS ��?
vi hate Contractor pl-IIXp AMPS 1 `
�tnZ ARCI IITTICI'S DECLARATION 2sU-10)00 MPSAMPS SQ,FT.FL AREA $/SQ.FT.
OZh❑ l umlerstud my plants Nell be undo W�records
SIGNS ELECTRICAL
[y � licence Poolmionel
row OWNER BUILDFJI n the Co DECLARATION SPECIAL GIRGGIT/MISG.
dX Oy LUF. 1 hereby.farm that I on cxcmpr Tann the Cmient;Corte:
•e:Ary law es Nc
W3�y fdWwinQiioes. ccum entire ,itherandwn,d,slom Co de:Arydry IENP.ME1FJt OR POLE INST.
7n>� wM1icM1 require a pcmtir to cannruct,elan,improve,JcmMiN,m«p'r any nrtetu¢
y'�QF prior in its iswwee,alw requ'oca the epplia�ed for Such temut to file u Signed emtamnl POWER DEVICES
pts<p Nu he u Ilea dpvauanl to the pwvisiwv of the C«uranot.License law(Chwer SWIMMING POOL ELECIRIG
dd � 9(roromnclngwiNS«tion901p)ofNvision3ofth Bmir� Profeeioru Codc) VALUATION
WEK mrhet M1e ix cxemp Ncrtfrmm od the baste f«tM1e ellegM exemption.Any viMedon of OIfTLETS-SWITCIIFS-Fl%'NRFS
_FZQ SmianI0J1.5 by any appiwntlmepmnit wbje<u the applicant to ecivil petWryof
my store than five hundred ddlen($500).
. NERFIDRALLE= SQ.FT
TS,
n: STYPECONRUCTI)
L3. will Ju the work,and rhe srucmm i.v not nwrdsd oroffe¢d f«mk(gec.AM.Bmir.
ed Pwfainns Code:The Crnt.Wit Ll.law dod not eptly to an ow¢r of
pnoe,rr,wMbtdlds«impoves Nmm�,ed wbodoesion work hinesclf«thmugM1 hu
wnemrloyca.PrV k1cdlhatsuch irom enseen.—not inendd«offaed fmsale.If, OCC GROUP RES UNITS
hmvcvcr,the building m Impmvenrnt is wIJ wiWin me t<er of c«npldon,dre owner- TOTAL
builder will have th dudcn of proving Ilan he did not build m improve fm puryoa of
rale.).
❑ I,na ownerrfrlle prupay,em excludvdycmtwctingwiN liansd amtroctmm QTY' PLUMBING PERMIT FEE I1.000%O APN
clMwuer the Pmjecr(,Sec.I0A4,Btoinne ad Pmfesimu CUJe:)The Cunlwmr'a PERMIT ISSUANCE. �#
Lireme law dzrnd apply roan ranter Mpwperry wM W ildr«Improvea dorwn.W
I who pntmcuf«wch Projma with a conwctorts)Ileenrd pursmnUo the Conueetas ALTER-UIIAIN�VINT-WATERTEA)
License law. FEE SUMMARY
❑ 1 mo a+amp order Sa. ,B k P C f«Nis drawn BACK FLOW PROTECT.DEVICE SANITARY Y N
Dide DRAMS-FLOOR,ROOF,AREA,COND. RPCEIP #
WORKMAN COMPENSA'UON DECLARATION SCHOOLTAX Y N
❑ Ihcrtryaffirm lMtlhaviceanif Le of commtmvJf-inwrc.«a«rdfeuc rf 0 RECEIPI'6
Warleri C«nprnwtionluvrmt¢meanificd Nmeof(Sa.J800.Lab C.)whicb � FIXRIRFS-PER TRAP
ropy PARK PFJ? YN
eovm all cmpinycds oder this Pernint. GAS-FA.9YSTIiM-I INC.40fITl£IS REVISIOM
PnikyY BUILDING DIVISION FEES
Coorls ny I v' J A �A5 FIX 94SITAt. 4 ) PLANCHECK FEF.
❑ Crnified copy is M1creby fumiNd.
❑ G � �_ I. INERCEPTOR GRADING FEE
_ /I
CERTIIICATE OF EEMP TON FROM WORKERS L �_ v.I 'GREA$„F SOILS FEE
COMPENSATION INSURANCE
(This xminnncedtotbecompleedl iftheper it'uf«mchutdmi dolWy Wlq()) SF; - A Y MEA.2WFT. ENERGY HE
«less) an 11 U/'1 C
I eetify Bin this,perfosomee ofdc work fm which Nis p.mmut u uwM.I"I A /EJECTA
on.empkry any person in any tnermcrs o.to bettrc wbm
rjto the «
Wketx' PAID
Csn
z rnpeouminnlawf California DueWATER SYSTEWMEATING Due Rei 0
Applicant
O NOTICE TO APPLICANT:If,Ac mating this Ceeificate of Exemption,you rhoM NEIV RFSIDENTIAL PLMIL SQ.FT. TOTAL:
FIxx«lendjcct to NC Worker.Corri rserionpwvisions oflhe LaMrc CaJe.you no
> forthwith comply wlN such lnuvisiots«Mitt pvmit Nell be,deemed mvotd. BUILDING FEE
Z
CONSTRUCDONLPNDINGAGENCY SEISMIC IIS
1 herby affirm Nv Mere is a ensorunion ktding egcncy for the perfonren¢of
U O the work f«which Nu pmvut is'...w(Sec.31097.Civ.C) TOTAL 6.d�.O(7 ELECTRIC FEE
Q fardels None
L<nden AJdm.. QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 crnify Nan 1 hove reed thio eppliceti«ud ante Nal the above Wormntion it
�" � c«r¢L lagtce romnplyxiNallcisy and camrymdwrcn Wuvm l.ws rciuingm PERMIT ISSUANCE: MECHANICAL HE
I--' buikingrnnnrucuon.end hcrehy authmiss repvcnuives efir.ody teenier upno the CONSfRUC1'ION TAX
U Z aMwc menrimed pmpmty fm iturenion ALTER OR ADD TO MECI I.
(Ws,)rg¢c to neve,indent k bnrrolee The City of CupenOo agWrst
Ritoldt'Judgmenot osde in arty any rvueagaiew aid City AIR HANDLING UNIT(TO I0,OoO CFM)
rnnseNu of tnntin t it. rto
,a AIR HANDLING UNIT(OVER 14000 CFM)
eu f _'?
atone MApplianMen Due IXHAUST HOOD(WNUCFl
rnlD
IIA%ARDOUS MATERIALS DISCLOSURE HEATING UNIT(IG 100,000 BTU) Dare Receipt Y
will the applicant or ftwuc building r ,cru tt«e to hudk heznrdoua trwaial
es defend by Be Culcnirw Munici*Cork,Chapter 9.12,nd 0e Flee1N ed Safety HEATING UNIT(OVER 10LOB0 BTU)
Code,Smom 2553200^
El Ye, 11 No INVTIREM
O)PAN(SINGLE RID)
ISSUANCE DA
W11 the tppicantmfmmc buidine«cupwt ore rm4vicowhichanit BOILER-COMPfJIiP OR 100,0(10 BTU) PAID� � I]
gmpm
11air cmnuninanu as de0rcd by rhe Bey Aru Air paltry Menaganrnt BOILER-COMP(OVER 1(10.00)BTU)
DWrictY
OCT1 ❑Ym ❑No NE.W RPMI - AL MECH. SQ.FT.
have tend the bvunkes mweriaH nquimrcnu under CM1nper 6.95 of the
31 Lcqa%
California lkelN A Safe Code.Smions 2551)5,25533 us]Z55M. Imduvud dw CITY Ur
if tk building element bet eurrctxty Use a taunt,t� m
it is y¢em
yuibility to ramify We wit
cupenr of Nc rcquircnscros whkh rotor he met prior to issuance of a Cminfi re of
Oeehparey.
()wren«amharind egrnl Uuc TOTAL: ISSUED BY:
OFFICE