28267 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ,LL RI A. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
Nd'II,UINI:DIVISION BUILDING PROJECT IDENTIFICATION
B (DING ADDRESS: aKeDr '/ //f }1.�y1 /� (/��(/�. Q SANITARY NO. APPIJCATIONSURVIUDALDATE
6 I r . 1'Ir Vr OfNTRA I I� LOT f-�
�(/ ONIAACfOR'S NAME: LIC NO: N/C CONTROL J
AR IfIECT/FliGINh' ��pA/I�SIp/Iy'LIC NO: -I ADDRESS: ❑
CONTACT: PHONE;
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LI ELI! PLUMB MECH
PERMITISSUANCE
LICENSED CONTRACT ORIS DECLARATION El El
pPPL1ANCPS-RESIDENTIAL
pyy I hmcby affirm that l not fik nx untIcr Pmvixionaof Ch,,,cr9(a.nmrncing with
!+1076 Seclion 7")of Divuim 3 d the Bstw nand Prorevi«n Cde,call myli sot is in PANELS
full fur¢and nffal.
Licmx Cru. Lic.0 UPTO2 AMPS
v Dj flue Conlr.cta 201-1000 AMPS
FyK ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $,SQ.Ff.
C)Z—G IumkntuM my plm,shall be tocol rt
u Public cool, OVER I"AMPS
SIGNS ELECTRICAL
Lan.scd Profcainnal
OWNER-BUILDER DECLARATION SPECIALCIRCUI`DNIISC.
O0,F 1 l,mmy anon Jut 1 un cxcmq from the Cmtranor's Lice.Lsw r«thte
wnt; followlogrcasnn.(Semon 7031.5,Buwc.v and Pmfcaions Calc:Aly city a,.ty TEMP.MITER OR POLE INST.
k'u'�� which rmnirta a permit no construe,alta,improve,dmnrllN.o rnair my ntrucnun
5 }5 priorwit,iasuatgn.als0 requites the spplicaru fm such pe.tto fka sl'oeocI emcnt POWER DEVICES
�p than he is liomloc]Punumnu the Pr—kinin of the Canranor'e Liwva Llw(Cdtol
as K 9(cormtarcing with Scctlon,7")of Diviaon 3 M the Businwn cd Rvfasiun,Cock) SWIM MING POOL ELECLRIC VALUATION
t+x1 T—Q'�n r.Plat he ie cxcmPI Janefom end tk basin fa the alleged eaanpian.Any vlolWood
tea Scnm
i ](1315 mn .m
by y s,,A icmt to,a PcnirhjccO he epplicw to n civil pcndly of OUTLETS-SWITCHES-PI XTURIS
m mac Jaen fvc hmthcd Johan(SS( L
C(_� ❑ I.auowneroOhe propeny.omyemplu evwitha oro NI?W REMDENTIALEIECIR _SQ.Ff.
y gmutok(.. emmprmation, STORIES TTPI?CONSTRUCII)N
y3� mol do Jewon,Calctixt Tioc ureisnminlcndonc 1' of Tao k(Sec.](so ow.of
and Pmfw1a,bu Calc:ITe yc,, x h anti
law don not apply In rt mvnrr Of
Inupero wainbuildsa anpuveaclinic,nalwho Grinstiltwork hlmxlfor!!tough bin
awnemploy,WilchvidcdnhmsucM1imissold iteanmlimcaledaaffcrW fa Wc.If, OCC GROUP RIS. NIT
h.wbuilcl.ill We11ho, unto covinntomn is sold arirldnote Year or cl,royehmDaeowrac-
W ildnwill havcthe burJnt of Prnving thin he olid rM Mtild a irnprove fa purpx Of TOTAL:
uk.).
❑ I,u Owrnrof Je ptoPcny.vnexcluaivelyconlrxvngwiJtlirenxdcmtraua.w QTY' PLUMBING PERMIT FEE Fl.WDZ NE APN
cmwrun the Pt(Sec 7014,Businu.cd EnOc,inimu Cu )The C«tnelua
U� wAxirtdapplywenownerofpropcnywhn ldsmimMvcnnhm�,erd PERMIT ISSUANCT?
who mmnaet Swatch p,*ls to th.contfanm(a)licallpvnuwt no the Contracwl, AL'IER�DRAIN&VENT-WATER(EA)Li.law. ( FEE SUMMARY
❑ I en aaemp urdu Sa. ,0 A P C fm thin recon BACK FLOW PROTECT.DEVICE O D
SANITARY Y N
Owrrr
Dao, RI.CEII WORKMAN COMPENSATION DECLARATION DRAWS-FLOOR.ROOF.AREA.COgqD�,d�'-
aL• SCIIOOLTAX YN
❑ Thcnbyeflimtlhetl M1nveaanifwte ofcauent to xl(-iruurt,aeartiftmted FIXTURES-PER TRAP l� RfLT;IPTY
W«kera'Canpmamirm lnsuranmmecmlfmJ copy thcrwf(.Sca 3Blq,Iwb CJ which .O-v PAItKFEF Y N
cover.all cinploYcc',uMn the pumin. GAS-IiA cSJEh1�1 INCL OIIfLL ` RECEIP #
Polley Y BUILDING DIVISION FEES
Compnatty my
❑ GX1�EA.SYSIEMf 0 FTE a PLANCFIECK mPY is bcrtby fumiileJ.
❑ CenifeJ wyy is filN wish Je city impaOon Jiviabn. �a ' GREAS N N C GRADING FEE
so
CERTIFICATE OF EXEMPTION FROM WORKERSL AP SOILS FEE
COMPENSATION INSURANCE
aI�)fiia xnbn rem mtbe canPlned if nhclmnit is fm ore hundrM d11 . ti) -SA fYRM ' ENERGY FEE
I cmthanify than in thnncloclO —I'lhe work fa which lhia penia an holm,I nh,E x HEATER lECIA
ria mrplo,any pvaan in my numm a no bmare.ubjcn to the Wakm;' PAID
z Con"ama .Lawnnf Cdiforaa Dmc w WA /IREATINO Umc RacipY
A p l a n
z NOTICE TO APPLICANT:IL after making this Cmifcshe of Exemption,you mmuld,I NEW RPSIDENTIAL,iR6MB. gQ.FT. TOTAL
rfn h ,Ooclubjxt to Or Wakax Compcosall rcGxi.n.f Jc laboc Cloth,.
a fmhwinh comply wino each pmvisiman«this p.it ehall W J«ana'I rc,okm. 11.1 BUILDING FEE
w CONSTRUCTION LENDING AGENCY SEISMIC FEE
F.
5 1 hneby affirm that there is a c,nstrttctim Rolling egercY f«the pmfontwn¢of
U O the work r«whicb thus permit m ivud(Sec.3(97,Ci,C.) TOTAL: ELECTRIC FEE
IrMcf'a Nem:
1c .Addreas QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I cmify Nu I hart nod thin ap'licmion and awe that the above infomation in
} W carol.I-,,.In vontply withal)lily ed cuuntyadi.end slave hs,nlming an PERMIT ISSUANCE MECHANICAL FE
I" huildingcOnntrttnitc,andM1erehy auJronrc o,nn,monive.oflhiacityw mact. lo tic CONSTRUCTION TAX
r..) Z ebwc-meonmred prmPnY for urs tt npurpose. ALTER OR ADD TO MECII.
(Wc)agam to alive,iN.innfy cal kap harmless IM City Of Cupcnirw agvrut
liabilida,judgmrnu.connard expertsa which rally in my way emmeagamnavid Cty AIR HANDLING UNIT(1010,M)CPM)
uaec dile grmtl ispmni�
AIR HANDLING UNIT(OVER 10.000 CFM)
urcof App' _.l x F AU.STHOODGVIDUCFI
PAID
HAZARDO S MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) .. Unx Rcccipi N
Will he applicant or funam Wilding occupant short Or tumuli M1 dots nutcrial
u def lied by the Cupminn municipal Cale,CM1nplcr 9.12,and nhC Ilalnh and Safety IIIiATING UNIT(OVER 1M.000 B'N) TOTAL
Code.Sodom 25532(.)^ VENT L k'HON FAN(SINGLE RESID)
❑Ycn ❑No
Will Ncapplicmn afuturt Wlldingottvpmn uxequipmrnt adeviceawhich rntit
BOILER-COMP(3HP OR IM."BTU) ISSUANCE Df
ATE
it 4mlmtinmis av JofnN by the Bay Ata At,Qaallty Mmegcneot BOILER-COMP(OVER IM,"BTU)
Dixvin?
❑Yu 0N NI?WRFSIDFMEALMECIL SQ.FT.
I have rad the havrdwa ammint tcquinmmn uMc,Chaplcr 6.95 of the
alifomie Health A,S sfmy Code.Satiom 25505.25533 and 253}1. 1 mrdnuard thm
if the building!bier nm!unready have n¢ran.Nat it a my nyauibiliny to notify nhc
Occurym d the rcquirments whits mu,l Ito,non Pec.lis i.cwana Of e Cmiftcntc of
On'tpaey.
Owrma.uJt.,cnt Dave TOTAL ISSUED B}' V•�
OFFICE