30692 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O/y��V Q J Z
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSS: SANITARY NO, APPLICATION SUBMITTAL DATE
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NF$'$NAM s Plit), ^O CONTRACTOR CIA" S-�� �-1� WC CONTROL♦
•ARCHITE NGINEER: LIC NO AD ( 2 7 J/
2.9e 01Q. Y
CO A : PHONE:
BUILDING PERMIT INFO
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�/�O)k va,r &—(��j(� ❑ Cwwltant Fur;Paid by Applicant(Initial) H EC PLUMB MELD
WCFNSE)CONTRACTOR'S DE RATIO. QTy ELECTRIC PERMIT FEE IhiJv\
Lheeby err tlwl i ern brow airier prr,.inco,of Chapter 9 Ummcrrmg JOB DESCRIPTION
0Z with Seellon 70DOafD;dslm 3ofthc BudncuonJ l'mfesniatu Cuk,and my license i, R sID NTIA .:
O in PERMIT ISSUANCE ��
full face aN N(wt.
GF.CJF Liccwccbms Lich CISWL ❑KITCHEN RI1.10DFJ.
NQ2 ILm Conn.., APPLIANCES-RESIDENTIAL MON Ll PLUMBING RE-PIPE
P,prn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT EJ S1
z O to Z I Iamldmtmd my plans shell he Used n lowic retorts MODIFICATION
OZ-a UP TO 2W AMPS
rr,14 Licensed Profasionil ❑LNTERIOR El CHIMNEY REPAIR
oZ4 201-Ifl(M)AMPS IMPROVEMENT
Oat I sm eUILDF.fr m the CommetoRNI ION OVER IIMMIAMIN NYT♦ R MODEIBEPAIR ❑DEMOLITION
Y ,L, Of MSR
� a I Irteby.Trrtnmat I to eaemlR from rot,emteenu<,Caen..Taw r«th<
3IL Ler.. following rcuan.(Section]0315.Busircss sed Rofecvom Code:Any city acauoty SIGNS ELECTRICAL
LLy which equines ti permit to carommer,alta,impnrvc,demolish.or repair tiny structure
C) proem hd is m,e,also ,,mill llar.,ai=ant tar.,hch pcmdlmflc atiigned wmnrnl SPECIAL CIRCUI VMISC.
�} that heis liccmd purwvu lothepmviaimu oflhe Cunv.clor',License law(Cbeper9
fat=00 Icomrwvrin�wim Sauon]fN10)ol Divium Jof Jr Rusisu sed Rofasiam Codec)« TEMP.MTITER OR POLE INST
d e c I-he is cocmill tlererrom sed the haas fm 11 alleged eamhpdon.Any v'ioWion of ❑NEW B'PEODDr170N [I DEMOLITION
{v Scniun 1011 S by vny upplinnt fa u Pemtil mhjeaa IM:tippl'rant In o civil penally of POWER DEVICES ��1.
�Z} not more must fin,hundred doEm,(s5W). ❑FOODSERVICE
=a ❑Las owrcr Mahe proPeuY•«mY empbym with waleselhrir,ak emopemalim. SWIMMING POOL ELECTRIC IMPROVFMEYI'
will do the work,arch the slmcmeix otintrnded urofered(«ulc(Sec.7(W.Busirlos
El OTHER
a wd Pmfnsian Cvd,Tbc Commclor',Iicen.a law des dr apply lu an owner of OUTLETS-SWITCHES-FIXTURES
Ilrgerty wlm No"or improves thcem,arta who chat,...h work himclf Ur Ent
but own employee,.proviGil Jun such improvements see of thnavkd«ofercd for NEW RESIDENTIAL ELEC It s
sale.If,however,IM buiding err inupo,moeut is afd wiatirmte yewofcornpletion.the SQ.FT Iii-OOR AREA SRQ,pT
ter-mi Wer will have the Imrlso of lci IMI he AIA tar build on improve Gr par-
fulc.).
co wren prnyerty,em esclwivNY cmtmebry Nim I;cen 1[Wtrcton b (��j/�
the pmjeO(Sm.70W,Bushcu ant Pmfeui«a Corl The Cmasno(x Li-
ccnselawJlcnllaopplywfor owe,of property who builds or improve tk oo•and QTY, PLUMBING PERMIT FEE
who mntrxB for tarn poi with a cNlaaCllx(,)Icen.dpalmetto to the CmRctor'a
license law. PERMIT ISSUANCE
❑Tans uolim Sec. ,B&PC f«mix rerun
AI,TF,R-DRAIN&VENT-WATER(EA)
Iflwmr hut, J VALUA///T���ION
A MPENSATION DATION BACK FLOW PROTECT.DEVICE
I hereby arm antler Penalty of perjlsry coneoff thARhC following Jalvatim,:
❑Ihavc end will malimvin aCmlllcam of Conxnt mmlG;n,ue f«WorkcYs Compcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIS 'TYPIiCONSTHUC110N
lotion,v provided for by Section 3700 of tht,lab«Cale,for the pMarmuct,of Inc
work f«which this pemJt is issued, FIXTURES-PER TRAP
I nave and will noint.in Wmins",Cooperation I.e.m imimm l by Sectio
17M of the LtbrCale,fur the pefrnance of the work for which thispermit is iscal. GAS-EA.SYSTEM-I INC.i OUTLETS OCCGROUP APN
My Workers Compenvuiom Irw a wrier and Policy number an.
Cues¢ Policy No.: GAS-EA.SYSTEM-OVER a IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
1'Ihis.vm an need ad he comported if the Permit is far one hurdrN dollars(11 an) B G IVISION FEES
«lac) GREASE TRAP PLlUNCHECK T
Icmify tMtinthe perany mane-INewurkf«whish this IN,Woi,iuuC.,.- SEWER-SANITARY-STORM EA.+W FL '
titer employ wy peruse in any manner m aero hcome suhjat to the Wuhent Canlcn-
,z r,samn Lawsof Cdlfamia.Dem ENERGY
ZO Applicant WATER HEATER W/VP.NT/PIECTN GRAUI
ti NOTICE TO APPLICANT.If,after nuking this CerJficato of Excmprim.you should WATER,SYSIEMTRESTWG
lQF bcmrte subject to the Worker's Cnmpensetim Provisions of the tabor Core,you must _ PHOUSINGMMG .
irthwim comply with-ch porsk Rau or this P crit mWl he&cowl evoked. WA'D?H SERVICE
a �
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.PT.
U O IhuchY alhmt that thea isamn,tttrtimI Wingagce,fmtleperlomumccof D Receipt♦
P tlr work rar which no,remit iv,,trt(Ser,3(W7,civ.c.)
U Lcist Nelne TOTAL:
W Lcndel,Atlirsu
y 1 certify dean I have read this application sed Mme that the above infornwi nn is Z(A correct.I agrr<m mntply with all city end rnunhy ondihurcv otd sunt laws elating m QTy, MECHANICAL PERMIT FEE
,zh;ldingcontrunim.and hrrebyanthorix rcprexenwives oflhis city memcurm the EE 2above-mentioned property f«impestim punpU.cs, PERMIT ISSUANCE(We)agree to oc,indemnify end keep harmless the City of Cuparfm Wine Iiabilllie+,judgments,and and ext,. sei which may in any way acrnar against omi City gLTER OR ADD IO MECH.in mnraquence of thegmnting nflhis permit. GI EAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PUINT AIR HANDLING UNIT(TO IO,"CFM)
SOURCE REGULATIONS. C .FEEAI HHANDLING UNIT(OVER 10.1"CFM) NTAX Due EXHAUST HOOD GV)DUCDHAZARDOUS MATERIALS DISCLOSURE MMG HEATINGUNITITOIW,fI(1(ias detftrrd by(nt,Cuperirs,MNucilvl Cade.Chapter 9,12,enol the Health mW SafayCade.SeOim 255320):' HEATING UNIT(OVER IW.00)BTU)
0Yn ]Ro
VENTILATION FAN(SINGLE RESID)
Will then Bean,w future huildin t me, I or Jevicts which Dane RmrTs N
coil huaadous air mnlulEnandu Deft iby Bay Area Air Cathy Msmagement BOILER-COMP(3HP OR IW.IMMI BTU)
District? TOTAL:
❑Ya E]No BOILER-COMP(OVER I W,DDO BTU)
I M1avt,and the sectarian,materials mquircmcnu ueder Chapter 6.95 of the Cdi- AIR CONDITIONER ISSUANCE DATE
forma Health&Safaay Cod,Scrims 25505,25533 and MM.I uns w that if me NEW RFSIUENUAI,MECH. SQ.FT.
huiding dva
ON amanly have a Icnank that itis any reslcnaiNlity W vafy the oreulwx
IR the requirements which must Ise ort roar m i.uvamlre of a Catifrate,Qavpmey
(hvrm or authooud ag[nl Duc
IssucD BY:
OFFICE