26959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUI I,DIN7--rEFMTCAT, 11J 1I NO.
APPLICATION/PERMIT PLUMBING-MECIIASICAL (� r /�
BUILDING DIVISION' BUILDING PROJECT IDENTIFICATION L J Vy
BUILDING ADDRESS: SANITARY NO. AFI'LI(ATItXJ SUBMITTAL DATE:
N LOT �Lq q
O M : ON CONTRA NA Eu A LIC Nb r#
NIC CONTROLN
'0 ARCUITECT/INGINI?IR: LIC NO: ADDRESS: ❑
CONTACT: PHONE
QTY. ELECTRIC PERMIT EEE DUILDINC PERMIT INFO
L ELECT PLUMB MECII
PERMRISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IOBD CRIPDON
I]K2. Il7").ffDivi u 3.f be vadaedcr pto.visfcofOoptn toxi. it.with �1, QHS
w�00EE SJI1me doff DivisionlOr the Businne and Pmfeuims Code,erd m,llarne is to PANELS �T\�
C IF full Classeffat.
azOOul Littibe Clas Lie» IIPro200 AMPS w
Ci<y Due m
Canctor 201-1000 AIs1PS
'LO r`z ARCHr11=5 DECLARATION OVER 1000 AMP$ SQ.M.FLOOR AREA S)SQ.FT.
O Z—O1 udmwd mY PI+^a stW I Ce used d Public rtcmds.
Fa ryn oo��F m SIGNS EIPCIRICAL
Syri� I.ittnxcl Ftatuxionel
S u' lost I.csI IRDECLARATION SPECIAL CBtCUff/hfISC.
dOycOF.. 1 hcrtby off th.s 1.m earrtspt Tram de Cmtrctor's Lianae Love for site
CIS°�30.q following meam,(root 1.903.m elneav wd Prufcvims Code:Any city mcouvy TEMP.METER OR POLE INST.
mimloilsi • root u torn,alt«,itnprove,datwlish,«capg my wtctwe
Eyu{Y0 pattihli.suume,elsoitotththe.iMomaoforc Cmtriisi.in I.,sutmmt POWER DEVICES
I+nl.5 apo that Mix licetnN pitxuwt to me ptwlsionr of mcCmtrectarn l.ittnse lsw(Cruptn
o. 9(rnttrttemingwilh Sctim7IMM1)Or Uvixien3ofine Buxircaasd Pnfeeaiam COdc) SWIMMING POOL ELECTRIC VALUATION
amu he is exempt 0tnefrorn od the buis for site akged eaanption.Any violeuw of
tZY Sation 7031.5by.ny applicant rmepemiit subjectx the applicant me civil ornelsy Of OIIfLE1S-SWITCHES-FlXNRES
F
Om dun lvc huMtcd Jdhrs(5500).ptapmy,armyemploy=swishw MIhc'vsde NEW RFSIDENf1ALELECIR SQ.FT.
yt� .nowstnofthc 7 t ,B sitl RIGS TYPE CONSTRUCTION
a3— dl Pofces mace he Clmeietcsmkoded m ,cicfor.ul"ly 7094,Buuwx
Pmfn.iasx Cade:The Ca tse mix IJc.vc lsw don ru.poly tow owns of
pmpntY`vhtbui W mimpovn thermn,.sd whodansuch woh hivuelfmtlwugh tis
employees,ptovdelthetrvchimprovrntrntaue rd wmdvinoffertd fineele
If, OCC.GROUP RFS.UNUX
Mtwever,the bullJingm impmvemcnt is sold within arc ymr ofmrtopluion,the ownm- TOTAL:
builder will love th<bmdrn of pmvit0.tits M did.build m improve fm purpo¢of
nkJ.
❑ I,ax oxmcntf the pnpuny,wtndudvdy.mtmding wiN lkaual covt.norsuo QTY. PLUfv�BING PERMIT FEE FLOOD/,ON APN
carvwct the ptnjat(Sec.7094,9oviteu.M Pmfeuiaru Code:)The Cmioset,s f^I�I p^n
licrnul�wdnn mtgply soon owterofpropary who buil6s a'vrtprovn Oseran,end PERMITISSUAN j II r I u V 1
wbo cmnmcts GK such pmjcots wish etrontra.or(s)liocn poritt.,be Cmvrtor's II VV
Liartie law. ALTER-DRAIN&VEx T7WATER(E,O r'_' —t1 r I_ FEE SUMMARY
❑ 1 am exemptmidi,Sec. ,B&P C fa this scum BACK FLOW PR IECT. LVICE� c u a SID
IT Y YN
ITmcr Dte I RECEIPI'I
WORKMAN COMPENSATION DECLARATION DRAINS-PLOD ROOF.A (jjtD. Z�WCJDL
❑ IhctcbyaffrmmetlhaveaccnirlvICOfcamenttoxlf-inrurt,af.crni0RES-PER' J RECEIPTN
Worken'Corn wion lniuustccaacaJOed EIXN '1 .P--
pen nWYthaeof(Sa.3g00,Lab G)which PARK FEE Y N
cormellrntptayasumnmi,perttdt. GAS-EA.SYSTEM- INC.4 OUILGrS - RECF,IITN
Policy Y BUILDING DIVISION IIJS
COI" or
CICenifvcd copy u hertby fGAS-EA.SYSTEM-0VER 4(EA) PL NCHECK FEE
tvNsMd.
❑ CrniBW ttPY is Bled wim me city inspaum divisim. GRFASFIINDUSTRLWASILEJ'IEKUPTOR GRADING EEE
CERTIFICATE OF EXCMPDON FROM WORKERS' GREASETRAP SOILS FIJI
COMPENSATION INSURANCE
iThk senora tedeot bcwmpldcd fthe penis is fmarc hutdsed dollme(S 700) SEWER-SANITARY-STORM EA.200FT. ENERGY FFP
or Icsv)
I cenlfy Clotutic perfmrwxc oftM wait fm which Ni.permitis iss�W,I shW WATER HEATER WNEN'DElEC1A
not employ my Ietwn to my tram u m bernrrc subject to the Wo m' PAID
Cmtpetvstim laws o(Glifamia Due su WATER SYSTEM/IREATING Dmc Reaipt0
ust
i, IC2 NOTICE TO APPI.ICANT:If,mi,meting this Gran Ocoe MExanption,you edmld NEW RESIDENTIAL PLMB. SQ�F. TOTAL:
(- ^ became subject to the Worko's Campmmtbn Pmvivau a tk Labor Cock.you mtsu
> forthwith corply with such prm'isiwu«this pcsndt..-i be deemed tevokM. BUILDING FFP Co q _+
a [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hercbY of i wt Berg i.a cmemwtim wwttg.genty far me perm of
U O the work by whirn this pt n is issucd(Sec.3097,Civ.C) TOTAL: ELECTRIC FFP
IL E Lader'.Nemo
I 's Admen. QTY. MECHANICAL PERMIT FEE PLUMBING EEE
1 anify that I have rt this n,plicmi,t oxi aom Ow the.bovc informetim is
..tete I.gsccm romply with ell city.rd munry mditwce.and sok lewx chm,to PERMIT ISSUANCE MECHANICAL FEE
I--' t,, boBti,cmvncsimi,Wlereby.Wtoris rtprvmuJwofthis city torn.upon lie CONSTRUCTION TAX
U Z vhovc mmfomi prapcfty fm itupccsion ouBwsea. ALTER OR ADD TO MECII.
(We)xg oc to.eve,iM.ify wd kap hsrrNcas the City of Copmtim.gm.
B.Mlidn.judgncnu,coward nperucawhich myin any w.y.ceruc egaitw saiA Cry AIR HANDLING UNIT(TO 10,000 CFM)
ucsce oftte gnnling of 't.
AIR HANDLING UNIT(OVER 10.000 CFM)
igwureof ApplicmoCantren illvDate PXHAUSTHOODOVDUCI)
PAID
IW]ARDOUS MATERIALS DISCLOSURE HEATING UNIT CTO 100,00.1 BT13) Dem R.ipt0
Will the epplicuo m future building occupant tore cr hsodle harudoue snits
v dcftrad by lie Cupcnint M unicipal Grtle,Clwpa 9.12,and the l lnith end Surety HEATING UNIT(OVER IIML,000 BTU)
Code.Salim 255J2(e)?
❑yes ❑No VRNTILATION FAN(SINGLE,RFSID) I
ISSUANCE DATE
Will tk tmfuwrt WiWittgoaupantusc BOILER-COW(31 IF OR 100,000 BTU)
apptirw ryuiprtmntcdevices whichrndt
•hvofdw.x eu conumimrus as defnW by the B.y Mn Au Quality Maro,, wt BOILER-COW(OVER 100.000 BTL)
�:SVICI'I
❑Yn ❑No NEW RESIDEMIAL MECII. SQ.ET. !1T n B
1 hvve smd the hvatdous smtends t,,Pirtncno under Chapter 6.95 of Ile
Colifmnie lledth&Sofa Code,Section 2550!.25533 ood x5!34. I ondcrwsd this AUG 31
if Ile Wtidingdon tmtrnnrnayh.re.,o be,thisitis 1. rnptmubiliry to ratify the ��
rceupwt Of me rtGuiretrlrnls which mon M ran poor to Isxuence of a Ccnifimm of
(k'cuPancy.
Cl r
Owner or vmh'uvl.grnt Dam TOTAL: ISSUED BY: I - f1UO1
OFFICE