27577 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO \ .IHNG-LL,.,1'RFCAL N9 MIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C
BUILDING PROJECT IDF_WIFICATION J
BUILDINNG'/]ADDRRFS\$/�� +r" SANITARY NO. APPLICATION SUBMITTAL DATE
I Y V� V UNIT# LOT*
OWN NAME, PHONE CO DR'S LI(.NO
CONTROL#
RCI F, Dv GINIJHI: LIC NO: ADDRESS: F IV �J❑
(0 F1 c4p
CONTACT: P ONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE / 25—� ! /� fit
WCENSEDCONIRACTOR:4DECLARATION APPLIANCES-RESIDENML
pttZ IM1ereMy.fBrtn Oatlrom licenaN uNapmviaiwu of CTaPa9(camnvacvtg with TOB DESCRIPTION
�00[- Section"!000)a DsvWaa 3 of Bae Business and Poofassiosa Cads,and my Ii.is In PANELS
a L" full force and efftta. /'�
F<.Z U� I,iccn.c Clea U,N W Ttl 200 AMPS G
InD� INN, Commemr MI-LMAMIPS Ute`
Z O'z ARCHITECTS DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA 3/SQ.FT.
OZ_p IuMveurd my pfem shill Wrvdu Wblrn vrds.
SIGNS ELECTRICAL
�yros
n, Licccd Prot.,ond
,C'j< OWNER-BUILDER DECLARATION SPECIAL CDtCUIT/MISG
F':
C),U 1 hereby affirms NY 1.m attempt fours the Contractor's Limas,Lw fm IS,
FLL�vFi following.,(S«iiun703",Bossiness and Prafcniau Code:Any airy orcomry TEMP.METER OR POLE INST.
which a,yuirea a permit to corturuct.alter,Improve,demolish,or ncgir any muctune
;!� prier to iu ivunnacc.dao rtyuiru We.lplicatufa ouch pumit to Ekevgnd Yatvrent POWER DBVICFS
dj aZ<0 that he is licemed Pus,..,,d to the pmolsiorrs ofdn ComovoIci.TJcrna L.w(Chapter
9(mommencingwith Serious 7").f Divi.irm Jofthc Businessand Rmfeulom Code) SWIMMING POOL ELECTRIC VALUATION
aYj_y urdw he is nnnP drwfran and the Baia for de Wkecd eaemgian.Anyvioletlon of /� �•
ca
Satim]OJIS by any applicant far.1pmitsubj¢udr.ppriman ta.civilpesullY of OIffLE1S-SWITCHES-FUCII)RFS !.^I/
5 Z rot rnone thin Bre M1umdrtd dol W(5300). NEW RFSIDFI TAI.EIELTR SQ.FT.
� m ❑ I.vowrerMdeptgeny,wmyemploya.with w.gautheireokc«npercuion, STORIES TYPE CONSTRUCTION
wit I do the work,turd trestructure is not intendedre -fared for isle(Ses.]044,Busmen
roost professions Code:The Cc tr ole Liana Us.doe.wt."Iy to.n.woes of
property w W Wilds as lanproom hereon,and who dao ouch work hiomelfor Ww61a his
,m empbyees.la^ridW that wch imprmvemenu art not intended oroffeml!«sale.If, N P RES. IIS
hnwevar,the W-thin%w impmvcncnt a sold within me yav mf cmpletim,drevmt,r- �
builds will have rhe dudes of pmWn�thY he did rant boil m impo.s fa puryox of
sale.)
❑ baso oftM1eptoparty,roma.cladvclycmoamingwiNlim cmtraamto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
.sawn the pmF I(Soo.704.4,Business eM Pmfessiaa Cade:)The CAntmrtuie
licence hawdarrrot applYto enowrerofpmpmy wW Wid.mimpovp rhuan.and PERMIT ISSUANCE
Iiaear.
wacufaruch pmjecu wiN•mwrror(s)Ikenscd puuwNto the Convecta(a ALTER-DRAIN&VT-WAWA(EA) FEE SUMMARY
uL�w. EN
❑nl one cacmpt under Sec. B&P C fm thk sevum BACK FLOW PROTECT.DEVICE SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS FLOOR. AREA. SCHOOL TAX Y��* N
❑ Ihacby afOrm thud M1nvcattnifcate of ur.aentto elf-imurt,wroanifcate of RECEIPT*
Workers'Compewtion lnmmmtt or.catifiW mopY tbnrof l5a.3g00.tab C)whirA Fl%'ITIRFS"PFJt TRAP PARK FEE Y
moven all amploya'a ander this permit. O -BA.SYSTEMEIS-I INC,INC.40VRF.CETPf*
policy# BUILD VISIO
Company - SYSTEM-OVER 4(EA) PIANCIIECK PEB
❑ Ctttifed copy i.hereby fumi.hed.
❑ CatifiW mopyis Rlt,d with the wiry- gYuimdivisim. ` T%INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE,OF EXENIPITON FROM WORKERS' GREASETRAP SOILS FEE
COMIPFNSATION INSURANCE
(Thisactian rcd ossa Wcr.aplwdlfthe pcmltkfa on ($
1 SEWER-SANITARY-STORM E.A.2XIFT. ENERGY
a Ica)
I aetify that inta,,dfomuo,c of she work f,r whi 'tie aX WATER HEATER WNENT/ELECIR
mot employ any pain In any rouuer ao u to boom s b to W pql
Catpcwrion hawz of Cdifomia Dae WATER SYSEF TKEITING i—_toN
OZ Applicant
NOTICE TO APPLICANT:If..fim milking rhir Cenif teofa m,you ahold NEWRESIDFNTIAL!'LMB. SQ.FT. TOTAL:
1--' boonme rubiecl to ma Worknt Canpenvtlm rovithares of the L.In ode.you must
f1' > fmhrwith comply with such provi.or shla'omit shall be darted ocvakcd BUILDING FEE
6. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that thaw k.amsuuaion lending agency for the pafommcs M
U 0 - the makfm whkh this pendsIe-.such(Sero 3091,Cv.C) I ELECTRIC L
'w PIrMel.Name PLUMHW FFI:
Ier.ler's Addres QTY. MECHANICAL PERMIT FEE
U 1 oerdfy tMt 1 hoot,rad dds ewhoadm and ewe that the aboa ioJaornotiw is
orrnttr. lagee,.e. ply with W any and enum,mrdlvamca and.taa lawn relaxing to PERMITTSSUANCE MECHANI E
Witliny r.res and!hereby.uthonu oepe..enutivn of his toy of enraopm Na CONSRtUCfTON
U ehrrcmemimWln^perty for inspect bat Wrpaan. ALTER OR ADD TO MECH.
(We)arae to save,iMctfy and kap h trmleu the Clry of Cupertino el{a.
liabilitiadjudganu,casu.nd cxpcun which may In any way again, 'd Cory AIR HANDUNG UNIT ITO 10.000 CFM)
c fthc go.nting of Ni /I
�• IeAb AIR HANDLING UNIT(OVER IgIXp CIM)
'gouturcof Appl Z2 Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MA'HRIAIS DISCLOSURE IIEATWG UNIT(TD 100,fpfl HTll) Data ac_v
Will to apphoomorJunta,Wilding occupent Yat,or M1mxlk h.rwrdcua rratcdd IIEATINO UNIT(OV�R IM."BTU) TOTAL
as 4(ned by the Cupertino,Mmid a]Code,Chapter 9.IZ and the Heslth and Safety
Cads,Saban 25332(a)1
❑Y. 1:1 No VENTILATION FAN(SINGLE RPSID)
Will de apprimu afumt,buildingaeu _ BODER-COWUHP OR IW,(KIO BTU) ISSUANCE TE
h.ardous au commentators u dented by the Bay Aral Air Qoddd iry Management
BOLLER-COW(OVER I IXLOOU PTU)
I LaWa7
❑Yes ❑No, NEW RFSIDENHAL MECH. SQ.IT. n p ' D
G1h1 have a,ad the hvandams materials rarylremms under Chapter 6.95 of the h r 9Ny((�ay,,{�yQ}��Jj
,Wilding
oust Safetyentlyhveatrart,tht it is vtd253J4. Iuy to
that DEC ^•saY�vR
if1W Wildinge re ort. wiuh...be that it is to o.pmY'of.Carsfica the
occvpnr of the oequvoam which mYY W Ret pda b iuuaree of a CemiBate of
Occup"acy. (/ /�
Ownaer or.uthaUatl agent Dom T I. ISSUED BY�1-CN�INV
OFFICE