27187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BnILaTN'- ' RICAL PFRMn' o.
APPLICATION/PERMIT PLUMBING'MF,CII ANICAL 27187
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRISS', '1 SANITARYNO. APPLCADON SUBMTITAI,DATE,
LOTH BSC /�
OWN FlIONF_ ONTRA NAME
a� I C1
�f 14
L %N N/C NIROL
CHITECI'/ENGINEFR: LIC NO: DRESS ❑
CY)NTAM: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
PCZ Ihcreby aft that l w lianscd utdcpoviilornofCSapn 9(comoarimg with IOtl DESCRIPTION
{ 9 Soction 10(x11 of Dvi.ion 3 uftha Busi .and Prnfnsivn.CCo Ja.W my 1.i,In PANPds
!ca-..ltl l-. roll f� mxt uc.x �O S-a UP TO I(IO AMPS I• ,
to 6U6U Data"C_ — Cmtmi MI-IOOOAMPS �`��--//���i.!
ZOsnK ARCIITTECIS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA
O%—❑ 1 u'/may 'elEll b�teM y�b x�°A'. S/SQ.Ff.
SIGNS&F,L'IRICAL
Lit n Po.f.ioml
OWNFR-BUILDER DECLARATION SPECIAL CBtCUTffMLSC.
aX0yU 1 heaby affirm thatomo
I w uWt totM Cl ontrerLimine law f«Ce
rY�+m mFi "lowing meow".(Section 70313,Bo oaoas aed Poolmiou Coda:Any city a eamty TEMP.METER OR POE INST.
Ono< which te9u'o"a pcmJt to rnnsmom,alter,improve,mroolish,or oepvr wy m vure
� Y� pimmlu iaruue<,alw r�woo the epplicw fa etchpmeitmUk augad amount POWER DEVICES
"<0
thin Ie b liamed ptmumt to the poviaom Mole Cmvv:Om'a Licrnu law ICM1.ptc
LX�K 9(c mmtcoaing with section]00(l)of Division 3 ofthe Bond.and Poofmiom Coda) SWIMMING POOL CfRIC ., 'o I'� I VALUATION
IL�y
or that he is cacmpl thcmfoom mJ tk Buis f«the dlepad eaemlaion.Any violation of - - S
t7¢ Scnion 7031.5 by my n,lium fm.pmrtituage s the,ppfcwt on.civil pnuhy of OITfLE1S-SWITCHES-FUCDIRES
nt«c thin five hwdM dollen -rol (a500). Gt
❑ I,ovowncrofthe pm,tny,ormyemployecs wills nag",utMirwkcmnprnmtion. NE RESID AL EL" STORIES TYM CONSTRUCTION
will&da,woA,md thtamoctuta ie not intendei mroffatM mrsale(See.7OJ4.Busimos -
.M Pwfeuipe Code:Tha Coao.nmr a 13c.law dao no apply b m own of
,manna ht build or improv"tharmn,aM wlwdoe such work M1imselfwtkwghilia
employe",pmviJtd tlwlsuchimProvrntenuwaalnrentkJaoBeodf«ole If, OCC GROUP RES,UNIT,
M1owevc,the bulldlnym boproremem u sdd within me yeuofrntnple4on,the owar-
btil,ly will have the buodm of poring thin he did rwr hdM m inryowe fm puryoa of TOTAL
k.).
❑ I.n.owarofthe lael>Rtr,weaatnlvalyemttraatmx withlice dcattt,etmam QTY. PLUMBINGPERMIT FEE ti DzoNE APN
corupun ya,pmjm(Si 1(y4,Bwinev"Prof..Coda:)The Coo,o of
Littnsclawdmrwt.pplytomao ofpropcnywhobuildsa'unpov"tMeon,md PERMIT ISSUANCE
wlxtco umcfs fo such pnt,*t,with.coln.to(s)licensed pu amml to the Con.or'.
I-icense law. ALTER-DRAW k VENT-WATER EA) FEE SUMMARY
❑ I am"crop tutda Sec. B&P C fa Bth re..m BACK FLOW PROTECT.DEVICE OUTSIDE F
SANITARY Y N
Owter Union, DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT♦
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IM1neby Jfirm thulhave•cctif to Mcunsent to rdfiwue.ae anifioteM REClilff
Wtxkerw Cmnpauuiw louurenmme«ni0cd copy thneof(,Ss.3800,Fab CJwM1ich FlX'IUH['S-PFR TRAP PARK 191E Y N
covm all wporoa'. �pcs,ot` G / INC. RECEIPTI
%ll �r// J GAS-EA.SYSTPld-I N40lIf1Pf5
Policy. BUILDING DIVISION FFV<
Cwnpmy OAS-PA.SYSTEM-OVER 4(EA) PLANCHECK FTE
❑ Ccni(dcopyishaocbyfumisMd.
❑ Crnifwl copy is Mad with the city ioupccdm dirisioo. GREASRgNDUSI'RL WASTE INTERCEPTOR GRADING FEE
CTRTIFICATE OF UFMPIION FROM WORKERS GRF.ASETRAP SOILS FFE
COMPENSATION INSURANCE
(Thiaaatiom oxcdwtbammphla I lfthe pumit b(orae hwdml dollu.(S IW) SEWER-SANITARY-STORM EA.300FT. ENERGY FEE
mlm)
I cenify thin to pafarmuceafthc woek fm which thb permit is fnoed,I00 WATER HEATER W/VEW/F1-ECTR
not employ my peracat N my numao ao u to btt rc subject to that,Wakm' PAID
Z Cwnpewticnlawsof C.IRoml.. Due WATER SYSTEM(Ul EATING Date Reaipx
Appliom
O C) NOTICE TO APPLIGNT:fir,ally making this CaNfte of Exemption,you ahoultl NEW RES]DENTIAL RMB, SQ.M TOTAL:
F (A bacomawhiact to tha Wmka'a Compensaim provlilan of the labor Code,you two
a faNwiN comply with ouch prori.ticu or this pemdt Nall ba loved rtvokM BUILDING FFE
1 [� CONSTRUCTION LENDING AGENCY SEISMICFEE
Z Ibemby e(f thin thea h.comnuctian lvtdity.gency for di'.f.of TOTAL ELECTRIC EEE
U C) the wok fa which this pefam ie iswad(Scc.3091,Civ.C.)
u. 5 I,cntkr'c Nome
O IattJeh AJdrna QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I ratify then,I lura rod Ws"bution and Yue rh.,thaa above Infarmapoo is
�" a evxrecL Iagta to comply with all city and emmty a-tfi.and nate lova rela4ng to PERMIT ISSUANCI: it MECHANICAL
ITU?
HN builthiM conurvcdon, mJ hmby nuthove repeaomives ofthis city to enter upon the CONSTRUCTION TAX
U z .bora-marmoad poppy f«hm lmioo m,oaca. ALTER OR ADD TO MECH.
(Wa)ago¢10 save,indennlfy aad kmP bumlaa the City of Copcnimo against
limbi litin;j.d,m,ma,as artd ula+.sm'which may in my way a«rtaegvut said City AIR HANDLING UNIT TO 10,0000 CFM)
cnmscyuenea o'ma ting oflhiapamJI.
n AIR HANDLING UNIT(OVER 10f0(i CFM)
/o-Zo 99
Signnumof Appim uCaumcto Dore ExHAUSTIIOOD(w/DUC )
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date 1 c--pl N
Will the epplicw or Intoe huilding«cupwt tore a hu0dk haaarG o,nutmel
u deHEATING UNIT(OVER 1 W,LOO BTU)
f nM by the Cupanino MwicipW Code,Chaps 9.13,ertl the Hulth end S.fay
Coda.Notion 355311ap VENTILATION FAN(SINGIE RESID)
❑Yo ❑No
WJlthc elglicw«Toru,ebullJingreenpantuseryuipnrnlmdevlaawhich unit BOILER-COW(7HPOR 100.000 BTU) ISSUANCE DATE
huvdous.b cantwilmu u defml by the Bay Aro Aft Quality lvltmi nett BOILER.COMP(OVER 100,000 BTU)
" G24
❑Yes ❑No NEW RESIDENTIAL MECIL
SQ.FT.
I hura rod the h.audoua ntatciab oequiovnenta order Chaps 6.95 of the OCT O 1994
Cithfmmim I Ieulth&Safety",Scctbm 255(15,35533 W 255W, 1 undantwd that
if rile building Jou not curramly have"cunt,that it u my ms a ibility to notify 0e
..Wt of the main nano which.be trot prim to ilio.a.Cmifiote or
Occo,al "11'vUr UU_c;�u, t
owoa:rm euthonwlayent Due TAL ISSUED BY:
OFFICE