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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO '-
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
BUILDING PROJECT IDFNTIFICATION
PFRMLTNO.
26357
BUILDING ADD�D7RESS.
SANITARY NO.
A^PT]CATIONSSUBMIITAL DAM
/O�OG� / aC Q/�G UNITY LOT
J
OW lA� HONE
SLIC o% ,/
NIC
CONTROILY
RCfIHE (QJGINFER: LIC NO:
V�JJ99O'l^9Yso
CONTACT: PHONE
QTY. HE PERMIT FEE
BUILDING PERMIT (NFD
NLDG ELECT PLUMB MEOI
PERMIT ISSUANCB
❑ ❑ ❑
LICENSED CONTRACIOR:SionsoCATIGN
sofChaper9nd] my erense with
I hereby affirm that I am Ise Business
Section )0(0) M Divuin 3 U dhe Bmtsirca.nd professions Code, and my Ilttrue o th
full face uM effec
ueenae n•r I. //__ [
APPLIANCES - RESIDPNML
l� w - — . ON
PANELS
uP To mo AMPS
Dme Coo*,rar fcxsi; c(
201-1000AMPS
ARCHfTECI'SDE.CLARATION
I mdenlaml myphn.v shall W u asPublic recoom.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
® B
VSQ. FT.
SIGNS EfECfRICM, r
Licensed Profuaional
OWNER -BUILDER DECLARATION
SPECIAL CBtCIIR'/MISC.
G
I hereby ef! that 1 am . cropsBusier fisc the Ca arsons r'a cl. Law My rvo for the
rmgruwo. (Satlm)ancorr uamrnm,r Refusions YaryacomtY
n r, r�P
Irll.iy IEwhich
TFJNP.MEfER Oft P(HE (NST.= <
wisich require a penrdl b conmum, Jcr, improve, denmmt fi repair ed evuctwe
or rep
uiconellearvarmgolreatheappicanlfthe Chlmmlmfikaai
IIrm
Imo•
POWER DEVICES
he
T h(c M1e i ening with euam m the prmvI a of the Camracta(s l.icenue esimms aper
Law Ctust
4(camvncncing with Section )000)of DlrLim Jof thcflusircv and Rufeulom Code)
\�
SWIMMING POOL FIPCTRIC
ON
or that heir excmPl ih:rtfrnm anal the twain for the.11eged exemgion. My viclamicantifOUTI.
Section )031.5 by any applicant for a permit subjects the appli®II to a civil pmalty of
M- SWITCHPSFIXTURES
z CC
ml mac than five hurdlrl lotus 15500).
E)I, asowoeroftlhepropmy,armYempbYcewith wagnutlhebaokcmmpenulion.
NEW RFSIDEMIALELECTft _SQ. Ff.
STORIES
TYPECONSTRUCUON
wart, and the eVYClure is mlintendcAear note(Ser.]DI4,Bwloea
anllmthe
awdo(m
i a littme law does ons apply lf am owner of
mW PmfeuioIm Coda: Mscmpr
vesdresc
popersy who buildsaimpmvatheram,andwM deer Susi wmkldramelfmthroughhf,
smt intendimofferW fs.wo If,
m,Ilwtauchimisand
C.GROUP
RES. I'ti
mebm1dIo vskin oneyevofcompletiogNeowrcf-
however, ilihave
the varimpmvenw-muhMdcdid
W e.). ll have sire W Nm ofpoving IMI Ac did ml hwld a improve for purynse of
Qom' PLUMBING PERMIT FEE
ale).
❑ I,uoemeroftlme popvty,emezcltuirclycmtr.ctingoiNli¢nvtl rowslm to
FLOOD ZONE
APN
mmtrva the project (Sec. ]Ola. Bte'vm and Profusions Code:) The Contr.ctar'a
Licaac lsw Anes;..,Ply. anowmofpropenywhoddldeaimpnovu thcsmTand
PERMIT ISSUANCE
wlmcanuacla forsoch projects with accn iscarma) licensed pmuant to the Conuarmi's
License Law.
ALTER - DRAW & VENT. WATER (EA)
FEE SUMMARY
❑ Iamexemptunder Sec. ,B&PCfmmivreason
BACK FLOW FHOTIM. DEVICH
1 I I
SANITARY Y N
RI:CEJ PI'N
Owner Wre
DRAWS -FLOOR, ROOF, AREA. GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y 'N
Fl%TURES - PER TRAP -
I1. ef! tits lluvcacenifirere ofroncntmxlr-irwve,macvtifudc of
Wmken'Cargensuian I. aacertified copy ahnmf(See. 3800. Lab C.) whicJi
HF.M"0
PARK FTE Y N
GAS - EA. SYSTEM -I INC. 01IHETS
cava all mmpbyec'a under this permit.
PJiry N
RECF ,.
BUILDING DIVISION FEES
Canpany
GAS - rA SYSTEMT)VIR 4(A I )
PLANCIIECK FEE
❑ CrnifiM MY iv' M1ercby funJsheJ.
GREASEINDUSTRL WASTE. INTERCEPTOR
GRADINGFEE
❑ Cmificd copy it fled with tM oily inapvtim Jivisim.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS HE.
SEWER -SANITARY -STORM FA. 20017.
ENERGY FEE
(TM1it saction rxd and be completed ifdu Permit is furore bimAed mlW(SI00)
a teas)
WATER HEATER W/VEN'DRI-CIR
I certify that in the prfmrwm¢ofthe work far which this permit is issued, I shall
not employ any penin In any . to as to becr ne subject to the Waken
PAID
WATFRSYSTEW/T TMG
Cxnpm mer E_&wsaf Califi.w Date
Mtricsnt
Date RncipY
NOTICE TO AP%JCANT:If. after voting this CenIfi•.ee of Pxempitm, you ahold
NEW RFSIDFNTNL PLMB. SQ, ET.
TOTAL:
becarne subject to than Wakeri Cmopenwbn prmisions of the Klaus Cade, you tan
faNwim comply withand povisiuu or this permit "I W domed ocva4aL
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FFE
I thereby affirm that there is a csm a ivn tending a6c Y for the pvfumvmce of
(he work for which Nu permit is iaual(Sec. BaH, Civ. C.)
Irnder's Name
TOTAL:
nECRIC SEE
Lerida Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify JW 1 trove read this application and . that dna above information Is
erect. Iagrtc mcomply wlN aD clty artl runty arunnrcu and rats lea rtletirmg to
PERMIT ISSUANCE
MECHANICALFEE
building conared poo, and hereby wthoris nepurntahvpof 1M. city to ester upon tier
abw e) inspect
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
IWc)agreemcore if City caCupcnaera
( apace to save
C
liatdlilie' rnw mTdch y' ywyemmc ag.irmt ssid
uid Ci
AIR HANDLING UNIT (f010,000 CFT1)
in oft it
AIR HANDLING UNIT(OVPR 10,t00CFM)
UHAUS'T HOOD ( W/DUCID
PAID
.',store of Appllcun/Cwnamm
HEATING UNIT (TO mm BTU)
HAZARDOUS MATERIALS DISCLOSURE
One Receip t
Will the appliam or future Wilding occopam more a handle havardoua mmerial
as dcfmred by the Cuperiro Murdcipal Code. Clasper 9.12, surd Jac Hca th and Safety
HEATING TWIT (OVER 100,000 BTU)
TO
Code, Seetim 25532(.))
ID Yes ❑ No
VENTILATION FAN (SINGLE RFSID)
Will sire IiconlafutureMmilding a¢'ulmnluw cyui
app pan oralericu whichemit
hastnmus air cnnWmirwts as dcBnW by the Bay Ara Rif Qwliy Marm.gemrnd
D:arictp
BOILER -COMP(JIIP ON Il)P,Iyp BTU)
ISSUANCE DATE
F p
p
BOILER.COMP(OVP,R 100,000 BTU)
❑ Yu O No
VAY
NEW RFSIDENHAL MECII. SQ. FT.
I Tuve read disc hacardaus mater ala reipid rnts under Chester 6.91 of the
0,9 1994
California Heabb & Safety Cafe, Seclimr 25505, 21133 and 25134. 1 tindersmil Nu
if the bro
building does t currently have a tevnt, That it Is my responsibility m notify the
scupam of thc rcquismcros which must be mel prim w issuance m a Cerificate a
Ps/]
la I r
L, Lit,
Occupacy.
ISSUED BY:
OwaermeuthoriuJ agrnt Dare
TOTAL
VtYIGt