25525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUIN RBRMITNO,
APPLICATIONIPERMIT PLUMBIN G-MECHANICAL. 25525
BUILDING DIVISION BUILDING PROJECT IDEN'ORCATION
BUILDING ADDRESS: /.Y SANITARY NO. APPLICATI SUBMITTAL DATE
UNIT LOT ?
W SN PONE: CONTRACTORS bhk1 WC NO: /}
NEC L L NTROLN
AR TIiCrIENGINEER: LIC O: ADDRESS: ❑
CONTACT. RJONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
m
LICENSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL - - -_ ,rrR1��MON
pdz Ineleby of Division
l emhan.WuMcrpovisiwuorCnCo&Erol mylic heist \vNrOTSM/�N✓`�"(V,
aW fuhllticn far md)ff.1 dmJofh Bu.i"^.shod Rofodwe Cod,uJ mYlau u PANELS
UP T010AMPS
hoQ- Due Commit. 201-1000AMPS
G 1)'x ARCIITTECTS DECLARATION OVER 111!10 AMPS SQ.FTFLOORAREA PSQ.FT.
OG—a ltmevard my plum.hall be asd.public rtwlds.
P'4 L w SIGNS ELECfRICAI-
L h,,ohd Pmfe.iorW
�6 OWNCR-BUILDER DECIA VDON SPECIAL CIRNR/MISC.
�p('OaU I hmeby ofinn Ihnl 1 xm exmpz from the COIIPKIas Licwe law for the
W 34y following onwon.(Sava 10313,Busmes oral Prormorl Code:Any city mmunry TEMP.MBTER OR POLE MST. ,
OyQ which mquin n a penny to emWrucl,alfa,improve,demolish,or rtpeir my mrumua
J prier to mistnce,also nouilo the appliclm for suchpmNt to file.sigraWarlrn
i nl POWER DEVICES
�C> dw he is licrnssd PllrtYml u tlr pmvisiau of Re Cmv.clm'.LIceme law(I ll.pler
aao� 9(axsmmaieing with Semmn7")a Division 3 aldc Busslra shod Pmfeniau Code) SWIMMING POOL El C VALUATION
or nigh hi,is esemp tlwrefmn.rW thebms for IN,a[L,d exempion.An,vin mnof
CZQ Seoon 70311 by my ,1.1 fur st mlut mFjecls dle ggiicmt to•civil p..hy of O�PIS-SWITCHES-FIXTURES
22 G rwt marc lFnn Ove hunitrdJrilly.(SSW). NEWRESIDENTIAL EJ.CCIR SQ.FT. STORIES TYPECONSTTAIMIO
K $ ❑ I,vuwrer ofdlepmpony, isnot lnya.wiNwegorict hada mmycmmim,
will Jn the work.u1du: huclare�s not.Lin Muoaw root Wily to on Buono.
w Pmre..nn.code:I}x emvmnor.a«me law aoea�apP1y m m nwnn or
prope.tywW Wild.aimpmve llcrtm.nWwhodttn mch wmk himnlfmdlmugh Ns ROUP .UNI
empbye ,g,vidcd Nu wchimprove Ism not lnrcdcdar offcldfmule If,
Iwweva,IM1e holding-impmv.t is sold within one year ofcompleitm,the own,
bail4r will have IM1e Wolin of proving Iho he did not Wild or improve for ptvpos of Tep
ropeny, ively.vrur. ithdcomm�ast'o Qom' PLUMBING PERMITFEE C FLOODZiW
APN
14,
aluI do, roj.(Si,,.}Obl.Busiotan nod Pmfcrsich.CodI,:)The Cmrc.cwr,
jcalawdm notapplym
who build.airnprovalbaeoo,mod PFRMITISSUANCE G
who contracts fasuch pmjcclx wish.mgmbOcw )lianscd pulwunt'n' cConnor's �. -DRAW&VENT-WATER EA) MMARY
IF
Li.W w.
❑ I son excmq shale(So. B&P C fa dJs r awn BACK ROW PROTECT.DEVICE ".131M Em
Y N
Owmer D.B DRAINS-FLOOR.ROOF,AREA,CONT). REC"I
CTN
WORKMAN COMPENSATION DEARATION Y - N
❑ Iheebydf tl lh.veaa ifateofcmn ttoulf-iw ,m.cerpfimeof RECEIPI'N
FIXTURES-PER TRAP
Woheri Campermtim lrouruceaecWfid uqy 111awf(Sa.JB(p,Lab C.)which PARK FEF. Y N
m Jl emor,n,'s under chis permit GAS-CA.SYSTEM-1 INC.4 OUTLETS RF-CF-IPT N
Policy 0 BUILDING DIVISION Fl]
C-cY^Y GAS-FA.SYSTER-OVER C(FA) PLSNCf IECK FEE
❑ cmind mPy i.wehy rl1n�Aa1.
❑ Catifid mpyufild with thedryirl.pmuon division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FTP
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP S011SFI?E
COMPENSATION INSURANCE
(This sanction rl¢d hot M complcmS if Ne pnmlt H fame hurJrtd"t,mi($IM) SEWER-SANITARY-STORM EA.ZD()FT. ENERGY FEE
or los.)
I cclufy that in 1)c pif«nwce ofdle wort has which W.permit is luued,I"I WATER HEATER W/V[lIT IE=
not cmpicy my pawn in any mmner n to is m so l to the Wcr1.' PAID
Compa.wim laws of Glifanu Due >o WATER SYSTEMITREA'IING Ute Rc.cipl M
z NOTICE TO APPLICANT:If. this Cenlfiwe a Es
z making aor Coclrwshwd NEW RESIDENTIALP MB. SQ.FE TOTAL:
V_] bcmnlesubjoty it Wohai Cmnpmr this modisiomoflhelmi C Iival. rrmv
faNwitb comply with such proviaiau or this pvmil JuB be dc.end rtwtd. BUILDING FEE
❑ CONSTRUCTION LENDING AGFNCY SEISMIC EPR
z Ihneby.rBrtn thin lhae is.coowuclion baling egrnry for the'formm.c of
U O the work for which Nu pemul is igo,,d(Sec 3fy/},Civ.C.) TOTAL RECIRIC FEE
Ie ,N.
0 F hide!.Addrus QTY. MECHANICAL PER MIT FEE
PLUMBING FEE
U I cerufy dist I have,rod Its; and uue Thu Ik above infamauoo is
W mrrccl legrte tocmlply with Jl tory old counlY wdiwce mdsute laws rduing to PERMIT ISSUANCE MECHANICAL FEE
NWildingca.lructien,adhertby a athmircreP ho=t .cilY loetion,ponlhe
(j nbo,onchnvrcd yfm inspection pure au. ALTER OR ADD TO MEC]I. CONSTRUCTION TAX
(We)agrte vc,vdcmnify erd keep ilY of Cupmiro egmlm
Ii.bilitio,juJ u,comm experoa whit yinm y.¢rve.g.ir.n aid Clly AIR HANDLING UNIT(TO 10,000 CFM)
in chroo, the mooingM
AIR HANDLING UNIT(OVER 10.000 CIl
ig pplicenl/C,mimemr Date MIAUSTIIOOD(WMUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001)BTU) Date Raeio#
Will the.pplionl or fulurt building acup.m nae or hutlle M1umdm.mneri.l HEATING UNIT(OVER 100,000 BTU) TOTAL_
u&Eco i by the Cupcnilc Mwicipid Cale,Clcq a 9.11,.4 the Hedth and Witty,Cale,Smicn 2553$x)1 VPNf11AT10N FAN(SINGLE RESIT)) �-
Yo 1:1 No❑
Will the epPlicmtaa
fulmebuilJing .vpwm&
vi=Wuchemit BOILER-COMP(311P OR 100.000 BTU) ISSUANCE DAI1:A
hamrdwu.0 conwltiruw u defend by de Bay Aran Air Quality Mshr.gerad BOILER-COMP(OVFA 100.m BTU) p p
} 1:1 �1
Ya ❑No NEW RESIDENTIAL MECH. SQ.FT, n /4D
1 have nmol the bawrduus msheriJs rryuin memo urldcr as,h,r 6.95 of IM1e
1 California Ile.Ith&Saruy Cu .Seniau 25505,25533 and 255W. 1amerogi am
if Nit building does not Nlmllly have amch,Thu 11 is my ra.ponsubiliry in notify the ! `r /IYCTLI
occupml of die rtqulmnen0 w1ocb mug W mu Prior to iistIDICe of.Cmmfcate of
Oavpmcy. Vrl`
Q %Y//V(/
Ownn mlM1
muriud egrnl 0.t< TOTAL: ISSUED NY'