26765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .ISG�,1eU CA1 �`MITNG. 26765
KING DIVISION APPLICATION/PERMIT PLUMB ING-MECIIM3CAL
xuu,
BUILDING PROJECT IURNI'IFTCATION
BUILDING ADDRESS: SANITARYNO. AFMICATGNSUBMHTALDATE.
UNIT♦ Lor.
OWNER'NAME: / (NONE CO R' A LIC NO:
WC CONTROL
ARCIIIIECI'/FNG YVJFJFR: I C NO: ,1 ADDRMS: El
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
&P CT Ct G _Q ^) 9' � PLUMB MF.CH
( PERMIT ISSUANCE E-1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDFNDAL TOB DFSCRIPIION
OKZ I hereby m7").f Nall amlime asadBu udsanalPmfeasknr CCode.and
or,arose with
Smionerrd,f DivisionJddr Bluinue esd Rvf�loru Code,eM mYliaueuin pgryp5
full hrca and eRm,
tt--..Gly License Class Lic.:a UP TO 2(p AK/P5
1y-yZ UmARCHHECFS(DECLARATION ZEE.1000 AMPS SQ,FT.FLOOR AREA S/SQ.FT.
OOyQ I mdenurd."A.,shill be usetl as public raved.. OVER 1000 AMPS FF��
< w SIGNS ELECTRICAL I n
Y�� Licensed P-fzsionu L G \ EXXu' cF.. ID
OWNER-BUILDM DECLARATION SPECIAL CIRCUITIMISC-
W 3 fn fdlowinyrebmnan.(Salim]031 S.Btvvrnf ad Pmfeniov Cade:My Ery u cwnry TEMP.METER OR POIE WST. "
I=LLc3 which reoulrueprnnil lncuv t,alter.impmvq derrdlN.err repe'u any swcnue
m,1.it,ixmmce,elwre,uirsthe epplicunlrorsuchprnniltofile.ugndste,cmen, POWERD]OslF oCC `T
EaGp that he i.Iicrn psoam to the,rosisiw of the Contractor's Liana Law(CTuper
s.xao ff 9(ca .in,wahS fico 7").f Division Sofdm Buai.anPmfeulau Code) SWIMMWG POOL ELECTRIC VALUATION
ul=n artlmt he is e.emptherefmm and the buss fa dre&paged..anptim.Anyvloluimof VILEpS-SWRCHFS-FlXT1RtFS 01T—Za Satim7031.S by an,,,ficam for acmtit subjecu the appEternalu to.civil Eternal
FF rot more man five hmrdrd dollen(5500).
SCo ❑ I,esowncrofdrlrrryrrry,ormYempin axwithw pemmion, NEWRESIDENDALELECIR SQ.FT.
y aguastlr'nsole Hato STORIES TYPE CONSTRUCTION
wall du drwons and111Che CIYRi.not&.Li dmisa,d r«.9a1[(sa.n an
anal Profusions Code:The Cauractals Li.Lew dace Har eyplr m rt owner of
propenysvhobs.M,rimpovn tMmn,.rN whodocnsuch work himxlfor dwugh Ns
empbyen,pogcaried lhat,,mve emir scmrnuin one
iear cof leery,ruvk.H, OCC GROUP RES.UNITS
bawecr r.will building rr imo ofpromlisibinhold e ii noneyevr of rompininor the ownrn I.
hoiden will Haut tar harden of proving tMl he did racer build or import for pmpox of
ileJ.
❑ ,the rdthepopcstyeme.clldveln!Profesiowllhlic:)The Contaonm QTY. PLUMBING PERMIT FEE DZONE APN
cmnvs.ct the non(Sec.7044. nsrona ab Professions Code:)The Cmnrctvr's
who
applytosao ar.o. m.)whubuilda u,mprovu draonmr's PERMIT ISSUANCE
who aeLaw.f«.wen projects wim aconlrvemgs)licrnrd ws�mnno Inc Cmwetar's
ALAR-DRNN&VENT'-WATER(LA)
IJce,.e law. FEE SUMMARY
❑ 1 em ucmp under Sec. ,B A P C fa this reesan BACK FLOW PROTECT.DEVICE
SANRAAY Y N
Owns Due RECF.IPI'Y
DRAINS-FLOOR,ROOP,AREA,COND.
WORKMAN COMPFNSATONDECIARATGN SCHOOL TAX Y N
❑ Thereby affirm thmlhave ecmi0cvtc orcumcnl to mlf-iruwe,meccrti0rme of RHCIi11TM
FUCIl1RLS-PER TRAP
Wakcrs'Corlpuuvion lruuneoce ua artifid mPY dereo(18a.3800,1ab C.)wM1ich PARK FEE Y N
ven all en'A'ee s.der this pomit. GAS-Fa.SYSTEM-1 INC. OUTLETS RECEIPT.
Pabryl BUILDWGDIVIS N
Coanlmny GAS-EA.SYSTEM-0VFR 4(EA) PLANCHECK FIJ3
ElCenirdN isherebyfumisbed
❑ Cmifd apy is fled with the city lmpccBon division. GRFASFANDUSTRL WASTE ENITRCCPTOR GRADING FEE
CERTIFICATF OF EXFINPDON MOM WORKERSGRFASF.TRAP SOBS FEE
COMPENSATION INSURANCE
Obiasatonrradnu be complete]ifthe pmoll is four hond.cd dollma(3100) SEWER-SANITARY-STORM CA.2UIIT. FNMGY FEE
anus.)
(certify twlinWprfummre ofdr wah fa which this perWtlelawd,lshdl WATM IIEATFR W/VENT/ELFITR
sal emp)oy any scm mw m au any mmer to Mann wbjttt to the Workdi PAID
z CarlWeeruatdnlaw.acalifornia Due WATER SYSTEM/IREATTNG Doc Racipx
OO N TOAPPLICMsO`: ,aftu meking lM1l.Catificatc of Enarytian,Yw shoud NEWRE.SIDPNTIALPLNB. SQ.FT. TOTAL:
.N. Mhwithrjcclw it Wrdi mvisi.o Imo prmatshsofdrtlabor CsoLed. must
� > ruthwith comply with.urll povuiaru or UV pemdl shell be deemed revatd. BUILDING
1 Q C'ONSIRUCDON LENDING AGENCY SEISMIC FFE
z Ihcrtbreffort that there Is a mruo-union k+ding agarY for dr perforrrlumeof
U O mewokI.r which thn pemth is iesued(Ser.30J7,Civ.CJ TOTAL; FI,F.CRIC W-C
O V Lender's Noma
T<wer',Address QTY. MECHANICAL PERMIT FEE PLUMBINGIEE
I ardfy Ibr I have rod this eppliurim and.dat de above infomwion is
�" vmut lagme to cwnPly with all city and ceunry ardinecea anal. U.,reWin". PFJRMIT ISSUANCE MECHANICALFFE
F^ build1mgcvybuetim,and hacby aultrussncpuompvo ofthi.city tornluupan the
U Z aborC-mrnlimrd poppy for inspection purryacv ALTER OR ADD TO MSCI I. CONSIRUCf10N TAX
(We).gree to save,indemnify and keep harmloe the City of Cupenim against
liabilities judgmnu,cosh and expervn which may in any wry emue agdmr aid City AIR HANDLING UNIT(TO 10,000 CFM)
ie coruoglreRa d the gsandrtg of Ihia pcnnit.
AIR HANDLING UNIT(OVER 10,00(21 CFM)
'Ig rtuf Applir�nt/Cmtmam Dem EXHAUST IIOOD(WNU(TE
PAID
HA7ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Iffl.(K0 BTI) Due Realpl a
WOE tae applicant or futwe budding accupgn Bore or hmdk harndeu.mueciel
as defnd by the Cupertino Murdnpel Code,Chapter 9.13,and de HWN and Safety INATWG UNIT(OVER 1(0.000 BTU)
Coda.Sahi 2593$vp
0VP 1[_AIION FAN(SINGLE RPSID)
n ❑No
I$$lAN DATE
Will BOIIER-COMP(3HPOR 10h,"BTU)
V
�har ? airaan
r numinu p defml by Ne e BAnAir Qoliry Maeugot
em
DotrictrmIL, BOIIER-COh1P(0VFR 1011,000 BTU) 'f.� '/
❑Yee ❑No bMW RESIDENTIAL MILCII. SQ.Ff. /s J k 21 1994
1 hove rod Or haraCmu SeOmrss 515,15 33 oder C1. I oo,,N of the ^�I I yr /J�/
Cilifaanu Hoath C Safety Code.have
a o 23505,25533 and 33334. I ity to n4ud tM
if the building doesnmaunendrhaveaterunt,muit is my ropmsibility to notify de �I✓rCnl/IVV
ceenp m err me m9nimmmnu wnien conal ne mel hrt m drwlwlee of a eminate or
oeeapaey.
Oumcr«audrnud agent Due TOTAL: ISSUED BY:
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