27130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUff. IN-ME ^' PERMIT No. O
APPLICATION/PERMIT
PLUMBINGROJECTFIDENTICAL
FIC
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING AD RFSS: Fye .1TM�/ ��// //'�� SANITARY NO. APPIACATIONSUBMITI'A.DATE
1•t U/1.-- V✓ UNR♦ LOTY 1✓ to
I
SN PHONE: CO ICN N/C CON DUE,M
IIITECr/ENGIN'IR: LIC NO: ADDR• :� I , El/ I
ONI'nCl': PHONE QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG .FO: A MECII
PERMIT ISSUANCE, J 111 1:1LICENSED CONTRACTOR'S DECLARATION APPLIANCILS-RFSIDFlTI. L�HA
goy IIemM.If Di w l3 iwdcgvv'uau NChegcr9(cvsmocrcitse with OBD DESCRIPTION
�+t00 Sc von](MMI)of-yBwircas vnJ o---fcruc is in UP TO
y full force unJ
c<.'<y lien I UP TO 200 AMPS `��•'�y�i
Flo Contractor-DEC201-ItX10 AMPS
zc)� ARCHITECTS UC RATION OV U- EKCAMPs SQ.R.FLOOR AREA 5/SQ PI'.
OZ-0 Iundenhlad mY pHms sM1Wl be amol as publicrecnd+.
F In 1- SIGNS ELECTRICAL
SYaj Liccnsd Pnlfcnimul
p(u!<
OWNER-BUILDER DECLARA'NON SPECIALCIRCUIT/MISC.
�Oy V I hereby off the,I ata exempt Iran We Ccmmiremns Liceme Lew for the
%0 vv, following reason.(Sectim]03".Butircv end Rofessiom Code Any my mmumy TEMP.METER OR MILE MST.
C�-�; which maryire,a permit to nmsmu Orel,improve,demolish,m repay any.muctore
prior to its isware,a so rcquirei the applicant for mcM1fcomm to Me a simed storeroom P(IWERDEVICES
Ta o that he is wemN punuant to the povislent M de Cm,outor a Liomse Low(ChLpter
as Mff 9(cwmrcrring with Seenion]000)of Gomel.3 a if,e Bonrw and Profession,Cade) SWIMMING POOL ELECTRIC VALUATI�V
vr or slut he is exempt therefrom arl the basis fm the alkgcd exemption.Any vielation of
�Z< Scnion]031.5 by anya,rlicant Nr apermit subjccu the applicum to a civil penalty of OUTLETS-SWITCI IIS-FIXTURES l .-7� ��•
O mx more that five hunhel dollen(150)).
w�� ❑ m , _SQ.FT. STORIES
EMNS�=]ON3- win do llework,wJ de structure is am lmeoilcd nrntferW for.uk Cke.]014,lamd.
and Profcasiau Cole:The Conbrati s Li.Isw dos rot apply to an owner of
properly who NiMI,Nmofri tMrmn,W wlo,1ocv such watt himse fathrough hHIf, OC R IIP however,the bmldmgar Lnprovanam is sod within one Peerofcvm,pletia ,the owner.
bui Wer will have the burden of proving that he did rot build a improve fa PuTose ofQTY PLUMBING PERMIT FEE n. DzaNF;
metmio the pm ccr(See.70,t,l,Bosiaaa.N Proft,sims Come:)The Conamarter's
Dm<x l�wdmnotepplywanowmrofproleny who buildsaimlwva dtuearh,and PERMIT ISSUANCE
what contracts farmer projeeuwith.conuectm(a)limbal pwwan,to the Ca,t eW. Jv-
ALTER-DRAIN&VFN]'-WATFA(EA)
Iimue taw. FEE SUMMARY
❑ 1 am cac Pty`,dcr See ,B&P C fm this rcascm BACK FLOW PROTECT.DEVICE ID
SANITARY Y N
Otm Dae DRAWS-FLOOR.ROOF,AREA,GOND. RECEIPT♦
ALAN COMPENSATION DECLARATION SCHOOLTAX T N
I hcrthy m„ tuveeemifi^•,^ofcaveatwxlf-'aurae,or a catifieetwf RECEIPT
atm w, fied copy thereof(See3800.Lab C.)whip FIX'IURFS-PER TRAP
"T"
PARK EFL£ Y N
roam al pmmiL GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPI'g
Policy BUILIliNO DIVISION FEES
Can eby furnished. GAS-EA.SYSTEM ECK PFE
Cu,i 'h fledwith its,dty inspection divisiwr GREASE/INDUS'IRLW IE INTERCEPTOR y
fl G FIiEI
CERTIRCATE OF EXEMPTION FROM WORKERS' GREASE TTtAP - I t t.✓ 0 'ILS FEE
COMPENSATION INSURANCE
(Otis section mood not be emalmoed iflbe permit is for ciollm(5100) SEWER-SANITARY-STORM E: .2WPT. 27 � GY FEE
or las)
Icmify Thu in the perfomu . Jew k for whieh Otis pandt is;maned,l shall WATER HEATER W(VENT/EL RC
not employ any perwm in anY rower an as m hemme subject to the Worm' pelp/
,z Crnnpeu+tlsatl—.nf Cnlifomim. Dale WATER SYSTEM/IRHATMG / e)P Uaic Reai'#
Apphnmt
QO NOTICE TOAPPLICANT:Ifs e(mr m.king,hlr Cer,lf,e o(Esemp,ion.you shamM NEW RESIDEN'GAL PLAID. SQ,FT. TOTAL
V] becomewbja,rolle Wakees Cmpcnsetim Mp isi ofthclabm Codc.ywmuu
fnnM1witM1cmhply with such provi.siohumtM1i.permit shall to dernlN nevotN. BUILDING ITE L LILA �.
aD CONSTRUCTION LENDING AGENCY SEISMIC FEE,
Z IhwchYolf the,throe is.e..ion lending egrn fm the perfmmnaof
U O the work for which thio pcmot n issuad(Sec.YN],Civ.C.) I 1A3. ELECTRIC MT.
O
Leaders
Ims,deel Name
NNames QTY. MECHANICAL PERMIT FEE PLUMBING I'R'E
1 cm,ify t 1 b.vc read Nin.Irplia,an end mate that me,hove infomh„ion is
h>'s Llla. coved In cwc MECHANICALFEE
ply wiN ell city oM county omir,enm aM mmlows mlaing to PERMIT ISSUANCE
F' builme hereby aud,mve rep,eahtmva of,hi.city wenn uptmthe CONSTRUCTION TAX
V Z ,boyo ,iorcd y for irmiseian pur,ones. ALTER OR ADD TO MECH.
We) gree mlcmnify and keep harmless the City of Cap imo a8airat
If. hies to.v pcmxswhich they in any way,come I JCiry AIR IiAIJp1.ING IINIT(TO 10.000 CFM)
in oft f i.lem,it.
/ (e AIR HANDLING UNIT(OVER IO.IIOD CFM)
un of to L Grabef I EXHAUSTHOOD(W/DUCID
PAID
HA%1RDOUS MATERIALS DISCLOSURE HEATING UNIT ITO IOLDD)BTU) Date Recelptg
Will the afpJican,or fumne bulWbg..l unt,tore or hada,hnaardaus material
as defired by me Cupen'un Mmhicipal Code,Chapter 9.12,and the He.Bh usd Safety HEATING UNIT OVER INE000 BTI!) TOTAL
Gdle,$CC4 ate 25532(gY
El yes ❑No VENTILATION FAN(SINGLERPSID) -r h
wi0 de.pplic.n,afu,mc Wiidineocc tore
BOILER-COMP(3HP OR IM."BTU) ISSUANCE DATE
open Amea Air mdevimwhichmmt I�
lua�ma.m contaminanu.s dcfinM by the Bay Arte Au Quality Marugrnemt BOIL[R-COMP(OVER IDI,OpO BTU) to
�B'sirim^, Jn
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. nor
1 have read the hvallovr materials ao,the ems uMm Chaptm 6.95 of the `/ s( 8 '
the
Nuio Ing ifar&Salmy Cody,fy have
a am 25505,25533 end 25534. I ity wnaml that �J4
if tl,ebullofthe"'strotan -Move, be that it is to rename, ilitytomdfy Ne s/Ir �r-
aculan,of the rt.phi,enmhts which r,wu be oat prim w inwrce of a CmtiO^,^of VL.
Occuparry. � J
Owm a euthori:td writ Dau TOTAL ISSUED BY:
OFFICE