28078 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E RI AL PERMITNO. 28078
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPJCATIONSURMITTALDATE
v lD 1 /V UNIT# LOT# / —�^ 7 l
O ERS AME
PHONE_ CO CIOR'S NAME LIC NO: lP ✓
NIC CVNIItOLM
• RCHI'IECr/FNGIM1 3R: LIC NO: ADD�E�s ❑
PJ r a
CONTACT: PHONE QTYELECTRIC PERMBUILDING PE PLUM PERMIT
-275-16-t- 3 PERMIT ISSUANCE BLDG ELECT POMECII
El El OP ❑
LICENSED CONTRACTOR'S DECLARATION APPIIANCES-RESIDENTIAL. JOB DPSCRIPIION
y.7 1 kmby.frimNet I am Ii rued uaMpmvisiotu of Chapter 9(rnmm og wiN
00 Scctian](a)))ofllivimion Sofdc Bu.irc..W Pmlasimu Code,rand my li«veuu PANELS
ywuF- full f«a andffc car
Qj� IJcuuc Claxv Lic.p UP 90200 AMPS
6a Dore Connector MI-100)AMPS
Z~Oy5 ARCO ECTS DECLARATION OVER IgMJnMP5 SQ.FI'.Fl(XJR RIiA SSQ,IT.
l to k tend or Aero skll k urea as Public tecorts.
F m F W SIGNS ELECTRICAL
G Cttxn.ul l4ofaxiimal
Ca
OWNER-BUILDER DECLARATION SPECIAL CIRNIT/MISC.
aX'Oa I krtbY affirm Nat 1 am cxcmlg from iP Cmtrwt Co ,.c yc law Por Nc
t+J3LL� f hictiogacnarn.(Sectltm]0313, 11.,s end l4aree.iwa JL oropirany rnunry 'IEMP.METER OR POLE INST.
whkM1aegWtn.pnmlttoc«utwc4.Iter,impose,hc nish.mrefairanYavuntue
E YS prinnu iu issuance,elan rryuires the epplimnt for wch penniuofkuagtcdawetr¢nt POWER DIiVICF_S
<p that k uliccmd pr,uwt w do l+rovi cos.f tk Co.s U.Law(CM1apaa
ad 9cvsmmcrcin SWIMMING POOL ELLCIIRIC
We� ( goN Scrt,f. IIO)af Di ,far Sofd tJ i,,.,ti .Any%eona Cada VALUATION
=H « ,ion73L5byny a,linanf the baniaf,ubjac D,i, o i.I.Anyviduimof OUTLETS-SWITCHES-FIXTURES
CZQ Section]OIIS by enYeltPlicantf«•pvmit wbjcutk.Pplicum toe Wvilprnelty of '
nm mort then f ve hutdrttl MI luu(1500)
o ❑ l.00wttvafde paopmy,wm em b agesas thrirwkcampetuatim, NEW RESIDENTIAL ELECDt SQ.FP.
yy Y P yccswiNw STORIES TYPE N'SIRU ON
a3a= inmtk work,C t: 1m Can iannt inte«ka«afrertdfor
od (sx."lI)a4.Basiof
era Profasimce ldsor him Cmnacmr's Liccnsc law don c&hi ly a ati owns of
pmpvtYwho build,«imlxove Ncmn,mttl whodae..ixh wM M1imsclf«thrwgh his
wnemployaa,pmvidcdtktsucM1 imPnwemenn.ren«imcwkd tvoffertdfwmk.
If. C.GROUP RFS.UNITS
hawerm,tk building m impamxmrnt u sold wlNin ax yevafcmtpkdon,Neowtcr-
hildcrwillhaveNabud ci that he did mt lvild w im for f TOTAL:
proving (mtvc purlacco
.k 7.
❑ Lae not,Mje t(Scc.7044. criln v�lyl Prot iorri C l t:)n Cmtrxv«.lo Qom' PLUMBING PERMIT FEE FLOOD ZONE AYN
mrtmct tk goject(Sec.]044.BuJness end Prurevi«a CMe:)The CmwcbrY
I.ianse Lawdoes rd apply toenowarafpugerty whobWlt6«impaovee thamoartl PERMITISSUANCE
who cmnuv fm such proj«Ye wIN ernntmetMs)Tic<ttsW Itnntunuo tk Cantrectals
(teem law. ALTER-DRAIN&VENT-WATER(IA) FEE SUMMARY
❑ I am aeml#under Sz. .B&P C fm thls rtman BACK FLOW PROTECT.DEVICE OIFTSID
_ SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRALNS-FLOOR,ROOF,AREA,COND, SCHOOL TAX YECEIPT# N
❑ Ikrtby efhrm Ctulheve.cenlBnte afemucm to mlf-ituur acatifute fxi 90 ECEIPT♦
Wmten'Cnmpcnmiion lrwtmnce a r.catifcd copy fla >(. fl00,Leh C)whi E J P PARK ITE Y N
covcrs all emPoyee's under Nis permit' GAS-EA.SYSTEM-I INCj4 OUTLETS RECT
Policy# UTLBUILDING DMSION FEES
Cwnpwy GAS-FA SYSTEM-OVER 4 UEAd PLANCHECK FEE
❑ CmiBed cgryis kaebY fumishd. -
❑ Cmirredmrpyiefiled with yiecspemim division. GRFASMNDUSTRL WASTE INTERCEPTOR GRADINGi
CF ATE OF EXEMPTION FROM WORKERS GREASETRAP SONS FEE
COMPIaNSATION INSURANCE
ltia.alian ro not lxmrnpekdif Nehermit of«orc Mmdnd dolWs(11 ) SEWER-SANITARY-STORM FA.200Ff. ENERGY FEE
ml )
nify Net in ate lcrfoemoce oftk cork for which Nls permit u iauad,I I WATER HEATER W/VFNHELF,CHR
tan n Idoy enY Pawn in any Atavan va to beeotrc wbjat to the W PAID
Oz Aalle dim laws of Cullfomie.SDutew rn WATVRSYSTIiv/f TING Due Rmeipt#
W
O NOTIC TOAPP CANTALeOcr Crnirimeof Ex oua acld NEWRFSIDIN ALPLMB. SQ.IT. TOTAL:
fn became ftk you
farthwi omPl' I - wNi.P�fIle be M BUILDING ME
6. Q Lha by elE it iN� Our F�I/JIIyG CY SIHSMICFEE
�T�� gegmc tk puformarc'c of
V p Ncwos f which gpermit Ia s .3097,Cir,C TOTAL: ELECTRIC FEE
LadelSN tet PLUMBING ME
u"' F Lamkran arca. QTY. MECHANICAL PERMIT FEE O
V I ani y Nat I hnrc rmd thio grplicutc n nuc Nn tk abwc ittfwmatim c
c«rtcl.lat inc«nplY with All city std my«dinmca end xtmelewe relating to PERMrr ISSUANCH Mr:CHANICAh FEE
buidingcm trixaon,eMhaebyeu rtprvmwiwsMNudryto cucr upontk
() z ebwe mmo edpraPmyfmir, IauNra. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We). ,,arc,i try ata l Iw tk City of Cupcnino.gaitm
liabilitia,judg u.cw cxpcme ch yi ywya¢nre eBaiw said Ciry AIRHANDLINGUNIT(7010, Y1CFM)
scq o'.
ng of thi
ADR HANDLING UNIT(OVER 10,800 CFM)
Sigtwt mor A,,I1car[ U. EXHAUST HOOD(W/DUCT)
PAID
IIAT.ARDOUS MATERIALS DISCLOSURE HEATING UNI'r(TO IBB,S)()BTU) Doc Rcaipt#
WJL that eppiic.nt«(none Wilding«e wd awe or hudk m.terlal
as dcfirW by,k Cupcnittn Municipal Cock,Cli 9.12,std N f1edN Awl S.fcty HEATING UNIT(OVER 100,00)IMID TOTAL,
Coda Sati 25532(a)^
El Y5 ❑No VENTIATON FAN(SINGL.E RESID)
❑ �a /yN
BOILER-COMP(3HPOR IM."BTU) PISAU1 f,DATE
Wlltk applicros«futurt buiditg warpam ux ryuilmtentmdeviaa whkhemit
hvardma ev c taorononts ar,defncd by tk Bay Arm Air Quality Mmmgcmcnt BOILER-COMP(OVER 100,"BTU)
Dial+icf; 1:1n/8 R Q Ya El No NEW RESIDENTIAL MECII. SQ.LT. JUN
2 �r+QV115
L kve t tk harardow material.rtWiarnma u.da Ckper 6.95 of the /�
CaLfmnia Heaem
h&Safely CWc,Sio-25505,25533 ata 25534. Itodcnmad that CIIti VF UUYLfiIIIVU
if tk bridling don twt Cu tly here a scnwt,Pas it is my m-wiantalSdity to retry tk
a«xpent of tk rtyaiacmmu which ma.I k met Fri«to ustuce of a C1oihc,rte t4
eut
Occup:ucat
Owren« hmi.M agrnt Da,e TOTAL: ISS
0FFIC