25484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILUING-ELE AL PERJvI
APPLICATIONIPERMIT PLUMBING-MECIUNICAI, n C /I p A
BUILDING DIVISION BUILDING PROJECT IDEM "CATION L J 4 O 4
BUILDING ADDRREE/ H
SS: so yIf�1L SANITARY NO. APPLICATIONSUBMTALDATE
S �� &% -� !/l UNIT# LOT# ^� 7�
O NAME: PHONE: ! CONIRACTO 'S NAME/ISON.
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b //,� NSC COMROLN
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LJCN
® CONTHI"IECT GINEEi: YI nNO: A 9 1/ /O#LICrl14i1 lD 4�OD ❑
//
,�y QTY. ELECTRIC PERMIT' FEE BUILDING PERMIT INPO
L61L �� 1 ��� PFAMRISSUANCE El 13 El
ELT PLUMB MECH
LICENSED CONTRACTORS DECLARATION APPLIANCPS-RESIDFMIAL
nwz Iheresy inn that lain Named uvingmEiaruol'Chalnrr9(awmcrcing with JOB DESCR�TION
0.100 SOiccr7IEp)of Division]cOh.Business end Pmfecsions Code.and my liana is in PANELS 1` _-
tty-d2 Lull. lad-(Tint.
(F'�.CC.:Z Llanx Cans Lic.N UV T0211f1AMPS
yQy Doe Contractor MI-l"AMPS / �(p
7 FO y- ARCIrITF.CTS DECLARATION V .FI�FTq All $/SQ,Fr.
C)z a
I uMrntaM my plain shall be draw!u public sada OVER 1000 AMPS !1!1
Fy[=; I SIGNS F.IECIRICAL a
LicrnsM Pmfcsiarml
pJp.OK6
OWNER-BUILDER DEhe Cora ION SPECIAL CIRCUIT/MISC.
DAI
w3 N follow hcrthy ern(. that I am cxrmp ss an the Cooidne; o e:My law co tnc
following rcnson.(Sntion]0]IS,Btuinrn and Rvfessiom Code:Any city orcounty TEAL P.METER OR FOIE INS f. 's h3
F_'u'y 2 which requires rnpail-to cmwan,alta,Impose,h sernsi.n fi rcpev any strtctuae
�J
;!1 J� prios to ill issuance,also rryuitea the applicant for stchpmnit to llkaslgned valemrnt POWER DEVICES
Y
W_ O tMt he is licrnxd Ptmrtarn to do pwvisiam of Ne Canuacetota ticeme taw(Chapter
z g emUrcncln SWIMMING POOL FJECIRIC
X W ( galfl,retion'1000)ar Division 3seall BuutwerW Pwr,stm Cad e) VALUATION
ly_y
or San heiaexbyanyrtlidawfire baaiafadcdkgcdcacmrd,to AnYvidatim of
��Y notnionl0Jl.5 by anyappliaafl fnr$500).lwbjalr do epplirant to.nvilprnWty of OUTLETS-SWITCHES-FlXTI3RFS
STD rW nvethnn five hundred dollera(SSfIO). NEWRESIDEM3ALELECIR SQ.Ff.
yzzE ❑ I,uowncranct pmperry,amycmploYm with we6nu Nnrwi.7 m. usa. STORIES TYPE CONSTRUCTION
3� will Bothe wak.endtlte e,cmteismtslJoma oRerdfor soapplc.]000. wrlrof
ud Pnywhom Calc The Cmtractats Inaanx Law eon wt apply to N owner of
pwmrwho W Ila,a imporn theran,wwW eon mon work waxvaNmaghn;.
ours errrpbyees.povieM dw sahimprovememaartrwtimerM imof(ered ferule,If, OCC.GROUP NITS
however,the building or ann"vemcnt is wad within oro yevofcompaetion,the owner- TOTAL.:
Wilder will have the burden of proving Nut M did rot W ild m Improve for pupa M
mac.).
❑ Lnowrcrafthproperty,opcnem
y, eadusivdycowxtloem
#wlthlked tra
conctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
e onand lite pmjean(Ser.1050,Bu W Professiau Code:)The Contrwrds
License lawdoramr yglyxmowrcr Mpr�perty whobuidaa impmratherean,erd PFAAJIT ISSUANCE
who autraca fssaouch pot with.contfnna(s)licemcd pufsuuutatliecontaanor'a_aw.
Licettx ALTER-GRAIN&VLNT-WATER(FA) FEE SUMMARY
I
❑ L am esempt uMcr Sec. B&P C for Nir rravinL F
BACK FLOW PROTECT.DEVICE. SANITARY Y N
Owrcr D.- I`111.
ROOF.AREA.GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihercby affnn thvtl hnvc.anifcatc of commtwxlf-iwue,avartifotcMRECEIPT#
FIXTURES-PFR TRAP
Walcm'Compcnwimt lnsurvtaa•cmifW copy thereof(Sac.3800,Lab C.)whkh PARK FEE Y N
vers all employee's uMn W a pxmlt. GAS-G.SYSTEM-I INC.4 OUTLETS RECEIPT#
Pdiry# BUILDING DIVISION FEES
Company GAS-G.SYSIGM-0V ER 4(G) PLANCI♦ECK FEE
❑ Certifier]copy is hereby furnished.
❑ Certified avpy is fled with the city insprcuan division. GRFASFJINUUSfRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXENIMON FROM WORKERS GREASE TRAP SOILS FEE
COMPENSATION INSURANCE.
(This sen ion noted not be cvnplctee litheperntit is for one hardreddallus($10p) SEWER-SANITARY-STORM EA.2001`17. ENERGY FEE
or lea)
I candy that In the perforrrwta of the work for which this sernin is assured,l shall WATER IIEATEi W/VENTMdLECTR
not employ any erwn in any m v to becoro:+object to Ne Workers' PAID
z Comperuvtiun L�wa of Collfamie. Date w WAWA SYSTEMtPREATING Dave Receipt#
Appliren
z0 NOTICETO APPLICANT:If,afar nukin *is Cerodifiwe of Esemptiaa you should NEW RPSIDENITAL P1MB. SQ,FI'. TOTAL:
a
N become subject to the Worker'.Comperrunion provisinso of the Labor Cade,you mull
7 forthwith comply with sw
uch priaiau or this petition deemed]it shall deerevokedEE
. BUILDING F
(� CONSTRUCTION LENDING AGENCY SI]SMIC FEE
VI hcrehy affirm that there is a coan0ucticm Ie r,egeocy fa the,perfaumnce of TOTAL: ELECTRIC FEF.p tlr work for which this permit u iniad lSec 309].Cir.C.)
I.eMea's N.
00F 1<,dria Addram QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I anify that I have read this eppliaalimt and cane that the above infonrution is
4 currm.Iegrcc tic yrs Y MECHANICAL FI'J?
umpywiN all cit Mount ordinances end iiia laws relating to PERMITISSUANCE
Wilding voastracii ,end hwclrye rh.nrco,p e t tivesofthis city m rateaupvt the CONSTRUCTION TAX
V Z above-mrntimwl ar,d,for inspection pcar,st ALTER OR ADD TO MSCI I.
(We)agree to save.ittaercirly and kaap humkes Bre City of Cupnhro agdrut
Inabilities,Porticos",cow acrd experoea which ally in any way accrue ayavnt mid City AIR HANDLING UNIT(TO 10,000 CFM)
un M. .a thetingf .ill mit.
/ AIR HANDLING UNIT(OVIiR 10,000 CETD
gruture of AWlicant/Cannenm Date EXHAU!I'HOOD(WMUMI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO Md"BTU) Lhte Recelp N
Will do epplimm or future building occupmt vassal,is,hao6e turardssrc mserial
as,deft cd by the Cupriin l Municipal Code.Chapter 9.12,aril the Health and Safety IJEATINO UNIT(OVER 1OOA00 BTU) TOTAL:
Cadc.Sati O25n32(a)? ❑No V LATIONFAN(SINGLERESID) L
BOILER-COMP(]IJP OR IM."BTU) ISSUANCE DATE
Winton,coiantor tutors Wilding by the B.,A Air orality wh,edisit ^ p ' D
hazeNom air canmmirenu u Ballad by the B.Y Aire Air Quality Mmagenunt BOILER-COW(OVER M."BTU)
r /i '
Dalrlet]
❑Ya ❑No NEW RFSIDENfIAL MEC11. SQ.FT. AUG 4 �gg3
I have read thma
e larardon terial
s rrgttbcmmu ut Chapter 6.95 d the a
California UW th R Safety Code,Senlssru 25505,25533 cad 255]0.I uMerstad that ;_ 6�p
If theWm ildingBaca ncurrently have.tauNetnt. it is my rary m pwniNiirdary thewapent of the myuinmoulast pwoents which ms rins to inree a of Certificate or
wC cupcy. Doc TOTAL ISSUED BY