25705 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
bti,.111
inLICAL IM
PMIT NO, 25705
APPLICATION/PERMIT PLUMBING- CIIA
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING AADDRESS'. SANITARYNO. ANLCATIOIJSUBMITALDATE:
v PIP,""MeVl LOT#
OW E SN PILO CONTRALIC NO:
J. NSC CONTROL#
�ARCHITE JENGINEER: `—` LIC NO: ADDRESS: ❑
ONTAC HIGHS,
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG EJECT PLUMB MECH
PERMIT ISSUANCE 'Et ❑
LICENSFDCONIRACfOR'SDECLARATION APPLIANCES-RESIDPl.'IIAL eomenc
JOB DESCRIPTION
OCi IEe0[0)of mill 3 ofteBusinssmil iionser6epa9(ci myHveine cairn
,iloo S«uanem,]efDidaim3MJe Bmirca egd Rofwlntu Code.¢d my liavcuin PANELS
cUErill farce ud cRm.
licrn¢Clw 10 IIP T02l10AMPs
to Q y Duc Conor 201-1000 AMPS
z OyZ ARlbi Ise CTSDECIARATION OVER 1000 AMPS �Sp�T.41pO�1BFA � SISQ.FT.
o z—� 1 nM«sund my dens shill be wetl u pubfk records. �, - II E1J1 p''�II 11nn�VI''
Q'�U1—w SIGNS ELECTRICAL II H [_ R
Lices¢d PMwioml OWNER-BUILDER DF,CLARATION SPECIAL CIRCUTTMSC. �./ �,✓ V' T�
pxCC0.x,ossa!! 1 hereby atri m thet 1 can esemp from the Contini License Law for the
W3 wFQi following renown,
(Section 7011.5,Business mel Pmfeuion,Code:Any dry or costo TEMP.METER OR POLE INST.
E1:0 which myuirm a pmol to construct,toter,impure,demolish,or repair my somene MTr
POWER M"CES
'DD m Print to its i.e.slag ryuires the ap m,mt for wch'vonh w Bless
dataremoJ
,N,<o Jvu he is licensNpuPum mthe ro—i oft he Conuecmr's iLiw(Clupes
c,ao� 9(conunencing with S«uon7")ofNvWm 3 ofthe Busioeu and Pmretaiom Cade) SWIMMING POOL FT ECIRIC VALUATION
tz altoMia 1 a rnt by eref.
aril Oc in.f«IheascgMeaempli to ciyl Fla sty of OUTLETS-SWITCHES-FIXTURES
Section]ol l�by soy vpw mi , a pcmil subjects the nppllrmt m a civil perwry of (�
tw throe thnn Ties hundred dMlare(5500).
� $ ❑ propmry.mmycmploymwithwugc+es Jeirwlccmnpmuum, NEW RESIDENTIAL FiFCIR —SQ.C � I,mowternf the Q STORIES TYPE CONSTRU N
a3_ w;uda the wmk.ardlMammartnmrintendeentwr«ed ran a.le(s«.'rasa.a-' -
end Pmfwimn CMe:The Cantmcmr's Llcerue law Ones m1 apply to en owner of
IvsganY wMMildsntimpmves dertm,and wMJm wch wohhirruclfmrhtwghhis
can emPloym,povided Jut aucM1 impmvemouart rotinterdd moffe¢d fwsde.If, OCC.GROUP RES.UNIT.
however,thea,l the mimt of oviniswIJwithin oreyeaac imnovefu,Jcowrcr-
bulkier will M1ave the burdrn of poring thel M did to build o-impwv<rw NRme M TOTAL:
owoaof Je pnopcny,uncaclusivclymwanitnwiNliccmcdcmtr¢room QTY. PLUMBING PERMIT FEE DZO,N'F. AM
mt.the Pmj«I(.Sec.I0a4,Busioc.0 end Pofaviem Cwle:)T,e Gmlmclas
emelswdoamt applymmno ofpapenywMwldsmU Tovathvea PERMIT ISSUANCE
wMcantmcu fm such pvj«u withnconu«lor(a)lieen¢dpunuanl totM Conmcmla YsLTER-URAWRVENT-WATER(FA)
Liwmc law. FEE SUMMARY
❑ I am uempl midst See. ,B&P C(m rho tmson BACK FLOW PROTECT,DEV ICEII
SANITARY Y N
Own, Date
DRANS-FLOOR,ROOK ARE .CONU.
RECEIPT#
WORKPENE ATION CHOOLTAX Y
N
❑ IreYofmlhavcarnifmwofcmw¢ir-im ,mamfvcof
Fl]i TURES-PER TRAPRECEIPT#
Workvs'Canpo.uritm lmumnrcwacarlfed cpy Nernf(Scc.3900.Iab C.)whicn PARKFEE Y N
c0om all employee's uM«thin pemJl GAS-EA SYSTEM- INC.4 OUTLETS RLCEIPr#
Policy# BUILDING DIVISION FEES
company GAS-EA_SYSTEM-OVHR 4(1A) PIANCHECK FEE
Cl CenlBedeopyuMebyfwmJlN.
❑ Cenifcd copy is fled with thin city impection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING EFE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This i.rrd trot be complee,lifthv Pmnirn fm ma hurmie]cinlim,(SIOo) SEWER-SANITARY-STORM EA2 PT. ENERGY II:E?
or Ica)
I cenify Jur in the perfonewceoflM wvalr for which r os pmNt is lewcd,l ehdl WATER HEATER W/VENT'/FJECER
not employ my pesen In any rrwucr so m to bmme subj«r to the Workcn' PAID
C��.• on laws o(Ca4famia.
Out, WATER SYSfEMTREATING 0.tc Receipt
O z APPIIont
z 2 NOTICE TO APPLICANT:If.e(t«making this Catilem,of Esemptioo,you alwull NEW RESIDENTIAL PV.IB. SQ,FT. TOTAL
toe to wbjecr to the Wmkds Canpenuwt povisiwu M the,labor Cade,you must
fanhwilh comply with town Potosi.or this panus shell Mdremetl revoked. BUILDING FEE �+
y Q
CONSTRUCTION LENDING AGENCY StISMIC FEE
Z 1 h nebY dr.IM theme n a conav«tlon lending agency for the pert.of
V O Jc work For which lM1u permit is i.M(Sc.3097,Civ.C) TOTAL: ELECTRIC LLE
OUmkfr Norte
Iadera Addrw QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 crniry Net I love rem this appOcarion sad nets Ihv the above InfocmaJm is
cmrtw. lagree to cornPly with,all city and county vdiwrea arM sure laws rewing to PERMIT ISSUANCE MECHANICALFTE
I--' Wilding cwumrclion,ud hechy awhntice rtprexnurive citing city lornur upon the CONSTRUCTION TAX
U z above-mmliwed pvprny fa impectlm,puryog ALTER OR ADD TO MECH.
(We,)agree,to save,inicmnify and kap Famtlwg the City of Cuperino egeimr
IiebiliMs.luJgmenu.cmuacd cxp which not many way roue agaimr¢id City AIR HANDLING UNIT(TO 10,"CPM)
u cvrrayurna of Jin grmtiog of Nis Pmttil.
' AIR HANDLING UNIT(OVER 10,)00 CFM)
Signetum of APpliwntlCamroclor Dem EXHAUSTHOOD(WIDUCq
PAID
HAZARDOUS MAMRIAIS DISCLOSURE HEATING UNIT(TO Ion,"BTU) Dem Rccei,0
Will the qrpliscm m future building occcwt owe ar hurdle Iossams mss iJ
u defined by the Cupeniro Municipid Code,Cheptm 9.12,now,U Health and Safely HEATING UNIT(OVER 1OO,(ls)RTU) TOTAL:
Cada Section❑Y.J2(e)'f 0 N VENTILATION FAN(SINGIERESID)
Will Jcapplicosn m furore buildingo«upwru¢ryuipmcntmhvlm which emit BOILER-COMP(3HPOR IOo,0o)BTU) (�� ISSUANCEDQTE
• .h�dom sir rentnmimnw eF ierr,ea by me Bay Arte An Qudity Manegctncnt BOILER-COMP(OVER 100,00)BTU) /volt
I �J
DisWcn V � 9
❑Yes ❑No NEW RMIDHNTIAL MECH, SQ.FT. Cl/y Fi 993
I live ton the,h,ccfcly Cana mstiorts Sty ,lis ms undo 3,1. 1 un 6,95 of Jin
ifthe,mie IlcalrhhSt clot Sccate255(15,255]]ar�25534. Iuwlenod Out C%T JJr#
ifcurit ofydoescotnscros Yich aterror,et it is mYmusnce off ytetwdfy toe
«cupam of the rryuirnrcnts which mmr by inn pith to uwerce of a Crnifcere of
Occvpwey.
IArcrw vuthori>W egrnt One TOTAL: ISSUED BY:
OFFICE