25015 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO D'11i-�Il` kPERMIT"°. 25015
APPLICATION/PERMIT PLUMBING-MECIIAN'ICAL
BUILDING DIVISION BUILDING PROJECT'IDENTIIICATIOS
BUILDING
GAADDRESS: SANITARY NO. APPIACATION SUBMITTAL DATE
/ UNIT LOT
OWN A 6P110 CONTRACTORS NAME IC NO:
NIC CONTROL.#
ARCIIIDIiCT/IWGINEIR: LIC NO. ADDRESS: ❑
vs
NNTACf: PHarvE TY ELECFRIC PERMrF FEE BUILDING PERMIT INFO
ESBLDG ELECT' PP11..UMB MECH
PERMIT ISSUANCE ElIC7
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RIDENTIAL I-�
CeCZ IM1ercby affirm Wu lam lianed urdepovhi«nofCluptv9(emurlvcing will JOB DESCRIPTION
�200 Snyion7")of Division J ofthc Business and Pnfeetimu Code,ad my limfe a W PANELS
yWF full ionic,gad-Pett. n +
<V utttue," Licl UP Tp 2,10 AMPS /K, K
NLW
<y Dmc Cominscow201-1000 AMPS
'L O d`"IZ ARARCHITECTSTI'SDF,CLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/sQ.FT.
OZ—,'] 1undcnurd or, shall he u.cl gawblic remds.
F ti L W SIGNS ELECDUCAL
u ,et Profeaiwul
25yg< OWNF.RUBUTLDER DECLARATION SPECIAL CIRC EFIMMSC.
ap6x�Oo.F. 1 hereby affirm War 1 am exempt fan Bre Costrama's l:mm.law for We 1
folbwing..(Semian 7031.5.Bumnsw and Pmfeuiom Code:Any city or cdmry TEMP.AtL+IPR OR IRI'
which e4 «tiea penin m mi Wer.mr,mr,,demolish.«ri any ewenne
f M pnm w,its ievures.also requva We appliam fm"a permit to file a 4plw mt«rcnt POWER DEVICES .�
,YQp Bw he is licensed foment to the provisions of the Conwcurrs License L.aw(CWq«
a axxo� 9fcamrencing wlW Sacim]000)of Dinsmore]of Be Butiagaand Rofmi«u Code) SWIMMING POOL ELPCRIC yVA UATION
W❑N
car that Wcm
chat he is eaefrum ad Be basis for the allegdem
exemption.Any violetionof Q
tKQ Scryian]0313bymy Adie'ontforepenldlwhjectsthc licontioselvilpe ryof Dlm.e'Is-swrreHES-Flx' AT 'O /�'
M=p ons oras than It,huni dollu0).
s(S50
ElI,asuwrcroflhclrrnp«ty,ormycmployeevwiWwxeca�s lhcvsokcompewlion. NEW RESIDENTIAL FLECIR —SQ.PI'' S RI TYPCIIECONSDtUN
c. 2 win l do the work and Bre goomure H not intedd or offend for We(Sa.701 Busirtm
gad Profit bions Code:The Cmeamor's License Taw duce con apply to an owner of
pnrpmty wim buil ds or im mve.Wi em,udwbo dace etch wag,mosielfw Brrmgh in,
own cmplq«s,ryovNd WawMirtlpmvcmcdsuendlotcrddmoff«edfaeWe
if, OCC.GROUP _.UNITS
Wwever,the building sir impcoVero t awld wbhmacymrufcmfImm,BreDwrer-
buildef will M1are the burden of proving Wu Wd rot a he t halM impove for puem
pe of TOTAL:
we).
❑ I.uuwrerulrkprrperty.nmexcl,av-ly«mo-anWgwiW licerudcwurxfmlo QT' PLUMBING PERMIT FEE IL OZONE APN
ca.wct We poject(5«.71 Business W frofeuiom Code:)The Crmvecla'a PERMIT ISSUANCE, .S O
Littmu Lew doo ml apply to an nwrernf pmiccrty who W ilds aimpruv«Iher-m,.nd
Who«ntrxu fawch pmjm,with.moonclm(a)Keened pm.nant to Bre Conuecta(e ALTER (FA)
Licenfe taw. FEE SUMMARY
❑ 1 am exempt uNer S«. ,B&P C fm Nis roman BACK FLOW PROTECT.DEVICE
SANITARY Y N
Own« Dae RECE�1'M
DRAWS-FLOOR.ROOF,AREA.COND.
WORKMhaiaAN COMPENSATIONe,ii to seRAT10N SCI{OOL TAX Y N
Irs'Co affirm that 1hove• or r cevreio cos Ni,cof(Se.313nim,or acmifiw-of RECEIPT'x
pe IIXTURFS-PER TRAP
akm'Canp<neuiminsmara urecertifdcopy W«m((S«.Jg00,lab C.)which PARK FEE YN
Miova Wle p t Imnik RECEIPT#
a 3 GAS-PA.SYSTEM-I INC.40U]LETS
Mi, a BUILDING DIVISION FEES
GAS-EA.SYSTEM-0VFR 41 PLANCHECK M.
❑ eerB pr nel �rT"
Certifdcopy is flld wlW We city inosmim divl.elo, GREASEaNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPDON FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Itis section need not E-cmnpletd if Bre permit is for me btsto,ii Mign,($I bat) SEWER-SANITARY-STORM FA.2(X)FI'. ENERGY IEE
al aJ 06
I ploy
llutimor in
recofir ract for which Wi.p«mito its,wmi WI WATER HEATER W/VFI T/EI,ECfR
not employ any pawn in .nY mermen w u ID become subject to We WDhrn' PAID
O z A�pnrvrion law of Califmrua. Due WATER SYSIEhV1RGTING Dere Rc ipn0
z NOTICE TO APPLICANT:If,Utas making WL CircE.MEa«nption,you WwW NEW RESIDENTIAL PIMP. SQ.FT. TOTAL:
a >
become bo W We Wuhc'sC pmotlm poviiini Mlle labor Coh.you muN
both.th campy with each prosi org sir,his nout sbal W deemd revoked. BUILDING FEE
(]
CONSTRUCTION LENDING AGENCY SEISMIC FII
I herebyaf�rm Wait Bore la a«nuvuaitn kmding ag«cr for Bre perfmlwncs of TOTAL: ELECTRIC FEE
V Q Bre wock fa which W,permit Is lulled(sec]091.Cas.C.) $�
,r Tenders Attire,
O [v-' mite',Addr¢s QTY. MECHANICAL PERMIT FEE PLUMBING FEE SQ
I mtify But I have recd Nis.ypllcaBm end orale Wet Ih-above ioforratim r.
wrtcct Ingres to cci wild all sly and county oiclfiu _s gad use Hwa relm,to PFRMITISSUANCE MECHANICAL FEE
F' i Wilding mnYMcion.and hereby sudrarire nepremutisv ofti city corner upon this CONSTRUCTION]'AX
U z vWvc rrcmimdpmPerry for inulr«lion pvpeer. ALTER OR ADD TO MECH.
(We)epee or gars,idrnnify and keep hempen We City of Cupmim against
lialyditics,judgmrnn,cels and exPce'«which may in my way accru-egainst said Cry AIR HANDLING UNIT ITO 10."CFM)
urncc of ti g of W,,mni,
AIR HANDLING UNIT(OVER 10,000 CFM)
5`
tic of ApplxvruC' mclm Dere EXHAUST HOOD VODUCI)
PAID
I IATARDOUS MATERIALS DISCLOSURE HEADING UNIT(TO 1001 BTU) Dote Receipt 0
Will the applicant or future Wilding occupant store or hmdk hvxdvus mmmJ IIIrADINO UNIT(OVI:R Ifq,gq BTU) TOTAL
ea d-frcd by Ile Cupenidr Mwlclpal Corse.Contriver 9.12,W the HedIW W Safely
Code,5'eai 255J$o)?
0Yes ❑No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
WHI Br- BOILER-COMP GHP OR 100,000 BTU) D
ecortarrlm is st Wlldm by«mote Atat Air Quality
marthwNwu air conlarrrin.nre nt deBrcd by the Bey Ane Air QuWly Marugrnrenc
m d BOILER-COMP(OVER MiBTU)
Cl Year ❑No NEW RISIDFNfIAL MECFI. SQ.FT' WAY 19 0003I leve red We hanrdous nruende r,,,iscmi under C'hnM«6.95 of the
CWifm,ie I Ic.11h&S rey Cud,,Scctioru 25505,25533 and 35534. 1 wdrntad Was
if We Willing dm wt currently have a crank that it 4 my res mrsibifly to ratify We CIl'► Ur uurcr.n _
McnpNl sir rte nqu i.c.which rotor be,mcr Prier m issumtt ref.Cco Mime of
OcmPmcy.
Owrcr a auWariud regal Dae TOTAL: ISSUED BY: