27682 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PLUMBINGCITY OF CUPERTINO BUILDING- L APERMIT NO.
BUILDING DIVISION BUILDING PROJECTIDEN'TIFICATION
27682 7vo2
BUILIUNG�ADDRISS(� SANITARY NO, APNJCATION SUBMfTTAL DATIi
UNRN LOT♦ _�' I C
OWN' SNAME: HONE CO ROR'S NAME: r WC NQ J
(C.GLC (4 1 ZS hfC CONfftOLet
WoRCI IIECUFN IN[JA: 'et LIC NO: ADDRESS: ❑
'O TACT: Y PHONE
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INF-0
c� BLDG ELECT RDMB ME;
PERMIT ISSUANCE ❑ ❑ ❑
IJCENSFD CONTRACTORS DECDARATTON APPLIANCES-RESIDFMIAL JOB DESCRI �
OCZ. Ilerebyeffrm NmTamliCONT uACTORS lwofC `DO9(mrmancinewith 11
010— S,,full]ton 10)oorce,mcl Division 3 t4 the Bnrinessane/14nfemium Code.and my Dicasts',,in PANELS
sU� 10
C 1 ) UPTOMAMPS
lis<cc Dote mZ Cntracmr C µGk•/ 201-IME)AMPS
'LOv'z ARCIIITECT.g DECLARATION //`"' OVER It]Bp AMPS SQ.FT.FLUOR AREA SISQ.IT.
O'G-0 1 ypleer.fullbc.".publicn,cmdr.
l-to 1 SIGNS ED£CIRICAL
9 '<] lian.ud I'ndcvinnal
y� OWNER-eU1LDER DECLARATION SPECIAL CIRCUIT/MISC.
XdX O a cU. I hveby.ffmm than I em exempt mfircon
un th Cnnvanuh e:Any Lew co the
W3u-tn w hick nert¢wn.l•S ii to conson,BuW her, WR,de ions Coate:Any city acwnry TEMP.METER OR POIF.[NSf.
1_�0g which t quirtsaeer It tocunsi the ul fislmpnirsodemnliilnrcrepw as] etrvctufe
W of doteproorhe i,
Liu c,.lwrtquim Nnoumoto nape ConartdtmLiC..La,,r mmfer POWER DEVICES
n. o<0 9(cnnitncinsed purwnrm Nc)ofDi mnof the Cmn.nots Lianalrwns Code
� 4lcommcncing wish Section 70W)of Divinion3ofthe Buri M.a and Prnfcvions Code) SWIMMING POOL ELF,CIRTC VALUATION
y^y adurheis exempt Nrmf.mid the bmis for the a ei exemption.Any vioWion of OIIILEIS-SWITCHES-FlX'NRFS �w��
t Z,Q
Section by my aWliam fa.pernur subjects the•pplRaru to civil porathy of
�2 G not mon,than Eve hutWnl dollars(5500). NEW RESIDCII
MALELFCIR _SQ.Ff.
,�,{CO ❑ I,mowmm�l0cprupeny,mmYvnPluYecwilh w.gca¢s Ncirwlecartpetuwion, S'PORIE. TYPE;CONSTRUCTION
y3GO wdl do the wart:,od the,nncture urtm intvdedar offit for We(See.2041,Busirtea
.rid Rvre cions Cosfe:The Con.."Urania law does of apply to N owner of
Innpeny who builJXorimE,os-Nercat,eml whodae such work hirroelfaNmugb his
V, OCC.GROUP RFS.UNITS
employee.,provided Nv wch impmvctnent.ere notimrndW moffercd fa rale
Iwesn,the Iiii ing aimprovement is and within ante yruofconwlcgan,Nteowon,
Wider will bare the burden of proving that he did non build a improve fan purpme of TOTAL:
v eJ.
❑ I,nuwrcrMNepropmY�.mexclusivcI tr.chngwit bionscNronv.cta.m QT' PLUMBING PERMIT FEE APN
Nrttdurl Ne proles .IOe1.Basi Pmfevian Code:)The Contr.cmr'a PERMITISSUANCE
licemelaw doe nm WRtlYn n progeny whobuild.aimprove dvrsn.ud
whnevtvacu for such pmjectrwt ono- tor(.)lianud punuent to the Contrst«s �.�g-GRAIN AVFM-WATiIi(FA) FEE SUMMARY
1ini.c law.
❑ I.rn exempt urtda B&P C!a thu re¢�mi BACK FLOW PROTECT.DEVICE, Omi
l
SANITARY Y N
Owtmr Date DRAINS-FLtbftfttR)F,AREA.CONDRECEIPT#
.
WORKMAN COMPENSATION DECLARATION , . SCHOOLTAX Y N
LEIhcreby NBsm tlwltia ani Frnm of rnnu nxlfinsurt,aercrtiftcote of RECI:IPI'♦
akm'Camprnvnienlmur.riceo cni0ed Naeoffgs.3glXl,lab C.)which Fl%'fVRFs PLA TRAP PARK FEE Y N
m.11 employs i uMc Nie permit. GAS-EA.SYSTFAI-I INC 1 OVDFIS RFMPf�.
Policy♦ BUILDING DIVISION Fli
CmnPany GAS-EA.SYSTEM-OVFA a(FA) PIANCHI!CK FFH
❑
Cenifisolo,yi,hesebyroKitleal.
❑ Caifrcd ropyuf0d ani rte city inrpaticn diviucn. GREASEINDUSIRL WASTE INIERCP.PI'OR GRADING FEE
CERI'IFICATT OF FXINPfION MOM WORKFASGRFASETRAP SOILS IEE,
COMPENSATION INSURANCE
(Iles section neN not be camplatial if NG pcmir is fa one hundmd faWn(SIM) SEWER-SANITARY-STORM EA.200FT. FNFftGY FEE
a lay.)
l anify dui inti and thewak fa which tK pcmtit it the, still WATERHGTERWNFMlP1E
tta at y R Y nimmv ro r P c r j r' •-de Worken' PAID
Canpenr 11 Cal' f Dune m WATER SYSTEM/IRFATI Dene Receipt#
Q2 A liam] .� —
O NOIICE'10 ran ICANT:If,.frer truking this Certif neo(Eaarynim,you should NEWRESIDENTIALP! B. SQ. TOTAL:
t� ^ becvrrc rubjcct to be,Warkcr'r Com,..reuvisiom of Bic Lmcx Cade,you no.
> fata
hwinh cnply with such Pma N <mm
vl:lons i.pu Wl he d
sbsM rnmvckW. BUILDING FEE
4 STRUC ION LENDING AGENCY SEISMIC FFE
I brtcbYaflinn s
U ansu
thatch ouction lcroing Mency for the pvfmm ¢e
um
Inc wmk fm which i his perout
suul(scc.91Nt,Civ.C.) TOTAL: ELECTRIC FEE
I.rndcr'.N. PLUMBING FEE
F Undees Addrev QTY. MECHANICAL PERMIT FEE
V I codify tbm I bre mad Nis.pplie eM stem tlwt Nm aMve info onvion it MIiCIIANICAL FCC
F G y. Iegra marmply with all ci ntymdit�ceswduvel....claing no Mfr ISSUANCE
_ Vl bnik1ittgcavtrwetien.eadhrtby
ewlvnafthir ciry meorertrtm the
U Z .bore- anted PmRnY fm' Ilona ALTERORADDTOMECN. 'ONS UCf10N TAX
(W gn,e t ify unit keSp ha s the City of Cupcnitn action
li.dlitl ,j ci rs, bsu exprns w b unity invrywgrcerve.g' .rid Ciry AIR BANDUNG UNIT(T CFM)
as n grentingof Nu L
AIR HANDLING UNIT( 10,000 CET.
Si of Appli t/Cmtrrta Due EXHAUST! D !Ji
PAID
IIAZARDOUS MATERIALS DISCLOSURE H TING N W,000B / Dare Receipt#
Will the xpPlicsruafuturebuil g acupvu naem h.ndle houti roneriN
u defnM by the Cupmino Mw ilul ,Ch.pter 9.12.and the He¢1N eOd Sefery IflAn 'UNIT(O Iliffil p L
CaIG,Seadon 25532(gR VENTMTIO AN(61NGLE RPSID)
❑Yea ❑No
WiIltlrapPlicmitmfutme bu0dity ruse devlarwhkberwt BOILER-COMP(3 OR 100,000 BTU) ISSOADCF DATE
egaipnmta N7 0
izmduu.yr unneminnntr as def Y t Bay Arm An Quality Menngcrnenr BOILFIt-COMPfOVIR I BTI17 Pee Q
13 Y. ❑ NEW RESIDENTIAL MECH. SQ.PT, T, a 6 �n
I have read the h Ommbus mwcriils rcyulrsmenu utda Chapter 6,95 of 0c �r /.. J
G ifomu Pet h Safay Calc,Sections 25505.25533 mal 25531. 1 undcrsimd Net rI-(c /
nit m,of gdoe not errantlyh.vc.nn k Nu Inis to terpauioihtrwttaify dtc V/'rA. .1O
Ocutunt of do rcyuirtnwnts which moot be met Iris m iuuurce nl a CmiOrue of �I
Oatupwry.
Owns a.uNorired.gent tate TOTAL: ISSUED BY:
OFFICE