25192 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B I. .-1,LEC7RICAL RMIT"° 2 519 2
APPLICATIONIPERMIT PLUMBING-NWCHANICAF,
Bou.mNc:�rvlsloN BUILDING PROD CIP IDENTIFlGCI'ION
BUILDING ADDRESS: �'_�—y'—y^) OM
SANITARY NO. M'PLICATFON SUBMITTAL DATE
FrQ �i.A� r -�CNITa LOT. 6_L X13
WN t AM8, y PHONE CO R'S NAME LIC NO:
NEC CONTROL
\RCHFFl2CFAi N LIC NO: ADDRESS:
� y
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Lf%l FlECT PLUMB MECII
PERMIT ISSUANCE �� � ❑ ❑
LI CFNSEUCON1RACr,VvWoi;of ChWION APPLIANCES-RESIDIJPDAI. JOB DESCRIPTION
py, Ihneby affnn JwlmnllernxaawerptavixW«sof Cbarpter9(mmnencingwiN
�00 Sttxkn]000)af Division hof Jx Buvnm aM Prufcvions Cade,and ylicrnseisin PANELS
y�F full force said effect. Up TO](p AMPS
azrW lei IIc.N 3 G
�6d Cmv.mm L 101-1000AMPS
'7~OyN fl-FIITECTg OF,'I RA 10 SU.PL FLOOR AREA SRQ.PT.
OVER 10011 AMPS
OZ-
1 uMrnlvnd mY pleas xMll 4 u W w paMic mads.
Fo', SIGNSI:I.E CAL/
a S,� 1' need Profu•iwl I!.�q 1
cd i& '6 OWNER-BUILDER DECLARATION SPECIAL,CIRCUIT/Mi M..
XOy1UU. I hereby affirm Ilus I am exempt from the Contractor"licrne Lew fm the
u13 u.`♦n following mmon.(Seclion TGI1 .Baxirev and Profevu—Codc:Any city m county TPJNP.sfl I- . ORPOLHINST.
C trJ'�g whirin rryulrea a pennil m nnxlwn,alter,Impnrve,rkmuliah,nr repair nnY vwnun
fC!�Y� prior to ILL ivuence,aBO myuiru the appBeant f«.weh permit lofkesigrxd auxnrmr POWER DEVICES
Wa
<C,
Jw he is licxnsed W rauant to Oe pmvisiau of Ne Conaanm'.rico;Lew(Chagas
cyp qc SWIMMING POOL FJR,CIRIC
e� ( rtg wiN Secuon]0001 of DiviaionJnf de Busirnus.rW Pmfcalau Code) VAI.UA''ppppyy��
_y
or Net he is exempt thmfran W the ltad.But Bse alleged eaco cion.AnyvioWiannf CZI
t,-�Q Scnion]031.5 by any appliwnl fnrepermit wbjectx the Cppliunt loacivil prnallyM Of1TLL-fS-SWITCHES-FlXTIJREs jqqS
p nu marcthan fvehurdrN dJlvn(SSrp). NEW RISIDINITALELECIt _SQ.rr.
Cl Ills,wrcrondthespeny.«mye_mploYemwilh w.gesu NciSee.canpenwion, STORIESTYI'F:CONSTRUCTION
will dotheial.Code;he Cron is not Lica or offeredf«sek(Sar..an Buvnea
.rtl Pmfea.iars Code:The Contracts:a Li¢nx Vx dors ms arp(Xy lf am rost ft d
oo m khem d.vr thwethim apt lM1 wcssuchwork muff mfrou e.If,
der,theaping or tote ouch impmvemmu uerove roMNmof(ved toe ow ,-- ROUP RIS. NITS
b.il&r ,will
building or imprwemml is sold within nth year orarmPlnion,rte oos er-
builrkrwillhuvctM1ebuNmnfpruvinglhnrbeJldmbuild«impave f«papme of TCIT "
cele).
is ❑ I,aeowrerdNe properly,emexclydvelymnmclirrgwilhlicenxdcmv.note QTY. PLUMBING PERMIT FEE ZONE AM
carvtrvc't the rynjeet(Sec.ICED,Buainva and Professions Cade:)The Cmm... PBRMIT ISSUANCE
licrnx Lav de.ru apply to en owns of properly who builds m improve thvmn,ud
wlwmnuxu f«such pmjalm with.comnaGons)licensed pursuant m tM1e CmtrnclNa
liaoc law, ALTER-GRAIN&VENT-WATER EA) FEE SUMMARY
❑ run uempt uMer Scc. ,B&PCI«thi.rtawn BACK FLOWIMF '
SANITARY Y N
Oxxr Da< DRAWS-PL ,R( "fi RECE�I'N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IM1erehy ef(IM1nlheveaanifa¢o(comauo xlf-inwm,«aarefirneof Fl%TURIS-P RECEIPTN
W« er:C(mpenarionlnxumncreacmifeduy ie f(S .3W),l C.) hich PARK IIJ? Y N
em all employKs uMer this pconit, GAS-FA.SYSTEM-]INC. OUTLETS RECEIPT'N
Policy X BUILDING DIVISION FEES
❑ Coifed mpy is hcrtby fum.s-^ GAS-EA:SYSTEM-OVER4(EM PANCHECK FEE
❑ Ctnificd copy is fled wiN the cityimpeceon division. GRFASETNDUSIRL WASTE INIFRCEJTOR GRADING FlE
CERTIFlCA'FF,OF EXEMVDON FROM WORKERS' GREASETRAP SOILS ITE
COMPENSATION INSURANCE
(Thi•eeclwo recd tet dcanplcrd if the pamiruf«mehtvMrN doilan(S 100) SEWER-SANITARY-STORM EA.3(pFT. ENERGY FEF.
«kv.)
I anifythat in the perf«marce of the wont f«which this permit is usucd.I shall WATER HEATER W/VENUELECTR
na employ any person in any
m u ra bec«newbjecl to Be,Warkeni PAID
Canensmicir"wsofCClifomia. Dam
WAIILR SYSTEM(FREATTNG Dere Receipt
Q Z Applicant
Z C) NOTICE TO APPLICANT:If.after makiry this Cetifxac of Gcmption,you NouM NEW RESIDENTIAL MAA. SQ.PI'.
TOTAL
V) bean
t to the Wmkv'a or em Provisions ,arbor Cock,'you in"
forthwithnth com •+Ih such provwoeflus permit haRb,ckerN oIsc,J.
BUILDING FEE /,a
(] CONSTRUCIIONLENDINGAGFNCY SEISMIC Ili?
1 hcrcby uff mi Dat Bete ie a conWUClion Irnding egerwy Im Nc perf«mena of
V O u,work For which this pemtil i.uauoJ(Sec.J091.Civ.C.) TOTAL: ELECTRIC FEE
O Kotler'.Nurc
I<,mtAdfy tho Rha QTY. MECHANICAL PERMIT FEE PLUMBING FIE
certify I M1.ve reel tali.city
tans ou ay awe they the.hove iw,rm.tlm u
hoccorocn. L.gmcmmmaid heyel,th authorize
countyadinarcaCnd city to enter lating
a PERMIT ISSUANCE MECHANICAL FEE
U Z building caron,,J an,anJ heyel, ercprtxnterivcx of Nis my mcma upon the CONSTRUCTIGNTAX
U '� above-mentinm properlyfmmapxeon parposm'. AFTER OR ADD TO MECI I.
(We)agree to ave,irdcmnih and kwq de Ciry of Cupeniro;gaol
Babiliee,jW LL.crosaard any wayattrue agaimrsaid City AIR HANDLING UNIT(f010,000 CFM)
u mrr;q dee ons of
AIR HANDLING UNIT(OVER 10.000 CEM)
Signa u A «ism r Dam EXHAUST'lI.G(W/DUC)
fll:= S MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) —�, ,Ase Receipt
Wi the applicw«future Wilding«cmpanr ase«hWlemarvv1
u lefined by the Cupmmo Munici*Code,Chapter 9.I4.rtl ee Hader and Safely HEATING UNIT(OVER 100,000 BTU)
Code.Section 25531p)?l VENTILATION FAN(SINGLE RFSID)
11Y6 D
� p
Will the applicunramrc
finton, whlcheont BOILER-COMP(3HPORI00p00BTU) ML[AN�I, r IY
i M1vydoua conmmlrlefred by the Bay Area Air Quin ity M�ngarcnt BOILER-COME F0VFR 100,000 BTU) JU(y 11
1
11 Ye, No NEW RESIDFFIIAL MECH. SQ.ET.
1 have reil ane to r,Ioov ouaials uyulrcmrns araer CTmpser 6.95 of.le UI-t.'lYF'tH 111VU
California I leallh&Safely Cale,SeGioru 2505,25533 5, 533"255M. 1 mMersmM that
if the baildiny docs not cunemly havetenial that it is any rt•ponsibiluy to mefy e,e
ar ,,am".1e rcquitarrnu shiN m,,,be met prior to ivsuat of a Ccefi.of
t>aap.rey.
Owner or emhnrixN Cgenl Dam TOTAL: ISSUED BY:
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