28033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOi- L.0 rRICAL PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 2803
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
O45 Ad P4AOA4A , UNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LICNO: NIC 'Ow
Lq
2-4 _ I c' l
c ARCHITECT/ENGINEER: LIC NO: ADORE
U /l0 I7N V
caNTncr: : PHONE: QTY ELECTRIC PERMIT FEE _BUILDING PERMIT INFO
q,70 V,p
/� PERMfI'ISSUANCE BLDG j;LBCr' PLUMB MECH 2� G �..
LICENSED CONTRACTOR'S DECLARATION Y_APPLIANCES-RESIDENTIAL TOB DESCRIPTION
tyz Ihemb,efGr alliminmlicemmanderpmonomm
visisofChap[er9(oencingwith
�00 Section]CW)of Division 3ofthc Busine,sand Prefessions Code,end an,brimse is in PANELS
full force and effec
Fz Licen Lic#!e�O (([L/ UP70200 AMPS (�(�� CAA.
m<d Date Court 201-1000 AMPS `��
F M Z_ ARCHITECTS DECLARATION SQFf.Ef O AREA/ $/SQ.Fr.
z 0 h 1 understand my piens shall be used as public records. OVER 1000 AMPS
O Z F O SIGNS ELECTRICAL
ti
5'z< Licensed Prbfessional,..W
Cm
"i6 OWNER-exempt R n the ChATION7 SPECIAL CIRCUIT/MISC.
f'O y O i hereby affirm that 1 em exempt from the Contranor's License Law for the
W 3"Hfollowing reason(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
,I]fS OC;
ADDITIONAL PERMIT FEES
' BU I LDING PROJECT IDENTIFICATION VALUATION
ewCmrvc p )
AOORMES *p'T^Q!E��/I 1
awNER s
NAME FEE SUMMARY
ZRS ZZAR .CNE
NAme/Rnc.ORs �/ /J7 /�j{ BUILDING
GU e%/ o l<17,5.. (OEo- PLANCHECK
CONTRACTORS FEE
SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
TOTAL
SIGNS TRANS.
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH. .�
O SERVICE CHANGE
Z Z
�7 ° TOTAL `
cr y
ISSUANCE DATE
UJ > LTV. PLUMBING PERMIT FEE I Loc ELECT. PID. mECH.
d D ❑ ❑ ❑
0 Z ALTERDRAIN&VENT-WATER(EA.)
O BACKFLOW PROTECT.DEVICE
LL
O 10 DRAINS-FLOOR,ROOF,AREA,COND.
} FIXTURES PERTRAP \-jt
F.- Z GAS-EA.SYSTEM-I INC.4 OUTLETS
() GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
L AWN SPRINK L ERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2005t/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TQTAL
CITY, MECHANICAL PERMIT FEE A
.410
ALTER OR ADD TO MECH. Y"
APPLIANCE
AIR HANDLING UNIT(TO 10MC.F.M.) hi , 79.
AIR HANDLING UNIT(OVER 10=C.F.M.) V/
EXHAUST HOOD(WITH DUCT) LurCkI�NO
HEATING UNIT(TO 100,000 B T.U.)
HEATING UNIT(OVER 100,000B.T.U.)
A . _ VENTILATION FAN(SINGLE)
BOILER-COMP(3 H.P.or 100,000 f.T.U.)
BOILER-COMP low•,1OTWO BTUI SEs FEE SCH.
I`_� TOTAL