27949 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO UIEI`JNU-p`FCTRICA' 1'ENMITND. 27949
APPLICATION/PERMIT PLUMBING-MECHANICAL
RUII,UING DIVISION BUILDING PROJECT IDENTIFlCATION
BUILDING ADDR2SS: SANITARY NO. APYIJCATIONSUBMfITALDATE
sf UNIT LOT#
OWNP 5 NAME: PIR CONTRACTOR'S NA WC NO: 7 {�
O A l ' 04, u NIC CONTROL N
•AR I /F INI:I?R LIC NO: Y AD FSS
/ : ❑
cGNTncr:{O C AOA.GO I'tIONe QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDGFl ECT PLUM F1ECH
PERMIT ISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDEM'IAL
upW1wZ Ibtchyaffirm dw l un llcassal wdctpwrviomMpuga 9(cmmaaingwnb JOB DESCRIPTION
u~OU Sc,doo70m)of efDl,eminn 3 or the Bwir...ad Pmf.ona Cade,ad any lin/rue ism PANELS w
1F<..Zw Licma CJpes d .ZO Lic.1 L� UP TO 300 AMPS
tn?y Dem Cmtrrr-��_S�� Ejey 301-1000 AF1PS
GO,z ARCHHECTS DECIARA (ON OVER i"AMPS
SQ.FI'. RAREA "Q,FT.
p Y"O 1 undcrsnnJ my)Jws aM1WI Ne uvcd m pulaic
F�
W SIGNS ELECfRIGV,
6 Lkemd Pmfevfmal
Kw yrw< OWNER-BUILDERaa IteC ATION gPECIAL CDtCUR/tASC.
1 rt,. '.firm than 1 em e.emq Tran Nc Coward.Licata IAw fa be
r+J3t'-vi following.cn.ur.r( i1.coa1.S,Businrxswd Pwf¢slmn Code:Any ciryacaunry TFI./P.FfE1FR OR POlE INST.
whichn a.I mapermit manstt alta,im for Jem iter,au eirmymrvcmrt
�t.,r.u<0 pelma iuls.uuee,droaquim th ituctntf tieuchaa sBkaeLa smtemmt POWER DEVICES
j w p then he u ncen,w th Se,o to tk)oviuom of Ute too Boo ads License Law(Ch"
code) SWPvI IING POOL ELE
4dXo� othat eia withSenim]aralthf Divi.ion the theBminma staad.Any aau Code) VALUATION
uJ:w
or that he is cxcmMihaeftant ernd the bu..i.for the olkgd exwgion.Any vlalation of OUTLETS-SW
tz,¢ Sarion7031.5 by miy.,11e1 torepermitwbjauthe y+p4".t ,.eMIpenah,.f �.
rwr nta.e Nen fire burdrd"I.(SS00). �O'��
dF� ❑ Le.awncrnflhc NEW RESIDFMIAI.
pml.tua.rmyemployemw.ff eJ faetae,(u .mmpvmtioo, STORIES TYPE CONSTRUCTION
a3� al do Nc,ion,mdthe ena.aloto-tt�'.0�aema.do,fa .,Iy.,.. .of
end Pwfeasiun.cmc:Tne Conincim'.I.icrna law aces rwt apply to m owner of
IstopmY wMbuild.a'vntgnrm Ihcrtm,mid whodmsuch wtrck himsclra Nmughhis
ownesnploy�povidcd thusuchlingovemetu.uenmimeatdcdaoffcad fasWe,
If. OCC.GROUP RES.UNITS
h,nldkT ,rhe building or de.of,.tram is rod within ate ymr ofcmttpl,e fbr the owncr-
huildawill nave the burhn of graving Net he did tta bw10 a hnPm'rt fa puryox of IA
� ❑ I,uawnao(Nc Txnle'+tY,mnc.aclmivclyconvatingwirh liccnud contrena.m QTY' PLUMBING PERMIT FEE ElOOD ZONE ppN
comtrvct Ne feoj t(Sec I0m4,Bminea toad Profo.iau Code:)The Cm ,,
-t--
IJLawJannorepply tntnowmrofpapaty wlw bulld.aimgova NveaF adL, PERMIT ISSUANCE
wacta forALTER WATER(EA)suchfrmlauwirM1ernnwcror(s)Iittnad PunuenOo Dr Conuards
Li.L�w. FEE SUMMARY
❑ I sten e.anq ranch Sa. ,B&P C fa Ni..raum BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY YN
Owner Dam RECEIPT.
WORKMANCOMPENSATIONDECLARATION DRAINS-FLOOR ROOF,AREACCOND. SCHOOL TAX T N
e ❑ Ihaehy affirm dwlheveecmifeme of mnmtm:If-insert,oreanifcue of
S-PER TRAP REC [n#
waren'C FlXTllRF
anpatvumtlmureatcsmeccnifid copy Naarf(Ser.JBlp,lab CJ which PARK FEE Y N
coven all emplGAS LA
gcNNy/ndv�lry b�'� RECEIPT#
Itch,N /(/M ( 7,� - .SYSTEM-I INC.60UILLTS BUILDING DIVISION FEES
Cmnpwy �w w .n d GAS-EA.SYSTEM-0VER G(EA) PL ANCHECK FEE
❑ Certified mPY it hereby fumi.hd.
❑ Cenifed copy i.file with etc ciry ieeparlw division. GREASWINDU.STRI.WASTE INTERCEPTOR GRADING FEE
CFRTIFlCATB OIt EXEMPTION FROM WORKERS' GRFASETRAP SOILSFr-),B
COMPENSATION INSURANCE
obis section need not be complete iftbe p it ie fm one hundred!dollas(SIM) SEWER-SANITARY-STORM EA.JMFT. ENERGY FEE
wk )
lcenifythetintheperromuaeofthewakfmwhichthupm tise.ad,I.lu11 WATER HEATER WNENT/ELECTR
ton employ any p in any menar w as to beanie.abject w the Wa.k<n' PAID
Compcwrlm Lows of Glifomie. Due WATER SYSTEM/URFATTNG
O z Applkmu Duc a<igM
APPLICANT:If,erur oa1ing N Cerofiwe of Excmpin ,ynr thoold NEW RESIDEM'IAL PLMB. SQ.FT.
V) laane subjar to rhe W.AeY.Canpenurim povisioru of the labor Code,You
0 NOTICE TO APvuau TOTAL
a > forthwith campy with tach pmrisiaumthis PmNtsball be dmad make, BUILDUNGF
y CONSTRUCTION UENDING AGENCY SEISMIC
Z) z I ten,by tff dad,dtece is•caeutezi.lading egcmy for rhe pMarru e M l, lf�L,7eTArELECTRI
U O Ne wak ra wni.n this permit le l•"_ (s«.JovJ.cit.c.)
Le do's Nanta
Qlit Addtas QTY. MECHANICAL PERMIT FEE PLUMBING FF:E
U I cerafy that 1 have reed Nis ts,licuioa and Awe tJua the above infmmetial is
�" F17 caoar..'gree to wrrylywiNdlciryW rowry adlestr<.and�elawertwing to PERMIT ISSUANCE MELT IANICAL E
(•- DO building etmetrecrion,end ltnehy euthorite tete«taod ofdda city mmw upun Ne
U z above mcnfimcd gapen
ty for inspection putryar.. ALTER OR ADD TO MECH. CONSIRUCfI TAX
(We)agog to.evc-iMmaJfy ed keep hannlns the Cl,a Cupcnlno egmano t/
Ii.MnYm,judgaaw,rose stand e.pmum which tray in any wry acNCagstinq.aId City AIR HANDLING UND'(TO 10,1100 CIM)/ /s L
mna4aae of be iranting of this p ir.
1j yy AIIt HANDLING UNIT(OVER 10,000 CFM) _
v+r
Si meof Applieant/Cm is , Date EXI IAUST HOOD(W/DUCT)
PAID
I IAZARWUS MATERIALS DISCLOSURE IIEATWG UNIT(TO IMI1o0 BTU) Dote Re,ci,I
Will Ne tt,h-nr a fame building..,.nr.a hnMle,6ermdoue muainl IIEAT'1NG UNIT(OVER I W,11W BTU) L
m dcfind by the CuPcnirm Muniripel Cee,Chato 9.12 and the I lealih arta Sarny
Cade,Soli 2SS13(e)]
11Y. ❑No VENTILATION FAN(SINGLE RESID)
❑
Will rhe apgicantorPomrehuilJingaxupem uaequipnenra0evke.wnichaoir BOILER-COME dHP OR IWMO BTU) ISSUA A E
hav o air cannminenu m defined by the Bey At.Air Quality Mmmgrnunr BOILER-COMP(OVER Io0.0o0BTC) 10
Dishier?
❑Ya ❑No NEW RISIDEbMAL MECH. SQ.FT.
I have.sad S hverNw Sections
teyuire 533 under.XL I a 6.95 of on 4�1
if do, niallcdrh&Safety CNc.Scctions33a00.2953Jand
,,onmu ImndasaoM don 1996
itNebuiloft Jonan,anm t,lb vnerut,rae, it ismyns .oil.Ceir notify the r (fir
recuPstnt of the mquirttaou whdh rtwst be met Irian ro ivtumx of•Cmificate of LL
OcIN��ma,d.gt Date ISSUED
BY: