26021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '- LLC7RTCAE PERMIT NO.
BUILDING DIVISION
APPLICATIONIPERMIT PLUMBING-.MECHAN'ICAL 26021
BUILDING PROJECT LDEMfIPICATLON
BUILDING ADDRISS: r SANITARY NO, APPINA'11pN SlIBARITAL DATE
C.. UNIT♦ LOTH
OWAME 1G PILO C AMI" C I� N/C CONIR LY
• Pit I��T/ L
RCIIITECT/FNGINEFR: LIC NO: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG Fj FCT PLUMB MMU
PERABT ISSUANCE ❑
11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSRIINTIAL
p�Z I hncby Haim thin lturn limned uederprwi.icmofChepter9fconmiertemg with JOB DESCRIPTION .
�00 Sectiat 7")of Divioun 3offhe Btodo.end Pmfesions Code,erd my lkxnx u in PpNETS
full foie e,d erzm. .,yam ^ �._
¢ztu uc.gC Conn J -1 MI-I"
MP5 WPM .�lul
l-6vai Dae-'-f-tv-F'�'"�Cantrec 3[II-1000 AMPS
l-,z ARCHtI1:CT5 DECLARATION OV02 IOW AMPS ^ SQ.FT.FLOOR AREA S/SQ.Ff.
pz'?a I undcimerd my PWs"I be oW u public reetxds, '' I `P /Y � II.� ^ I�
pyF� SIGNSBLECIRICAL /� TE yLrYI) P �]
�YE� LcendRofmaW L'� P U C G;
you OWNER-exempt fr DECLARATION SPECIAL CIRCUIT/hBSC.
qx 0 W I txveby sffirtn Nett I mit temp tvn die Conuatr:s lienee I�w ra the
fsI3 w tw¢it following rmrmi.(Secoort WOE ,fhm' eM Rofmsae Cock:Any city or comity TEMP.MEIPA OR POLE INSI'.
L�J which rtyuiiee a permit to cawuc0 doer,imlrove,drnwlish,m rtpair any swctun PQWER DEVICES ATE
KQ� )via to its i+.u.nee,Haorryuiro Jc.ppliattfawch punct to fk NugrtM stuunw
ty K 0O
that he is lic,necd mm,mant to the pavilion of Ne Comtracter's Lkcve Law(Chwef
a'a 9(cinimencing with Setom7(XXo of Division 3 of the Busineu andmfca
Piau CodS W IMMNG 1'001.ELECHHC e) VALUATION
mdnw h,is ex,mN theiefmrn utd tie hail fa the dkged exemption.My vioWion of
1-.Za Sectian70313byenye hcztmfms permit.ubject.lncelglicmltosaivilper [yd OVD.EIS'gWRCT{J;5-FIXTVRFS
CpG tta mrtm than fire M1uevlrtdtlWWa(S300). NEWRFSIDFNML CTR _SFT.
❑ Lmownerofthepvpcny.mmyetnplvywwith w' suthairwleco,opewtian, Q. ORIFS TYPFCCINSTRUCTION
a3$ will MNcwork,std 7044,Bcamcss
sM P ofessiora Cale:The Cmvactor's Liana Taw docs not apply to an owner of
popenywho bulTdtar impmvetlrrtan,and wholes such wmk lnmelfa through his .ORO RES.USE'IS
rntployces,novicM pmb ar
that such Imascconc notimcmlcdaroffercd forsale IL
hui wilt,W e ithe tori enof,ntntt is sok wdis!not I old ofcmrttplvefm the owner-
ddMer will hese the burden of proving 1Mt he dd eta build o-Enpov<fo-povpoc of TOTAL:
mc')' QTY. PLUMBING PERMIT FEE FLOOD ZO APN
❑ I.0 owiterof thiel .71),0,Bu must elyammctiion,C lie:)The Coo ton to
cviutrvn the pm3ect(Sec.7044,Busu,ev end Profeuiae Code:)The Cmtr.tor's
whaeoclsw loo trot apply to enowncmocroc .)who buidam'unpvve Comott,md PEAMITISSUANCF.
whoisc forsuch ptojxv with•contrtucta(Oliiznud puivtant mtheCmtnetMs
Lioenx ALTER-DRAIN&VENT-WATER(GA) FEE SUMMARY
❑ I mn,tempt u,der Sec. ,B&P C fm Nk reason BACK FLOW PROTECT.DEVICE OUTSID17 ME
SANITARY Y N
Owner Dun - RTiCEIPTY
• eO DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TA% Y N
❑ em'Co NnsmtnImuno,em iftoteof can,
lercof(-Ireme,a acerd(eof FIXTURES-PPA TRAP RECEIPI'Y
Wo-k,n'Cmtpensvim liaunncemeaniEW rnpY thertof(See JtlW,Lb C.)which PARK FEB YN
vmvl ernPk�'dNP '� GAS-EA.SYSIENI-I INCAOUTI-1 RECEIPTI
PoIiryN ICJ BUILDING DIVISIONFEES
Y�—L-61 r GAS-FA-SYSTEM-OVFR 4(FA) PIANCUECK FEE
Cnefted copy is nercby Tum1f1Bod
CeniftN copy ie filed with tha city inapectiat divisor. GREASrANDUSTRL WASTEINTERCEPI'Oft GRADING FEB
CPRTIFICATE OF EXEMPTION FROM WORKERS GRPASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section heed not bewmpMcd ifthe perp it u f«one huttded dolYn(SIW) SEWER-SANITARY-STORMFA.200FP. ENERGY FIS
m lea.)
I certify that N tk perfamsnseofthe woh for which Nis Permit u issued,Ishan WATER IMAMR W/VENT/ELECIR
not employ any Peart in any msruter n u In becaete imtject to the Waken' PAID
z Co,ipcnutiou laws of Gliftmds. Date SY REATINO /' Date RaciNN
ATTI'tcanl
OO NOTICE TO APPLJCANT:If,sfter,intuitg tNa Certlfl a of Exemption,you should N RESIDE I-PLIB. SQ.FT.
TOTAL:
be,cone subject to the Wmkele Qmlieiw0om provisions of the labor Conic,you.-I
> forthwith comply with ouch Nomsiau a thi.permit shall be deemed revoked. BUILDING FEE
W F CONSTRUCTION LADING AGBNCY SFJSMICFFE
5 IhefeM�.Nu tiemit mnamrtion lording agency for the peafmnurta of
U O the wak fa which Ni.permit i.issued(See 3097,Cls.C.) T ELECTRIC ME
Lender's Name
O F Idle',Ad QTY. MECUANICAL PERMIT FEE PLUMBNG FFE
CJ I a fy Wt I lave twd thin n,liodan.std.utc Nu the Wove infcmetian is
coria,. lsgaec to comply with VI city cul wumy molimmoe and.nk tout Man,to PFRMIT ISSUANCE MECHANICAL FEB
Building commxtian.and herethy smbaiu fep.vseeuW ea ofthiacity to enter upon the
V Z .1we-rrentiaed p.,,y m,inspection pupae. ALTER OR ADD TO MICA. CONSTRUCTION TAX
(We)agrec to use,i,dtmtify nod keep hesvdcss the City of Cvfi.thin—
IiaMlitio,judgmrnn,rnn
. andu an
cxpcwnlch may in y way amine id City AIR HANDLING UNIT ITO 10,00()CFM)
in canryucyNC'of the gmnEngyf dkA 1.1. AIR HANDLING UNIT(OVFR 10,(00 CFM)
Sit#
same of/off A,�,,1o5 nt1 Cta��/_)� ate tYl' EXHAUSTHOOD(W/DUCT, PAID
IIAZARDOUSMATTAIALSDISCLOSURE NETTING UNIT(TO IW,O(Ml B'fl0 Date Recoil
Will the spplictsm m futon buik0ng occupam store ce hmldk hanedous msterlal
as defined by the Cupenisto Mumd,I Code,Chapter 9.12,turd tie llWN mrd Safety HKATNG UNIT(OVFR 10(J"BTL)) TA
Code.Scetl '1
2553$n)
0 Ye ❑No VFNIILATTON FAN(SINGLE RISID)
Will the aWlicantafuturthuildingacupnt uxequipmcm crdwlee which emit BOILER-COMP(3HP OR 10(i0lq BTU) ISSUANCE DATE
• luauibus tui'<ontnmiruna u dcfiid by the Bsy Aro Air tpully MER
anyoient BOIL -COMP(OVFR 1 W,000 BTU)
u
D icit
El Y- ❑No NEW RMIDFNTNL MECH. SQ.FT.
1 hese re]Ne lmz d s mate .h reyuirc—ot ural,,Chapter 6.95 of Ne A A '
Cnlirania Unlill R Safety Code,Seebs us 25305,23533 turd 25534. 1 utdetaund thio A
if the building doom.1y nave n taum,thet it is my mponuNllty to Mgiy Nc
acupam of tM:myuiremenn which must he mit prior to luunoee ora Ccnific.t,or Jtl p/ p �OC
rxo,N y. - /tt��l� O
twmasathon,edegw Date TOTAL ISSU pY'.
OFFICE---
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