27693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOO2bThfG-FLF�i - Ir:RMfr No.
APPLICATION/PERMIT PLUMB NG.MECHANICAL
27693
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPIJCATRJNSUBMrrI'ALDA3E
LOT l
W S NAME: I PIIONE: CO 'S NAME: A NO: NIC CONTROL M
ARCH CT GINEER: LIC NO'. A R 1- '`
CO cT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG F1.ECT PLUMB MECH
PFRMR ISSUANCE El � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLJANCES-RESLDENf1AL LOB DPSCRIPIION
,yZ I hcal+y affitm Net l can Bectu 1un,kr pmvuioreofChepler9(cmultencilg with
00 Secti—7")of Divi.ion S of the Business a Poofunm„Code.td no,licmc is in PANELS �\
yUF ts full foreMnx
c . '1
aF-..ZU' Liatuc Cl.—Lic.♦ UPTO2 AMPS
"o. Dara Gntr ' 201-BXD AJP
Z O'z ARCHITECTS DECLARATION Gig lg� pS SQ.FT.FLOOR AREA S/SQ,FT.
OZ—❑ 1,mdmamrtd my pla s 001 h,ucdm public tccnrd..
f-y w SIGNS EECTRICAL
Q Y Lianud P.pact mml
z� Q OWNER-BUILDER DE,CLARATLON SPECIAL CIRNIT/h1LSC.
XO a cUF. 1 hcaby tuff.Bout em ezemp4 form the Cmmnvr'. Tsw f
following reisoo.(Salim]0313.Beinee tum!Pofasiwu C Any city m count 'TEMP.METER OR POLE INST.
which«quim a permit to constox Htv,unptuve,devtN m fepair any
af priormim ivuwa,aka ttyulrt do
to
to Goch Uo Rkaaigred POWER DEVICES
'ad des leulicaud purvmnl Bo the lnovuims of deC Bur's �L-yy��a�lQYagcr SWIMMING POOL FJECIRIC
arm P.4 9(cmnmrncing wiN Sccdm]IXp)af Divisim Jof Busies. fe}i�tkC� VALUATION
ny mBhuheisexcmptlhuefarnntd Nab fo Any OUTLETS-SWITCUES-PXTURES
,Za Stttion 703 l.5 by enyappllcant fm'prrucB laudo C4 oa614p—
caSp
not mere IM1an five hmNrcd dolly.($500) RFSI AL EIECfR _SQ.FT.
CF ❑ 1.arowner MBhepmpmy.mmy vymwiN Neirw� RIES STRUCTION
W3 wit doth work,end lhc.vunua un nandedmoff uk(Sa.Ru4.B Rk
m.
nota Pofdims Code:The Cco t Y Licence la Y to N of
progeny who Wild'mirrtpvre ,utdwhu Har gh N.
«aployce..ptov;dddtu s,chi vrno offe.cd We U. OCC.GROUP RES.UNITS
however.the buildingmimpovcmmB .owe 11 0 1 ,tlteowncr-
WiklawiBlurethebm4nofpovin tlo Idarhnfuuv arpupmeof
We.).
❑ I,uowonoflM1c propcny.unuclu lycamvu 'withlcon..h. QTY' PLUMBING PERMIT FEE FLOUDZONE APN
mrutrutt Ibe projal(Soc.70 .Bum. Prof..C . TbCOMacta'. PFRMff ISSUANCE
li Lswdoesnotapplyuamox'nvof wltohnM' vesthoam,aq
wIbooao lsfosttchpmjauwiB ttacrow bcocooi I t ha C.'oca �.ITg-DRAIN&NGT-WATER(EA) FCESUMMARY
Borns Low.
❑ 1 w',,m under Sat ,B&P C for Nu roanOMIDE FEES
BACK PLOW PROTECT,DEVICE SANITARY T N
Owrtu Dau DRAINS-FLOOR,ROOF,AREA,NND. RF.CE
WORKMAN COMPFNSA]ION DECLARATION COT N
❑ IM1meby off dBulluve tcutifigee efamwN Bo alf-imme,mtavf aof PXTfIRES-PCR TRAP RECEIPfI
wotm•Conpawtion lmm'nce maeertirtd copy dtawr(Sec.Jg00.lsb CJ which PARK FEE Y -—N—
Puns M
Punsell anphay s utdcr this Amnia GAS-E.A.SYSIEM-IINCAOUTLETS RECEIIT♦
Policy It I BUILDING DI VISION FEFC
Company GAS-EA.SYSTEM-OVER 4(EA) PIANNECK FEE
❑ CeNBd copy u hacby(umalod.
❑ Ce.ufid mPY is ltd wilt da city imparim divieian ORPASFJINDUSTRL WASTE INTL'ItCE.PTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS ITP.
COMPENSATION INSURANCE
(flue veBknrtmd not ba cmtpleud ifthe pwmil it fm.htoo e[".Uilm) SEWER-SANITARY-STORM EA.200ET. ENERGY FEE
oc h,)
Icertify tbet in the perrmtnuce ofd,e wok fm whkb ads puna'it iarvd,I HWI WATER HEATER WNENT/FJ.ECIR
om anpbY any pea.on in any ntmnr.o u to hems.ubj c,to dtc Workmi PAID
Cono, uim Taw.of C'lifo.;- Due WATER SYSTEMORPSTING Dalt RecsiN
Q z Appl rn
zO NOTICE TO APPIJCANT:If,after noticing But CaBif u of aannp'im,you should NEW RESIDENTIAL PLMB. SQ.FT.
F ^ TOTAL:
ba anbkct 1.Ne Worker''Cmnpenntin ptovoimn of do I Code,you
� > fmdw,alt comply with s hpmonoomu m But Pcndt.hall to d avokd. BUILDING FEL
Com,• CONSTRUCTION LENDING AGENCY SEISMIC Fl
1 hereby allhm des B cit for de perfmnurce of
L) O dBe work for wh'nJt BLit pcmut i.itwd(Ser.3097,Ci,C.) TOTAL ELECTRIC FEE
I<r .Name
Lrndu'e Ad QTY. MECHANICAL PERMIT FEE PLUMBING FEE
O Uj I cenify dot I nava rod Ni'g Renn'iand.uta Boutthe.Love infmmadm i.
Gcmrst,lagactoro plywitM1 icity"cu ty7 inuuseed lawsmil ng Bo PERMIT ISSUANCE MECHANICALFEE
[-• (� building cx , im,tundh lytuhmias reprecnmuvo of Bhie city Bomar upon the
U z 'love-tornfiottd popery for itupcaion puryoses. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(Wc)agtcc In indcrrmify and kap hennka'Bhc City a Copmtino.poult
litbiliti ,judgmrnu,cmu ertlex whkt,may Many wayxrnxagtuinu City AIR HANDLING UNIT(TO hLoo0 CFM)
ingof Nie
AIR HANDLING UNIT(OVER 10,000 CFM)
t
S' tmtuaof Applcam/CmlmcBm De EXILAUSTHOOD(W/DUCTI PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,(Nlfl BTU) Due Rmcipl0
Wdl do applicant or future building occupant eBoa or baMle M1arerdoua mttuiel
m defind by tlo Cupmim Municiptul Cod,Chapter 9.12,end d,e Heath end Safety HEATING UNIT(OVER IW."BTU) L:
Cale.Section 25532(.)]
❑Y.n ❑No VENTILATION FAN ISINGLI?RESIT»
Will BM1eepplimnt orfatumbuildingasupant ore equipmentrrdevla.which nnil
BOILER-COMP(3)IT OR 00,000 BTU) ISSUANCE DATE -
�"ixo a air cmu biro n.m defined by Ib.Bay Ate.Air Quality Manogemen, BOILER-COMP(OVER 100.000 BTU) P A D
Dlnrin?
❑Yes ❑No NIiW RESIDENTIAL,MFOI. SQ.FT. /�
if J, 1 have Gad the he+enkeav mnmrinle o,cianscros.M Chagas 6.95 of the NOV (�'(]'}0���9�y1yYa�7�/
o lmie Hulth&Safely Cady.Sections 255U5,2553)and 255]4. 1 ualctxmM that J/"T
o,cu,ui of
ocr tux ctcntsw hch mt,t ,,noct Out it is my r tou,cc oily t ffiaay the //
Otto,t of the rcquirrnxnm which mml M mel prim to ivuerwe of n Crniheum of
aawnyy.
OwnernreuthnrizdogenB Dale TOTAL ISSUED BY:
OFFICE