27423APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBIIILmNG-eLi'CTRIC
APPLICATION/PERMIT ItivaxlNc. MECHANICAL
BUILDING DIVISION BUILDING PRf IJKCT' IDEN I IFICATION
PIiRMIT No.
27423
BUIL INO ADDRF_SS: --
C J UNIT# — LOIN
SANITARY NO.
APPLICAGON SUBBsdn`I AL DATE
9's
OR'/AME: LI O: /
L
N�
❑
NTROL#`-/
ARCUUE.CT G.I:ER: WC
A S: /-
1.
/
CONTACT: PHONe
- S
Q.�, FI FL7RIC PERMIT FEE
QTY
BUILDING PERMIT INFO
BLDG ELECT M U MECU
PERIAN ISSUANCE
❑ ❑ ❑ .
LICENSED CONTRACTOR'S DECLARATION
I herebya arm, mint l sm llttmd under pmvieiouof(Chaper 9(cormoenan#villi
Semim7000) of 'vI J the Bwinme and f 'au ode, eM my lis. u u
full force and
//
APPLIANCES. RESIDENTIAL
PANELS
Llanx n N r
UP T03fIB AMPS
DDiCmTS
201 - 1000 AMPS
ARCHfTECTS I) U
I ordclsund my plaru shall be uxJ public
OVER IBOOAMPS
SQ. FT. FLOORAREA
E/SO. fT.
SIGNS ELECTRICAL
Licard PmfviorW
OWNER -BUILD ER DECLARATION
SPECIAL, CIRCUIT/MISC.
I Meby effmm Nat 131 uemg fmn the Cmbamar's Licaee to
TEMP. METER OR PORE BTST.
city mo
,hith tngrcuwn.enrilosoIrm21. Bmlrevm,..e. sand Code:MYc11Yucowry
doom
ehtt, improve, delmut t, fi munwe
myuirm a Penni, m cores
pror 1 he e ti n oars,ed
priohoiboxwood, Ith ,M1ovpiumormsuchpmldtto fik.
POWER DEVICES
'
humin
dw he it boxwood IruSeen. ,he) a Eb ma of of Co,"Iner'sUse
orsim. and Pre I�w (Clwpw
9( con he is NgwiNSmim ]said the Didsfor t MNe desioaaMRofcuiana Cob)
AnyvbWim of
or don heir 1.by iya,,lwn said the buUfm Neter de
Sation]011t
wunla,d eantfuepcmd, aubj¢ude epptiau bacivil pvmlryM
SWIMMMO POOL ELECTRIC
VALUATION
Gv
OUTLETS-SWITCHES-FIX'RIRES
Fee
mr mxe Nen five hwulmd dollars ($5 00).
❑ I,uwlwrofNcpmlarty.mmyemploymwiNwagcauNensokcar,pautim.
STORIES YMCONSTRUMION
NEW RESIDENTIALELECTR _SQ. FT.
will do EmceeduoRuedfmmlepply ]B14,Busioms
wok, ad Ncrs,
fe
end Profmsiau Calc: TTe Conuamm'a I.icrnx Isw does na epplY to an owry of
Coreis oo
pmpcny who builds minyaovcs thenan,eM whodomsuchwork hiw ifar Nrwgh hu
em
if.
lairuendcduoxcld fusvotea-
OCC. GROUP RFS. ITS
hebuddieiddNnlauchlmi,sold within
budder s,theset, to burimpmvememixion withina Yearofimpim,Neower-
builJer will Mve the bores of Imving,bat he did ux build m improve fur punpme of
TOTAL
QTY. PLUMBING PERMIT FEE
uk.).
❑ I.uowneraftle pvpeny, annea<lu+iwlycm,uaning wlNlicemd cmVKbAIo
FLOOD ZONE
APN
o ,.t the Folecl (Sec 44
]0, Business and Pran afeadCo4:) The Cmmassit a
license,awd nn,eplJy,ounowneroflxo whob "mimlmveN ,.d
PERMFT ISSUANCE
who cmme,M fawch Mm" with Ccomreeml(s) Ikemd foment to the Cormosemis
Us. Lew.
ALTER - DRAIN A VENT - WATER (EA)
FEE SUMMARY
❑ I em e.emp undm Sec. , R A P C for Nia renwt
BACK FLOW MOT ECT. DEVICE,
IU
SANITARY Y
Ow— Doc
DRAWS- FLOOR, ROOF, AREA, COND.
RECEIPTY
WORKMAN COMPENSATION DECIARATION
❑ Thereby affirm Ilio,loveattnifa,a nlrnnxnt,u xlf-imuw,aactttificve of
mvm .ell amPcnuu wld unaneem• mild copy thereof (Sa.3S00,�bC.)whieh
Ihlicy((/�
SCIIGOLTAX YN
RECEIPTN
RX URFS PPA TRAP
PARK TEE YN
RECEIPT 0
GAS - EA. SYSTEM -1 PVC.4 OUTLETS
BUILDING DIVISION FEES
CmmIwY
❑ Cmu t
OAS -EA. SYS]F.M-OVER4 (EA)
PLANCfECK HE
❑ Csnifd mPY is file hde city iluprcum diviaim.
GRFASFJINDUSTIU. WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OFETIMPIION FROM WORKERS
COMPINSATION INSURANCE
GREASE TRAP -
SOUS FEF.
SEW ER. SANITARY - STORM EA. 200FT.
ENERGY FEE
(This smiml need nut be Cmpild ifthe Panmil is faune bundeed dollan(S I00)
or Tru)
WATER UEAT W(VFJ/ CTR
Iccnify Nat in the pesfomunaofthe wat fur which Nia Penni, is issue, I atoll
w, mopley any pmon in any minder w M to become subject to dhe Wutm.'
Canpertmtian ,sus of Califomie. Dew
Applicant
WATER SYSfEM/IREATIl,G
PAID
Date Receipt#
NOTICE, IYI APPLICANT:If, net nuking this Cerifteate of Escmptime, you should
becosle subjm to,hc Whets Compunaum pnovi'donsof the Ludy Code, You mtw
NEW RESIDENOAL"B. SQ, ET.
TOTAL.
BUILDING FEE
finohwiN comply widt such pmvisimes or Nis permit neat be leenwd revotd.
CONSTRUCTION LENDING AGENCY
SEISMIC FIB
I herchy affirm Pot men, u a mnsmraim lending agency fm the pMumuee M
TOTAL:
_
E.I.ECTR IC FTE
Ne wort for which this pemd, is issued (See, 1 7, Civ. C.)
Lendcts Nese
I<fhr'a Addrev
QTY. MECFANICA RMIT FEE
PLUMBING FEE
I certify tot I have read this applimmut and awe IMI the above infarmetion is
PERMIT ISSUANCE
MSCI IANICAL FEE
area.Lague to mnply wlN all city ad camryadiwee and swelawsrcla,Teem
building eons,mnim, and Meby i m uriee refaeco adives of Jds clry meal upon the
shave-mdse
rnoned pro, fsr impeclion purfmxs.
ALTER OR ADD ECU.
CONSTRUCTIONTAX
(We) nose to uw, ind mnify end keep Mrmlea,he Cry of Cupenino against
liabiliucs.fud ;a,.0 ex ' anyway gamn.mt City
��o
AIRHANDLI UNIT(rOW, Axt 4/
me
a/�(/1/y��
AIX HA LINC UNIT (OVER 10 )
Si w,uwofA unVCm,mnu Dow
Sr HOOD /DU
PAID
UEA G=(TO 1, TU) its
De,e Rettig,N
BAZARDOIIS MATPAIAIS DISCLOSURE
Will Nc apptium or fmuw building occugn, nine or handle Mrardoue ma,viel
as defined by de Ce some Municipal Code, Chapter 9.12. and de HaIN and Salary
IIEATIN NIT(O ,00(1 BTU) is,
TOTAL:
'
Cade, Sx6ca 25512(s)T
VEA TILATI FAN (SING ' RISID)
❑ Yes ❑ Na
Will the npplicantafutuw oilJilp ucvpantuxryuipnen,udcimwhich ami,
hmdoui air coma nioenu u defuse by the Bay Ana An Quality Mamgcmcn,
Do Vlell
BOILER -COM HP O0. IIXI,IpO BLV)
ISSUANCE DATE
BOILER -COMP (0\-100,000 BTU)
❑ Yes ❑ No
/� C
V
NEW RESIDENTIAL 1, ISQ. FT.
1 Mve lead IM hassrdam m ncriala Mmikemau unto C x pmu 6,95 of Ne
Cdiromie I Ica1N & Safe,Y Cade, Secdam 23505, 233J1 and 25514. 1 mein ..n Na,
i f,he bedding doa not eunemly Mw. krem. Jw it is my leyumilnlilY to wlifY d¢
acupent of the Ic9uilenema which must theme: prim le isv .f. Ced ifica a of
Ixe„par,ey
Nf
CII L/r
`- s -I N NO
ISSUED
0,e er a aentionzd aka, Uwe
TOTAL:
OFFICE