26391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDILDING-RLRL"TRIGAT. PRRMI F NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
11UII,DIN(:DIVISION._...._........«,.�..._._....__........ IIUII,DINGPRDJIiMIDEN'1'IFICATION"7-"""" "
BUILDING ADDRESS: T SANITARY NO. APPLICATION SUBMITTAL DATE
U •_•.,...�.�.- UNI'fk. LOT# �
OW NPt NAME: XHDNE �Q
/vk '
'RACTO AM a LIC NII: 111
\.. ..S_L- Q• .•� ••_J_J' .�''')k� bunt 1 '1 N/C ^CJ/ONTROLp
��Cy�THIpATECI' iNGINEF:R: .__.-.. ._ A V L� 1
CO1/@ I,; rte^1(�1 \ pp�.38\qq.'` QTY. 45I/7 ELCC IC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE 'BLD CL PLUMB MIL'Ci
/• _ __Je
LICENSED CONTRACfOR'SDECIARA'fION APPLIANCES-RESIDENTIAL JOB DESCRIPTION , V
Ceti Ih70 a Division mus3,dDeB Business
and rofesion,Code;and
my]Joe.with
eq d 0[--� Section fall "ad of Division 3 of the pusineai and profession,Cade;AddL licenu is in PANELS
1Q„ZfsU1 License Cess C I o .l UP TO 200AMP5
m D. pate_S/ftp Cu nracmr I 201-IOW AMPS
'z ARCIIITE S DEC LARATION....._..._. OVER IOW AMPS SQ.FI'.FLOOR AREA S/SQ.Ef.
Zoos—
OZ-0 1understandmy plans shall bc,ased as public records.
Q"j,�w SIGNS ELECTRICAL
Licensed Pmleseiodal .... _.,_._�_......
CKKQ Or I ER ca"men in from
m the CoATION SPECIAL CIRCUIT/MISC.
p.�0.F hereby affirm that 1 um exempt from the Cnmrucmr'i License Law far the b L aQ/Q
nx)3 a to whichfollowing hers a audit in?031.6;t,dust,impar f de o li Codc:My cin Insecuritystructure TEMP.METER OR PoIE INST.
which requires a permit ro cnnawm,alter,improve,Demolish,or repair pay swcmrc
f WT2 prior m its issuance,also requires the applicant mrsaftlnnnit to File a signed statement
POWER DEVICES tel.
µ�j oar p that he is licensed moment to the provisions of the Comractols License Law(chapter \'
d o�' 9(commeacm,with Beer.700(d of Division 3Uf ME'BLgilfess and professions Code) SWIMMING POOL ELECTRIC VALUATION
Ma, nr that he is excmpuhercfromand the basis for thedl,cal dxctnpforu Any violation of „OIITLEfS SWITCHES�$ZQ Section 7031.5 by pay applicant foro'pemFi'fibi-mislfieepplic'anf ioocivil'penaliy of - - II
d not more than five hundred rich.iSSoi •'
❑ I,esnwnernftM1epropeny,ortsiyempliry esi'v"iih•woyesoatAei'rsalecompensution, NEW RESIDEMf1ALE1.ECfR _SQ.FT. Sl RIBS CONSTRUCTION
i3Lo will do the work,and Ne strunureis not imendeduroffed forsale(See;10,16.Emiratesodd 11 Rains Code:'flue Comtrvnors Llcenso how Aoe.not apply 0 an owner of
pmMsy who builds or improves thereon,and whip does yuch work himselfonluough his OCC.GROUP RFS.UNITS
own employees,provided that such improvements are cut,ntendcd.r offered for sale;If,
however,the building.,improvement i"91d wilhlnndeyeai,of completion, -
builderwillhavetheburdenofprovingthathedidnotbuildorimPrmefo a,not flir z4vo
sale.). . ._-_.-.« «-, - .. _
❑ has owner ofthe property,amexclusivelycmn tingwithlJcen. ccdtr_Oorsro QTY. PLUMPING PERMIT FEE f1.O0D ZONE APN
construct the project(Sec.]W4.Busiaer�aud.wefaruiorle-Gude <Contrxetor'a- -
LicenseLawdocsnotapplytornowncro(property who builds proresthereomend PERMIT ISSUANCE
whocomramsfor ouch pmjeas withamonrsectwfylieelwwi .uanuolhc Connectors' ALTER:DRAIN&VENT-WATER(FA) FCC SUMMARY
I License Law. I W y-•_- y -
❑ leacco rmander Sec. •-- •W&'P C fnethis xpsonOUTSIDEFF...
BACK PLOW PROTECT.DEVICE SANITARY Y N
Owner '_'UDM RECEIPT4
RAINS-FLOOR,ROOT,ARBA,COND.
/ W OMPF.NSA I- DECLARATION SCHOOL TAX Y N
1 Iherchy off mthat l lavcpcedifcm of'ciitis'¢nii _sal Gins certificate of RF.CEIPfp
XTGR S-PER TRAP
skcrs'Cnmpc cation lnsumnre ora certified cnp�th2 f( tl L CJ which PARK IIiE Y N
�rs sllemploes undenhis permit. G S-EA:SYSTEM-I INCA OUTLIiTS R X
Policy N BUILQWIG IS )N All
Company GA, -f:A.SYSTIiM-OVER4(fiA) PLANCHECK FEE
❑ Cmified ropyt cuby fu 3 S�
❑ Cmificd copy is dwi c Inspection division. GREA JINDUSTRL WASTE INTERCEPTOR GRADINGFEE OU
�. . G
CERTIFICA OFn FROM WO Eft ';•' FAS:TRAP SOILS FE 13G QD
CO PENSA I UR - •- - �w[`
or lc.¢nsu no.newnot be c pletedi forone dreddollan(5100). SEWER-SANITARY-STORM EA,2111 ENERGY FIE 9✓7 p0
SSSS... ....._.�,.... ..
v
I cenify that in the perf0tman o(Iha work or which this pbmsit is izsuec,leh WATER HEATER W/VINTIELECTR
1 not employ any person in any in net.4d an-to h4Rrt1['BObfv2rtb the Wn PAID
Compensation Laws of California. u, -+m` I WATER SYSTEVTREA'I ING )areReceipt Z,Z., +-I
Qz Applicant «.,.«, -.._SSSS
z -0 NOTICE TO APPLICANT:If,after on 'ngthiscerificmeof Ex em n,you should' NB WRE.SIDINTIALPLMB. SQ,lef. TOTAL: ],.,�•
[1) become subject m the Worker's Compers tion provisions ofEp 1 *r. one,you must
� > forthwith comply with such provisions or is pernit shall be'd__cd'revokW. BUILDING I'1'.E 3 00
0. Q CONSTRUCI'ION L DINGA CY .. .. SEISMIC FEE ... J •b
VZ 1herebyaffirmthinthemissennsdaaI abench agency for the performance of ; ELECTRIC THE
O Ihewankforwhichthis pemothisa, )............. .. 1.:
Lender's Natrle .., .,.. ...�. ....'. -.._. ti IF
O U Leasers Address Q'fY. -•sMFCHANICAL PERMIT FEE .PLUMBING FEE `
U I cenify Nat I have read this c,' Henion and state thin the abdve Infcarrod on is
Wcorrect.l agree to comply with dl city adJ'cI)EII[gtlMlrceneesvadErettl taws aiming to PERMIT ISSUANCE ...-MECHANICALFEF, `
.. building construction,add
C) herebyenho"ris y the
CONSTRUCTIONTAX for inspecan—r" »
pOx �. -ALTER ADD 10 MECH.
(We)
egagree to
save,indemnify,and Is harmless the Citi of Cupcni�;$shi t
liabilities,udgmen¢,co J petlsee whmrmpynanywny caQpTlIIlsaid C ly) 4, AIR HANDLING UNIT O 10,"CFMI •�
AIRHANDLING UNIT(OVER 10,(lfq CFM)
-
in can. � t t4F Pertrl5t �'1'
atusnafAl _...,. ._ �..._ _,,.._..-... __._
6^' PP tcant/Commnor�� ' j�<: EXHAUST HGDD(WNUCT) , r'.l
_ . lY PAID
IZLS DISCLbSOREn.�I..T`1/' x •"
eTj
HAZARDOUS MATER»- .��..«�.-___.._.__...» ..._..._. .. ._SSSS.-. .. .
HEATING UNIT(TO IW,O(111 RTU) � ��-�����- � �- Date
- »',. .a
Will the applicant nr fwurebailding rcwpaMWorsp hetMk lseeWnusmnumriaP -•-- - ------- - -
as defined by the Cupcnino Munietphl Code,Chapter 9.12,add the Health and Safety -HEATING IJNIT(OVER 1 W,IXH)B'I'U) Ol'AL:
Coda.Section 25532(y° .. SSSS "' _ ..,. _."..
❑Yes ❑No' U;��In. •„ VENTILATION PAN(SINGLE RESOLD. e .'%,:.?
ISSUANCE;DATE
Wilhhea lienor or[oMmbulNing oerfeemu nI' HQILBR,_COME ONE OR HH11100 BTU)
suNous air cord rear inpnts its(T 111ncd fiylFb'Fh'g'Xih9_AiI"QSlityIt agement
nrict? BOILER-COME(OVER 100,000 BTU
L � A�t f� 'I
❑Yes ❑No - NBW,RESIDE.NTIAL MHCH. SQ.FT. AUG J J.
I have read the haaardous material.requiremelns under Chapter 6.95 of the AIV1994
Calilirmin 11.111,&Safety Code,Sections 25505,25533 and 25534.1 understand Nal
if the building does ant currently have a tenant,that it is my responsibility to notify the C11_Y Ur
occupant of Ne requirement which must be met prior to issuance of a Certificate of
Occupancy.
Owner orpumoriredagent pate ISSUE)BY: