28146 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B II.HING-F.EC N AI. PERMIT NO, 28146
APPLICATION/PERMIT - PLUMBING-M IDENTIFICATION
ICAL
BUILDING DIVISION BUILDING PRUJKCT IIIF_\TFICATION
BUILDING ADDRESS SANITARY NO, APPLICATION SUBMITTAL DATE
�l1NR0 ` LOT if /
OWNERS F � I � R N � � NTRACfORS NAME LIC NO: N/C COMHOLM
ARCHI C/ENGINIBR: UC NO: ISS:
CONI CT: PHONE:
,` ( //Q� /y./�Q QTY. ELECI'RICPERMIT EEE BUILDING PER MIT INFO
IS /� /� / / I 0141
PERMIT ISSUANCE B TSI?
0-0
Jffiail ilio TRACI'Mvisi DECLARATION pl'PLIANCF'_S-RFSIDIls'TIAL •� I • " V
1st ltrcrthy aBirm NmlanlliCONTRACTOR S DECLARATer9(wmm�cleingwiN ����/II
{a O L Mice ard)e f Division 3 of the Btvirwvutandi fmiau Cade,mil my liecwe u in PpNE1S
QU� Lisrnx Clens .G� Lic.x��7�7 �� t/ UP T(I2W AMPS
W
riFs a DweCCTrSD 201-1000 AMPS
Fy pRCHfTECTS UECIARATIONSQ.FT.FLOOR AREA SbQ.FT.
z'34. I under..sn ."Imy planl he used is Public baI OVER IOW AMPS
q yy ; SIGNS EUiC RICAL
yK< licenvd Pmlcvimal OWNER-BUILDER DECLARATION SPECIALCIRCUTDMISC.
Mxa Oyu 1 hofirmss
cby. m ded 1 exempt ftan he Conaaow
.ctor's lice Laf«tine
4,ti r4n following reavm.(Seclim 70313,Busies end Professions Code:Any city m county TEMP.METER OR FOIE INSI'.
1" ".J which bNo es u Permit to eoawrucl,alter,impose,demolish,or rtpa'v any saueturt
W>7 prior mitsissunna,.Lso requ'ucs the applicerc far al Rmdt an revrv'ed suxrri POWER DEVICES
�
W<0 Not he is Beamed l.osuNl to the prsrviuons of line Cmtr i Lireme law(Clupla
Lp�(.o� 9(commcncing with Section 100BUDivision 3afbe Busires,and Professions Code) SWIMMING POOL ELT;CIRIC VALUATION
41�w
or that he is esanp meefirm imd the Nais for the alleged exemMion.Any antitumor
F G_Q Seve6au 7031.5 by.nY epplicvc fr. amitati Ileapplimm too civil pelnityof OUTLETS-SWITCHES-FIXTURES
Eta mute door rise hurdrtd dol Ws(s5dry.
��p�pm ❑ 1....er.fllle:m,eny,maryemployecswilh wettest a stheirwkcompereurron, NEW RFSIDFJJ'DAL EU:CIR —SQ.IT. STORIES TYPE; 1NSfRU ON
S� willda Oe wenn,and 0a:madam is not inmrvlednaRertd for sale(See.]OSA,Busitlen
and Pmfeskcu Cri The Contin uf.Liana law docs nal apply Ia.n owrcr of
PapeaYwho buildsm mptora Ileremt,mM wM1osYc.such wok hirmelfa Juwgh hi,
rownemplai prosided tM1elsucM1 ina"sement.me am mieaded oroffered fnr sale.If, C.GROUP RPS.UNITS
Noveser,lhC Mtllding or linpovcnent'u sold wildo—e yew at completion.me c iamr-
buil) will have the buNen ofpmving Row he did nal build m improve for Wmose of
acetal.
❑ I,ssowneroftheptopny,.mexclu.irelycmu.etingwilhlimn cmir mto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
xlsimel do,prnJmt(Sm.7W.Has—and Vndmsims Code)The Cnatrecmr'e
License Luwdoes not apply to improves thrrtm.utl PERMIT ISSUANCE 7
wrocenincr.lo-such prcjttls with.conlractof(s)Keened pinau.m to the,Cmtncash
Licrnx law. ALTER-DRAIN&VIM-WATER(EA) FEE SUMMARY
❑ tem Sec. ,B&PC far Ws moa O 1.
BACK FLOW PROTECT'.DEVICE SANITARY YN
w
RE.CEIPT♦
WORKMAN 'EbfSATFON DECLARATION DRAINS-FLOOR,ROOF,AREA,GOND. SCIIOOLTAX Y N
❑ Ihmcby affirm then l have a ccnifcale ofenn¢m tosefinsure,or a sendricete of FIXTURESPHR.I.RAP RL7cI3IFT#
WoI Cmar,meelim lmuronce or.certified copy mereof(Sec 380,Lab C.)which PARKFEE Y N
.vs I)i employee's uni this Permit. GAS-EA.SYSTEM-1 INC.O COMES RECEIPT#
Polley Y BUILDING DIVISION FEES
Campton, GAS-EA.SYSTEA1-0VIR4(EA
❑ Gnifxd ctTYuhcrthy(umishN. ) 1'LANCIIITKPFE
❑ CmifedcopyisfLWwiml eilyim dandirision, GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXP.MP1'ION MOM WORKERS' GRIT M!MAP SOIL)ITH
COMPENSATION INSURANCE
(Tldsxclisn needml 4mmpleteJ Hde psmitu(aorc hundmi dollen(SI W) SEWER-SANITARY-STORM EA.200F`L EJFRGYFEE
or leas)
I cerdyIf.,In the Ferfurmvrreofths work far which this permit is issued,I shell WATER HEATER WNI:N'f/FUiCI'R
nm employ any p—an Ia any ren as to berme sub cel to Rte Warta ' PAID
Z Campenwim LewsulCbifu Due so WATER SYSEMIGRFATING Due Reeeiptx
AFFlic.nl
OD NOTICE TO APPLICANT If.offer making this Cenlfiom of Exemption,you should NI?W RESIDENTIAL PLMB. SQ.PI'. TOTAL
F i,, beaomeaubjcct to the WMer's Campen.swi.pro,lslon,offe labor Cade,you must
faMwim comply with each Pmvivau or this emalt draft be destined revoked. BUILDING FEE
0. CONSTRUCTION LENDING AGENCY SEISMIC FEF.
Z Ih by affirm that teem is a conxtructim lading agarY fm the perfmlwnce of
V O me vvc liar which Oda permit u ismW(S .3091,Civ.C.) ELECTRIC FEEbi
1, [--o Ups
N. PLUMBING FEE
0 (, Lenal Address QTY. MECHANICAL PERMIT FEE
1 rn Iy that 1 have read mice appliamian and nate that be above in am.ii t.
roost.lays mcamply wim all city mad wmtysMiwlcv asld.ux Iowa rtlanag to \ PERMIT ISSUANCE MECHANICAL FEE
I^ buiWingmuvuctim,W hemby wlharize rtprt.rnlauvesof this city laemer street deCONSfRUC110N TAX
I..) Z ,hove llelIllWKd pmpeay for imtp
peedm puox.. , ALTER OR ADD TO MCCH.
(WO On c m.reva imkmnify sad 4eep Iwmtless me City of Cupcaim ey.ina
lubililies,' gmen.ms if and e.peme,which may in erywa ecc .gums 'd City AIR HANDLING UNIT(TO 1000(CFM)
me min aft . at
11 AIR HANDLING UNIT(OVER I0,(I(0 CF)v)
SignatureApplies ContracmrDill EXHAUST HOOD(WIDUCI)
PAID
HAZARDOUS nIALS DISCLOSURE HEATING UNIT M IW."BTU) Date R pN
Will the applicant or future buiklWg accnpwl Hare a handle heracous rial IIIA UNIT(OVER IW,O(1)BTU) TOTAL:
a.JcOrcd by me Cuprnim Mmicipal Code.Chapter 9.12,.rsd Ih[He.Jlh an efety
Code.Section 25532(.)? VFMIIATF PAN(SINGLE RFSID)
❑Ye ❑No
Will the nPriliettmt or Cars buddingtux HOI COMP . PORIO(idriN) ISSUANCE DATE
by the cymt Air adl which
hvmistO yr cmlemill.rw u dcBlui by Ile Bay Arrest Air ped' h BOI MP)OVER IM."BTU)
Disuicr?
❑Vo ❑No F )FW AL MECII. SQ.IT. pp
1 here read the hazeNws marerial.bard ertems r Clasper 6. o he P M I D
Cclifnmie Helm&Stately Code,Scaixn 25505.2533 235 I de. 2
if the M1uilJingmes not uvarndy have.lawt.IM1al it ism xptm. 'I I icily tinMUN
..Wl of dta rtyaire nems which roma he met Arita m i ideate
Muwy.
Owrcrm.utMnrN agent T ISSUED Hn
OF E