25266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OF CUPERTINO A.AL
CPERMIT NO. 25266
APPLICATION/PERMIT PLUMBBJG-MECHAN
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
tlUI1DING Al3UR13S: SANITARY NO. APILCA'IION SUBMITTAL DATE
UNI
SN ��p. y�}/Jp,N�/, CO iN R'SN E LOIN LIC NO: NIC CDN�� �
A/ ; 'IRD1.1'
•ARCHITIiCT IA
IJGINE : LIC NO: ADD �J ❑
a
ONT'ACT: PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PER.NIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDEJOTM, JOB DFSCRIPI'ION
n=z I hereby affirm chat l um licrnxd umIarprOvisiursof Cluper9(coemmmncing with
OO Sttfitm 0s)( f Division 3 of lh Basin—and Pmfemiau Cale,std my liters,ism PANELS �1 �r 4` I��
Y CEJ full froca mJ eRmc. -Jv' `y1
F<.,ZW License Class Up.N UPTO2 AMPS
v,<c- Dale Commmr 201-I(100AMPS 1sn
"LO,z ARCIJUT.CTS DECLARATION OVER 1000 AMPS Q.EJ.
OZ—� Iunderstoef my plat nhell be used m public mcpN 'v
< F Liccmai Pmfcasionsl SIGNS ELECTRICAL
ty
OWN IMBUILDER DECLARATION SPECIAL CIRCUTOMISC. Itli•/ 1wf
Od1-.. 1 hereby affirm Nal I sm exempt trorn,the Conmaccots License law for the // ��• •••
W3Wy¢ following sawn.ISe,mcci 7031 S,Business and Professions Code:Any city or roomy TEMP.METER OR POLE INST.
F a ON J which ceyuira•permit to cormrVr,ager,impose,dcmul W,mak any amua4mC
Ecar
N7 prim as its Issuance,Her,reyuirm fla,"licant for such pwmitm file a sipcN alamrlera POWER DEVICES
he Is
Transaction 1.he proow.
dhxo 9rnmmercicis with Sacmun7")oDivivm 3o Buaxa surd Prof..Coal SWIMMING POOL P FCIRIC VALUATIO
W � assist,
=rn atlelhucxecq dertfmmand lie bass fm the ukged<aeetpabn.AnY violation or 1
FZY Sec0on L031.5byanYafTlicemfwapemlitwbjecutheapplionitoocivilprn ryof S- ITCHES-FlXTlIRFS I �
—�
not marclhan ave huoGcd tlmlkrs(5300). NEW RESIDENTIAL FLECIR _SQ.FE l •�J/
ElI.mmwnerafthe pmpeny,ormyemployaswOhwagpmtlmirademmpermlian, RIES T)'PECOhISTRUCTION
y3— wILl Jothewak,sed theswmurt is msinceMNorofreeW faaak lStt.]Oa4,Huuws
seed Ptferriau Code:The Conuactr a Licete law dm not apply to an owner of
popeerywllolhotldsmrimPmves tbecece,and who does such work himnelfor through his ROl1P RIS.UNITS
nwomplo,ope,porsicaddialsorch improver mmeradinlcndcdaroffe lfmsua If,
bowcver,the haddingorimPcmrecem is sold within me,year of aenplcsion,the owner- TOTAL:
hu Older will have the boom Of pov'mg Ihet h,did not buiM Or impose for purpose of
c.).
❑ I,uowncrnDM1e pngcny,am escluuvely cunuening wise liansN nnlxemca QTY. PLUMBING PERMIT OLE FL(ROD'l,ON. AIN
omitet the Mtcct(See.7044,Bainas and Profasias Calc:)The Cpm owtor's PERMIT ISSUANCE
Titans,low dues nut apply to en nwncrof Propny wMhuilds a improves Ihrrmn,sed
who eom unix for such Projects with ncondomou(n)Ii,madl posuanl to the Compactor's
License low. ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
❑ 1 wn ea,mpt uMrr Sa. ,B&P C fm IM1is remoral
BACK FLOW PROTECT.DEVICE SANITARY YN
Owrcr Dale RECEIPT N
DRAINS-FLOOR ROOF,AREA,COND.
WORKMAN haven COMPENSATION DECLARATION SCfI00L TAX Y N
Cl l�bypos'Coaffrmchat.hive•asificuws]copy no self-icrme.err aa,C.)siech RENIPI'N
PI%TURES-PER TRAP
WOrkui Cornpemuimtlneumrcemaanificd copy therecf(Sce.Jg00.lab C.)whkh PARK FEE YN
covers all employee's undo this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT It
Polk,Y BUILDING DIVISION FEES
Cmn14nY S �T-y br GAS-EA SYSMNI, VER 4(EA) PIANCHECK FEE
'fief c,Y is hertby fumishcd�
f-FawiGef copy is fled with the city an'sopcor ei'most- GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GRE rSETRAP SONS FEE
COMPENSATION INSURANCE
(This section need not bc cmpletef ifthe permit is for on,hundref dollus(SI00) SEWER-SANITARY-STORM EA.2UIFT. ENERGY FEE
er Ica)
I ccrifylM;i o thelerfmmsncc of the work fm which this monit is issued,l shell WATER HEATER W/VENT/ELECFt
not cmlloy any person in my memner s,as to become subject to the Workers PAID
Caro"mimi'votof Culifmrnin. Due WATER SYSTGM/IREATING Due R,ceipM
APpbcom
OrO NOTICE TOAPPLICANT:If,aOer nuking this Ccrdfiaie of EscloPM1on,you should NEW RESIDENTIAL ELM . SQ,R. TOTAL:
t'w hartsuhjat or the Worker's Comp:nsaman povisi.of the labor Care,you mus Vi
forhsoth mmply with such posis'wmmthis{+ennit slWl be canned revoked. BUILDING FEE /a
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
UZ I hertM1y affirm thal chase is eaerbutimn mcling at for be,perfmrsmc of TOTAL; El FEE
O th wart,for which his l<.t is issued lSee 3faD,Civ.C.)
[.. LeNcls Name PLUMBING FEE
CJ 1e IeA�rtII OTY. MECHANICAL PERMIT FEE
I an,s tller I love roc Nu sty sung im and sue chs the above..tea man,u
carate. lags wcmnfgY with all city and asumY ardmmca ands.laws rtlatingb PERMIT ISSUANCE MECHANICAL FEE
F" , hisn"ycarmvnian.tied!thereby,wthmice rtpeesenwiwof thu mym enter upon the
U Z above entiaN Fopmy for impc:uura puryma ALTERORADDTOMECH. CONSTRUCf10N TAX
n
(We)agae to ave.Bderm fY std k hanntkm abbe N
City of Cupena.gait;
Iubmass.' e.core c" may u anems egaiw
y way ac, N
Cary AIR DANDLING UNIT CFO 10.0(0CFM)
gof t
- � - AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of APp21:1,
a P EXHAUSTHOOD(W/DUC)
PAID
DOUS MATERIALS DISCLOSURE HEATING UNIT CFO 100,000 BTU) Dam Rcaipt0
Will the algor Terme Itui di ng act,upru yore or roMle bmardeos mmcrialIIFATINGUNIT(OVER100,gqB'N)
ia�Municipal Cude,Crspu 9.12,sed the HedN and Safcvy
Gale,Smtl 215R(ep
El Ya ❑Nn
VENT VAIION PAN(SINGLE RESLD)
❑
Will tleepplicwt sur fuwrt buildingcrcupmc useequipvmnlordevMx.whi<hcmil
BOILER-COMP(3H]?OR 100,000 BTU) ISSUANCE DATE
elf cormrNtnu m eefred by the Bay Am An Qudity Mmugememt BOILER-COW(OVER 100,00)BTU) PAID Dimitri
❑Ya ❑No NEW RESIDENTIAL MECH. SQ,FT.
I have rad be hvardoua ra aiaB ryu'uvoenu under Chnper 6.95 of Lha JUN 28 R93
California 1"th&Wary Code.Sections 253(13.M533 and 23534. 1 ucdvstud had
it the buBding doe nm correctly have a accord,Ow It u my ccsporuibJity to ratify the
oaulwm of the rquirntecn which most be cast Man ssu
to ianerr ce a Cerifum of CII
T Ur VUUrrtn I Ilvl
arc
Cupay L_ Y -
OwnerorwlMrizN agecc Due
TOTAL ISSUED