26631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ", reAti VEHMONO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 6 3 1
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: p SANITARY NO. APPIJCATIOf4SUBMfITALDATE
ZI (/�^P- AN UNIT« LOT#
OwNlilyy��NAME.: n PFIONE COMRACI'OR'S N LIC NO: �VY�
KO R l F 253— /oo(, NC CONTROL#
• RCHI'lEC1'/INGINFR: LIC NO'. ADD S: ❑
CONTACT: PHONE'
' QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
PERMITISSUANCB Elf < El El
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENIAL I�
p z 7 I hereby affirm dud l un linnsm uMerpmvielavofCn.ptm9(camrcrcing wish - JOB DESCRIPTION
�U 0 Sndon7")o1 Division 3 ofihe B.and Pmfmsimu Code,erd on,licence is In PANELS �y � �
run rarce,m erre«. � 7 ��
<W Licmnc Clic. Lic« UP TE"S AhffS
a Deb Cmtnw+ MI-IOOOAMPS
F,zARCHITECT'S DECLARATION OVER IMAMPS
SQ,FT.FLOOR AREA $/SQ.FT.
OOOZ-p—❑ 1iiry ttvd mr plwsseen be c,m w public record..
h F j SIGNS ELECTRICAL
Qy�J LinnmProf¢.iovl
W y W G OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Jq(C)R Uu I hemby affirm that I em exempt fano tine Cmtri Uce Lsw fm the
ut3t+-y following revan.(Section]B31.5.Biuneu.nd PtofMimu Code:MY city a ceunry TEMP.f.¢TFR OR POLE P'SI'.
C m0
which rtyuim.pemdt to ronwun,Jmr,improve,demoliN,a rquitu any wucmm
KMQ7 print In its ioamocc,elm)rtyuiru 0e a hoist fu etch prrmit bflc.ripml.taWnma POWER DEVIL
K 00 Wl he is li¢n.ed qusuw to the pmvluan or the Cow.cbls Lice.ue Vw(Clugm
�— � 9 conurcncin
SWIMMING POOL FJECIRIC
qX ( gwith Sttdm]OOOIbc Db.ieian dofthe,m ud Pr Anyviaru Code) VALUATION
W H athat heir exempt thertfrtmnt fw a ba.Hfntbedlegmeumurn w Aivilpauan of OUTIE TS-SWITCHES-Fl
�7YQ Sec tion]OJISby any cinmi ntra.pmnit subjects the epplicentwecivil pmahy of
not Im
0 momom rofbondrm y,w
o�efo ❑ I.e.owrcrnfhhc prap:rty,amrmMlaymswith wegnutletrwlecompem.tion. NEW RFSlDl1.'f1AL ELF• rs TYPE CONSTRUCTION
aim will do the wwk,urd the svlcote is hot inteMMncoffcom fasek(See.]014,Btvims
end Pfof.Code:The Cnntri Li.Law dace not apply to an owns of
propeny who M1uildraimpnwes thereon,and who dtxs such work biro ffw through his
cwncmpbYcn.govidmthelwcb tm soldrnumcaot inw.f.afrerW fars.k.If.
C GROUP RFS.UNITS
buil,kr ,tinebuildingorimpo ow on Iwldwithinane ildofmmpleuon,theowncr-
builJer will M1nve the buNm of proving that M1e did riot Wild m improve fm ptryme of
k.).
❑ I,mawecr Mdhc ptnpmy,em exclusively nnrraning wiW licm.m mnOwTmm Q1 Y. PLUMBING PERMIT FEE FLOODZONE APN
.tocc,the Project(.S¢.70W,Esher end Rofenionn Code)The Cmve.',
ficrn Uwdoo txplytoanowncrofpropenrwlro iW.a'ungoved ,and! PERMIT ISSUANCE
who conventf,such qajects wiNemnt.oci')liccrum ryuwenttottte Ccoi a a'a
Licence Lew. GALTER-DRAIN&VENT-WATER( ) FEE SUMMARY
❑ Ism earnpl rvtder Sec. .B h P C fa dhu tu.m BACK FLOW PROTECT. OUTMDE ES
SANITARY Y N
Ovecr Dau DRAINS-FLUOR.ROOF.AREA,COND. RECEIPT«
M
WORKANCOMITISATIONDECLARATION SCHOOITAX Y N
❑ IM1ermy effirtn th.tlM1nv<ecmthcele o(cunrmlto ulfinsu.e,macunfcve of REC ]"#
Wntkmi Compenw:n lmurarceaemtifimmpy Ocreaf(Sec.JS00,lib C.)which FIXTURES-PER TRAP PARK FEE Y N
Polity ltlUILDING
1einploy�fOA this permD
it. GAS-EA.SYSIFJ.1-I INC.40VETS ECEPT#ION FPS
Company GAS-EJ SYSTEM-OVER 4(EA) PLANCHF.CK I•FE
❑ Crniflm copy is hmehY fumi.M1ed
❑ Cmifim copy is film with the my inspection diviximi. GREASEANDUSTRL WASTE INTERCEPTOR GRADING TAPE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEF
COMPENSATION INSURANCE
Mi.emlim nem rot be completed ifthe permit is fists,hurvchm&11.(SIMP SEWER-SANITARY-STORM EA.30017, ENERGY IJ
I wufy thn in du Pefform.r eof the work farwhich thi.pmnilu ivum,Islull WATER HEATER WNENT/ELECHt
no,employ any Pcinon in.ny wwnrc ar to become wbject to the Warkcn' PAID
Comprrtvtion lava o(C.B(mni•. Due w WATER SYSTEM/IREATWG
o Z Alylicmt Dore RacigN
Z 0 NOTICE TO APPLICANT:If,a/lm making Ws Ceftlficate of E.emption,yw should NEW RESIDII.TV.L PLMB, SQ.FT.
TOTAL
y becmtc wbjirvto the Wmkrla Contprnvdvh povuiuuaf theMbarivnkmiou m,,..
a > (mhwith canply with such pwvi.iommdhi.pundl.M1rimokm
l be seemed . BUILDING FF.F.
C.
CONSTRUCTION LENDING AGENCY SEISMIC FIE
1 hecbr affirm that there n a cvnsvumi.Imding ageocy for the Pvfnnurce of
U O Ili work far which this pend,1.iwtm(,Sec.3097,Civ.C.) TOTAL: 1LE,7TR1C FEE
L<Ncr'.Name PLUMBING EEE F Lmdor'.Aden.. QTY. MECHANICAL PERMIT FEE
U 1 nrit y thtl L neve teed this'Pliralimh avid ewe thm du.bort iofam.q.Is
mrrcct.lalpabcanply with til ciry.rd mwry mdinnm W.urc laws rtlaotlgb PERMIT ISSUANCE MECHANICAL FTE
I^' buJdingcoruVuction,acd M1ereby.il ,cert schcsuva cf W,city brnter upon the CONSfRUCI'IONTAX
U Z nM1uvc mmlinnm pmpcay fa inspa'uonputpo.c.. AL'IIRORADDTOMECIL
-- (We).greeo.- iaaminiry"kxPr.nnlus lb:City of Ctipctnmegutw
liebilitiu,judgmrnu,c .Mexlctueewhic m.yinanyway veva eituh uid Cl AIR HANDLING IINIT(N 10.(pO CFM)
in urncc of .mung of thispmni _ I I,
/v[ifl AIR HANDLING UNIT(OVER IO)W CFM)
S nhurto )dkan anlR[l D.l< EXHAUSTIIOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO 100,00(1 BTU) Detc Receipt
Will the it,,F ed ow future Wilding mc,cW1 shote a herdle liv ioo,nlelenal
as dcftcd by the CupenimMwici*Cade,CTeptcr 9.12,ertd the llolW.rd Sefery HEATING UNIT(OVER[W,M BTU) TOTAL:
Cade.Semi 25532(.)1
11VEATION PAN(SINGLE RPSID)
❑155 11 No NITL
BORER-COMP(311POR 100,000 BT11) ISSUANCE DA
Will thcaMlicentarfutum buildingcccupent u.ecyuipnenl mdevianwhIch emit }rs
hemNom air cnnuminonhe ns cicftuN by 0m Buy Arm Au Quality Mmagctrcnt
IXacd1
S BOILER-COMP(OVER 100,000 BTU) P�
❑Ye ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 te
��� �� ����
hart ns disc hez .,m.t'hists mgtire.rcnu under Chegcr 6M of the
if 0,I nie Health c Safety Cmc,Sectiwu 25505,25533 and 25534. 1 um.notir,Out
if 0, ofibcocemuctvendyich a lbw nnWaismy m.ponsibfl. mini irr the CIIT Ur WrenIIIV
O,cu,nl ar 11K RxNIrCTCaI.wnCfl ma.l R`mel FlV b i.ftLbe ars cNirplC of U
Occupancy. PV
' Ownm awdcnud sgcnt D. TOTAL ISSUED BY:
I