26155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' '- ' wHLMrr N°.
APPLICATION/PERMIT PLUMBING
wPN-MECIIANICAL 26155
BUILDING DIVISION xbUING PROJECT IDTIFTCATIOV
BUILDING ADDRESS:
t^ pia /) /�� n SANITARY NO. APRIGTIfgSUBMIPI'ALDATE
./'O bU J ` ��-Gh 1 e-1.� '✓ UNIT♦ LOT "/
OWNERS NAME PHONE_ COM'Rt TOR'$NAME LIC NO: [�J
�- n>7 J e-S rn $mf a.53 -33 i.'L `oc(I– r(_ 0006Y LS N/C oNTRt L
ARCII :CI'/FNGINEPB: WC NO:
�Gl Av-r6-cl;4LIV Si g5/3u
CONTACT': PHONT4
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
B❑ ELECT❑ ❑
PL g MH
PERMIT ISSUANCEEl U{
LICENSED CONTRACTOR'S DECIARATION pPPWANCES-RESIDENUAL
n y�L I hereby effnmthat l wn licensed underpmvieionrof Chega9(commencing with C�aH{ JOB DESCRIPTION
00 Sectim'IIX)0)of Dlyulnn3oftheB 'Deis end l4ofeubre Code end my lieave i.in PANELS
fnufnreeweffcL f� EC-1AP (poo 5-q 5 / J
aztu Lice.Clan Ii It tm To zoo AKJrs 1945 �INY6 f2r Ne¢7v{
oo a v the snom n_ (�cmtr.ct LII-1000 AMPS
zclnaE ARCIIM SDECLARATION OVER 11100 AMPS SQ.FT.FLOOR AREA d/sQ.FT.
0'z�❑ 1 nJeot cid my phare dull be uxW u public ravdv
_ w SIGNS ELECIRICV.
Lremad Profex.mad
OWNER-BUILDER DECLARATION SPEclAt.mcua/MISC.
qX O W, I hereby elTmm that 1 tum exempt fen be Comnaor'e Limnve law for the
t+J 3 u.,Fit following ancon.(Sec'tim]031 S,Boxmesia erd Pmfeai«u Cde:Any city ce county TEMP.METER OR POLE INST.
which rtyuirntiretool,mc«ebucdaIter,impove,lemdith.«repautiny
mtctum
fC�Q$ miof to its lessunce,s1ho re9n lim
wtIle f«such Pmwt to Ok a signed euER teminil POWDEVICES
W� C that he ie licrnxd waNp
putm to e ovisimu a the Coninnor. «toe'.Ti Low(Cupa❑P' 9(canmcming whh Sccsleo 9000)),,(DiAzimm Sof the Busing amd Ptofcssions CodSWIMMEJG POOL ELECTRIC e) VALUATION
151 or dist he is exempt Ncrefmm and the bocsfor the alleged exemption.Any violation of �r],D
FLN Section]0313b anYaplintfarapamituNjthe epplionCoticivil pet of OUTLETS-SWITCEES-Fl%TURFS
a %%LL
5 ❑ to more the five hmaahN dol Win(5300). NEW RFSmFNM1 FlECllt _SQ.PT.
❑ .,lbc m ,and,the p. I,.., loyen WNwgnv e(Sele competwdan, STORIESTYPECONSTRUCTION
will dotooconte,endo: he Coeinmintendedma.st sco f«ot LFlc.to Bwirm of
erd Pntreisian.Code:The CmCnnnr'n Lieenx I�w docs not tippy to N vwrcr mi
on cnywhab,J vi impoveeJ ime vW humor ti w«t himself«throughhl. p /� p _
sun cmployea,pmvidcd thte Jlimpovcmcnu uc wtintvl0ni«offvM f«vlc x, H H�1 � C. RO RFS.UNrtS
howccrwill ye, ingnimpovrntrnti.soldwithinorcycvofcmnpkdoo,,he owr of _
huiklcr will hevc the huNcn of proving Nnt he did rot build«improve f«pwpo.e of TO /
p)Lnownaofthe papet,Y.unealasiydywnmedtrywithliccmN cmuticwnw QTY. PLUMBING PERMIT 1 D APN
.1 the Pxi(Sec.]Oed,Ranitcu arm Ptafeui.Code:)The Conurtaa
Licenscl wdmrwt.pplytomowturofptcpertywho Wild.«impovn�,m PERWT ISSUANCE' ATE
whu,ont.f«such projecu withecontr mr(s)licensed pursuantto the Convector'.
U.law. ALTER-DRAIN&VENT-WATER(I -- FEE SUMMARY
❑ 1 em exempt udder Sec. ,B d P C fm Nu rnwc BACK FLOW PROTECT.DEVICE SANITARY Y DCN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT♦
® '$/I hmebydfmOAe Ib ye B c niiAN Fcve acmoem NISATION o:1(--TIONhone,m .emifttte of SCHOOL TAX RE-chl It N
FIXTURES-PFR TRAP
coy al CanWmsesun Bxthis mecvdDW copy thercvf(Sec.Jg00.lab C.)which PARK FE2 Y N
coy—allemployees mesio this pmniL P�a4813Z GAS-FA.SYSIFM-I INCA OUTLETS RECETPTN
Polley N .p- BUILDING DIVISION P[FS
ElCComirnifcd wry is hereby fumisn d! `� 4 O"'N�'{�y GAS PLANC IECK FEE
ja;�xitiDcd copy I.nkd with the city mru oo byivam. GREASE/INDUSTRL WASTE TNIERCEPI'OR GRADING FEE
CERTIFICATE OF EXEWTTON FROM WORKERS GREASETRAP SOILS FITI
COMPENSATION INSURANCE
Ohi,,ec,ion need twtbe completed lftM Penni,ie for one hundrei loll.n(SIW) SEWER-SANITARY-STORM EA.30017. ENERGY HE
or I..)
ImdfY that in the pafammmee MRe wart f«whkb thiapetmitu u.uN.Ithittl WATER IIEATFR W/VIM/ELECfR
net r,4,any penton N tiny mama so u b become,subject In the Wodoer PAID
CmmpcnsationlawsMCalifymm Due WATER SYSTEMTREATING Date Reecno0
0 z Awhinin, -
z O NOTICE TO APPLICMM:If.after mtiting NU Cmlflcaceof Exempdm,you should NEW RESTDEMIAL PLMB. SQ,FT. TOTAL
ti hexose,subjen to the Wmkds Compemtidm pmvitii«u of Ne Mbar Cade,you mut
f«Ihwith coomply with tiuch piwith.or tbu pmtdt.x-c be leemM revoked. BUILDING ME:
W [] CONSTRUCTION LENDING AGENCY SEISMIC ME
5 1 hertby.Hirm dW there uit mnmugion kMine agency f«dr Pef.of
U O the wart!«which this Peed is i—exi(See.J097,Civ.C) TOTAL: ELECTRIC FEE
O
LNmtc
'.N
I<d .AmWxss QT"Y. MECHANICAL PERMIT FEE FLOWING FEE
I cenify That I have read this olpliutim eml nee dist he shove I f.6on ie
�" Lia cmmr. l agree to comply with till city and county md'wnm and.,e.uwv elating to PERMIT ISSUANCE MECIIANTCALME
F-' buil,ingc«uuuction,tied hereby anbadse mepnxnudvn of Nie city saner upon the CONSIRUCTIONTAX
U z abm'e-snerwarlea popery for iteration ps Tsi ALTER OR ADD TO MEC)).
(We,)agme to nye,mcien nify mmd keep hennlne Ne City of CLpcnim egwtut
liabilwcn,judgntenx,ussuand expense whmch may I.any way eccrveagwnFl said Cay ATR HANDLING UNTI'(TO 10,000 CIM)
m nrnxe,tenee of the gmNing or Nl\penmt.
AIR HANDLING UNIT(OVER 10,1X10 CFM)
Siywlmeof Applieanl/Cmtnnm Ilse EXHAUST HOOD(W/DUCfj
PAID
IWARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTI() Due Rezt,hA0
Will the applu'mu«fugue hllding«TuPam Moo,in buWle htisudout,nwenal
u def nect by the Curcrdno Code,Chapin 9.13,and the HeaBh and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Code.Satin Z5532(a)1
El Yu VENI'IGTION PAN(SINGLE RESLD)
ISSUANCE DATE
W llde epplicent«futmcbuildingaxuTmm ux sgwpmnt«dcvi¢.whichawt BOILER-COMP(JIIP OR 100,000 BTU)
hvnmLw�ur cnnranun.ms n hrjgd by the Bay Am Air Quality Muugment BOILER-COW(OVFR 100.000 BTU)
DlsWni �Wm/ PAI D
❑Ya NEW RFSIDLITI'UL MSCI. SQ.FT.
I Ieve end the huv meunith,nequucmenu uedcr Chepn 6.95 of the MAY 2 5 1994
Cdifmda Heshh&Sefety Code,Sections 35X15,V533 W 25530. 1 mde tuod this
if the Wilding doe mu cmrm0y have alenam,mhst it is my responsibility to notify the
f GU
Chi OF PEHIINO
xcua�CpC�pn�t,o�f t��he/m��yuircmenu whicM1 toter be crest prior to muu.rcce of a CrniB me
s 0/VEL m N.ITO TOTAL ISSUED BY: ti
OFFICE