26558 APPLICANT TO FILL IN INFORMATION-WITHIN-RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' J' A• PERMIT NO. /I•��a /}�(
uuD.urwG DIVISION APPLICATION/PERMIT PI•UMIf1NG-MECHANICAL 2 6 5 5 V
BUILDING PROJECT IUENTIFICATIONpy.JR,T-••p;;
BUILDING AIJDRfSS: n SANITARY NO. APPLICATIONSUBSIMALDATI
1A 1 C C R// UNIT LOT / QY
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: 7
Soo—,H C,RO SIO2'2711 Lfr/J T N Ur •W C 41 5 rvrc CONTROL is
•
ARCH)MCI ILNGINEER: IC NO: ADDRESS:
rgY6Y G04"I or+kS Vtlkl. SDr� ✓nu`
CONTACT: PHONE: .
QTY VNx4 r'K'a. ELECIRICPERM *t aXw ] k`IyFFEBR' ' : BUILDING PERMIT,INFO •'•r+'
�£'' BLDG ELECT PLUMB AfECIi'
PERMIT ISSUANCE SL-, ❑ jiq- ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ihereby affirm that l am [n
llcmd under provisions of chapter 9 mornmencing with
<gJ.p Seefail forceandrif Division3ofthc Nosiness and Pmfessiom Coek,and my license is in PANELS
UL) full force and effect. /L
<zuJ License loss Lim. 7 fID T02fp AMPS
�n=y Dat[ — — Continent /J!1 fn n£ OlL✓. 2UI.TIXp AMPS
��z ARCHITECTS DECLARATION OVER 10(10 AMPS SQ.Ff.FLOOR AREA S/SQ-FT.
z_ I understand my plans shall be,used as public records.
L-m SIGNS ELECTRICAL
so s_
Licensed Professional
,cw< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
?e, 1 hereby affirm that 1 am exempt from the Conuvaors License Law for the
0tn following mason.(Section 9031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
which minims a permit to construct,#her,improve,demolish,or raped,kay arrachum
};F Frio no its Issuance.also inquires the applicant forsuch perrduo file a signed sutement POWER DEVICES
YGO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
�oLL 9(commencing with Section of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
J_y or that he is exempt themfrvm and the basis for the alleged exemption.Any violation of OUTLETSSWITCHES-FVCLURE$
-zQ
Section 7031.5 by any applicant for st .it subjects the aua
pplicano civil Penalty of
YF� not nom than five hundred dollars S500).
❑ Luoxncrofthcpropny,ormyempl oeeswith wages ath<irsolecompemuon, NEW RESIDENTALELECfR _SQ.FT.
STORIES TYPECONSI'RUCTION
will do the.'ork.snd the structure is not intended oroffcred for sale(Sm.9050.Business
and Professions Code:The Contncmis License law does not apply to an owner of
pro;xroywhobuildsor improvestancon,and whodoes such work himselforthroughhia
own cmdiiYess,pfovidelthauuch impmvcmenummint intendedorofferedfmsale.l[ OCC.GROUP RES.UNITS
however.the buildingor improvement is sold within one yeitrofcompledon,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
Sal[J. �• •• r1(V5•-.•'r•yA.•Bila«•F F.CV nIiY
QTY. 4 PLUMBING PERMIT E' w't''ai!.+'FEE�'�n ttooD LONE APN
❑ has owner project
(Sm.70d,am cxduss and
ProfNng s with wnvactotors t s- a$.. _ n sy�sau••.,. 1Y•51. •.a
construct theenproject(Sm.]D14,Puniness and Professions Code:)The Contractors
Licensntawdaes such projects
ithacomacu rty whosedpumimproves thereon.and PERMRISSUANCE4Y
who contracts for such Projttts with econvacmr(s)licensed pursuanuothe Contractors
License Law. ALTER-DRAIN&VENT-WATER(G) ��;1-f17>';.r�Y'.�':{y�','X!_F_EE$UMMARY;:07 �SS�S'rvx�'T',.��';.
❑ I am exept u
mnder Ser ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE OUTSIDE FE
Owom Onto,
SANITARYY_N
DRAINS-FLOOR.ROOF.AREA.COND. RECEIPT N
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
3r' ❑ Thereby affimr that(haveacenificne of mnunno ulGinsuu.oramrufcau of FlXNRES-PER TRAP y RECEIPT#
J Workeri Compeyru�atiopnpldrtsJusvree oPI;kmn)arufied copy Nerrnf(Sm.J800,LabCJwhich t �Za PARK FEE YN
PolcyNl�pl nss2525 /Y GAS-EA.SYSTEM-II C.IOU EMS\,,.ot .e� DIVIRECESION
C��omPPJynty ', — BUILDING DIVISION FEES
Q`Cenificd copy is hereby famished. GAS .S SOyER O -\ t\ I PLANCHECK FEE
❑ Cenifiedmpy is fled with the city inspection division. DREAM WASTE IjJTE 'GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS P _ SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the .it is for one hundred dollars($100) SEWER-SAN' .200FT. ENERGY FEE
or less.)
IetiodYthatinthe perfomhincem'dowmk forwhich thispermitisismad,l shall WA'IIkRH -W/VENT/EL l
not employ any person in any manner so on to become subject to the Workers' AID
z Compensation Lawsof Calimario. Date WATER SYSTEM/LREATI Date Remain9
Applicant
0 NOTICE TO APPLICANT.If.alar making this Cadficam of Exemption,you should NEW RESIDENTIAL PI.N111. SQ.FT. TOTAL:
W) become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith romply with such provisions or this permit shall be deemed cooked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a construction lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Co.CJ TOTAL: ELECTRIC FEE
I<Mer's Name -'-t - 1"ns--J..r...at . -•':�...:
F Landers Address QTY. �1n MEC"NICAI:PERMIT .FEE#i' PLUMBING FEE
IJ 1 certify that I have read this application and shite that Ort above information is "u"a*"4•a"`e""' •'" `4" ~•ate r MECHANICAL FEE
cortmL I time rocamply withal(city andemol, finances andnat[Iowa refining 1. PERMITISSUANCE
building construction.and hereby authors=repmxmnives ofthis city toenterupen Ne
Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX S
(We)agree m save,indemnify and keep harmless the City of Cupciono against q
hid,ilitia,judgmenhi.costs and expanses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM) Y
in mmequeas of the granting of this permit gg
AIR HANDLING UNIT(OVER I U."CFM) i
Signewre of ApplicanUConvmor Date EXHAUST HOOD(W/DUCT) PAID
Dae Rttcipt N /,
HAZARDOUS MATERIALS
otson,DISCLOSURE HEATING UNIT(TO IOO.000BN)
Will the the Cuant or errin. ace hadmi lcomcupapter9.2,and the
huwdous,and Safety
HEATING UNIT(OVER 100,1100 BTU) TOTAL:IV
as defined io the 32(aTi nn Municipal Code,Chapter 9.13,and the Health and Safcry
Cade.Section
El yes (Ko VENTILATION FAN(SINGLE RE9ID)
Wi)ltbe applicnntorfmum building«cupantusecquipmenmrdeviins whichemit BOILERCOMP(3HP OR 100,000 BTU) ISSUANCE DA"
) i
rmdous tamantER
air commendations defined by the Bay Ana Air Quality Management
District^ BOIL -COMP(OVER 101"BN)
❑Yes 1K NEW RESIDENTIAL MECH.—SQ.FT.
I have tend the hamrdous materialsrequimments under Chapter 6.95 of the
Cilifomialicahh& 'Saml Cod,Sections_5505.25533 end 255NL L understand that
if the building done e n yhavea¢nwLthat it iz my responsibility to notify the
Ocupant of the hick m be mer prior m issuance of a Certificate of
mupao G-w-9y
Owner m aamnved agent Dam TOTAL: ISSUED i
OFFICE