27720iI
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO " ' '
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
.„S.In1a6 IL OPR er NI' C O -
PERMrrN°' O
BUILUINOADDRf:SS:
SANITARY N0.
APPI.ICA'I1ONSUBMII'1'ALDA'IE
i
OU UNIT# LOT
ERS NAME: PRONE:
QZZ
CONTRACTOR'SNAME: -gg y- LIC NO: iMfib
N/C
C(lN1ROLM
IITCI'/F GINRF,0.: LIC NO:
ADDRESS: a.e,Ca�'
❑
GNTAcr; Pnorve:
_
BUILDING PERMIT INFO'
NO ELECT PLUMB MG❑CII
PERMIT ISSUANCE
LZ 5)0
yo�.l(
LICENSED CONTRACTOR'S DECLARATION
I hereby aRrm that l em llcenred under prone,ions afCb pler9(commencingwbh
J Section9000)of Division3 of the Business and Professions Cade, and my license is in
full farce end arta �g
d Li<ev Class s [ic.N��g.9
Dem Comrecmr 6I ,.i}p}iLt7
ARCRITECIS DECLARATION
1 undenlend my plum shell he used m Public records.
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
s�••#�� 'C^_-
apT�.,(•t WA E
T
ea.4c4'A it l
PAWLS
UPT02MAMPS
201 - 10MAMPS
OVER I0I10AMI5
SQ. ff. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MISC.
OWNER -BUILDER DECLARATION
1 hereby affirm Lha, 1 ann exempt to. the Cmtnctor'e Llan, Law far the
TEMP. METER OR FOUR INST.
following...(Section 9031.5, Business ed Profession. Cade: Anydtymmmity
which rearp re,. permit to construct. eller, Improve, demal lsh, or repair Ary sweture
prior to Bsiemence. ehurequlres the eppllcanlfm emit Pennlua RI...iimedemmmenl
jNet he is licensed pumas to the provisions of the Conhectole License Law (Chepmr
d 9(commcming with Smdam 70007of Division 3 oft he Basin,. and Pmfmalom Cade)
p a that he it exempt therefrom and the basis for the Alleged esamptim. Any violation of
f Section 703 L5 by any applicant fm•pmmilmbjectr. the.,Iiuenl to a civil Penalty of
y ml marc tbun five
..ftha lropag,or mye 01.
❑ Lane wne.rindte.truclumhanthanndedoyeas r ohwed(ges mle(Sm.ale compnmtless
will dothework,andthemueunosretintendedLiamoa offeredfm ole (Sin.7M4,6.no
POWER DEVICES g,
R
SWIMMING POOL ELECTRIC
VALUATION
-
G'r
L
OUTLETS - SWITCHES -FIXTURES
NEWRESIDINTIALELECM _SQ. FT.
STORIES
TYPE C'ONS7R CIO
Cade: Contractor. law dna ret owner
IO an owner
Posend adywhPradfiwao build, ap ad who hiMlynnu is
own am wMsbuildsvi imPmvuthereon,andwandoessuchwoe hlmseHur Fm ,.hie
cmpluyun,pmviJad theuuch lmprovememaarenat lmmnJedoralfercd (oasis. If,
OCC .O O I'
R' I'IS
hnwevw, the building nr Impmvemmt is sold within one yam of romplellondhe owner
builder will Imve the buNen of Moving Thal he did M, build or Impove fm W rpnm of
TOTAL:
-1. .(' 1, r, la
QTlf si” 3a ;;PL•-UM13IN0 PERMIT .,"�''STl �F E':.
ole.).
❑ Lmowna nfthe pmPerty,em adudvelyconmActing wlN liconsed cmuec,nnm
lOOU Ls
AI'N
construct the Project 1Sce. )fled, Business and Rofersiotn Code:) The Contractor's
License Lew Amnnm applymon ownerofpmpmy whobuildsmlmpovu lhercon.end
PERMITISSUANCR
who cmtmclsforsuch projcebwith a cammlode)Ilcrosed Panum, tothe Contrmum'e
Licmss law.
ALTER Vi EA)
(
- - FEE SUMMARY
❑ 1 em elrempt under Su. , R @ P C fM this rteem
RACK FLOW PROTECT. DEVICE
..
SANITARY Y_N
RECF.IPfN
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
ckmI hereby affirm that l have a certificate ofemosem m elf-IM.Mare cenifirmenf
CmnPensa,ion hatmeae ore anifted cal thereaf(Sa. 3800, lab C.) which
SCHOOLTAX Y N
RECER,r#
FIXTURLS - PER TRAP
PARK FEE Y N
covenellem a'sgnal�Ihls�cgn l_
Polis M OWILOS 4a✓OI
Y
GAS - EA. SYSTEM -I INC.4 OUTLETS
RECEIPI'N
BUILDING DIVISION F7iES
Company 2.17
GAS- EA. SYSTEM OVER 4(EA)
PLANCIIPLK ME
❑ Cenificdcnpyishenhyfuraished.
❑ Certified copy is Blcd with the city inspection division.
GRP.ASPJINDUSTRI. WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM F.A. 20017.
ENERGY FEB
(Thin section treed no, be completed iflhe Permit is forma, hundred dnllun(SIM)
or las.)
WATER HEATER W/VENTHiLECTR
I certify the, in the pmormmu of Ne wart fm which this pemtit is Issued,I hall
ram emPloy any Peron In any manner an u 10 became subject ,o the Worker'
Campmnionlawenf Catifomis. Dee
Applicant
WATERSYSTEMIMEATING
PAID
❑ere ReoeiMN
NOTICE TO APPLICANT, If. she, making this Ccnificue of P.aremptlon, you should
become subjecfln the Worker'. Gmpnsation provision, of the Labor Cade, you muss
forthwtlh comply with Inch povi.tms or this Permit sbell he ddemed revoked,
NEW RPSI DEN TIAL PLMB. SQ. FT.
TOTAL:
BUILDING MR.
CONSTRUCTION LENDING AGENCY
SFIS M IC FEC.
L hereby affirm that there Is a construction lending agency for the perbanusim of
TOTAL:
ELECTRIC PER
the woe far which Ibis Penna is Issued (Sm 3097, Civ, C.)
Leaden', Name
Iandels
. ::i•;'- s ��1 .,.. ..
Q7'V. '•,11161,'HANIG�LlEeRUIT':'!.';+Ia�ERE .•
PLUMBING PER
1 congr a
amity the I have sed Ihis and sum that the shave iws mu„ am i.
PERMIT ISSUANCE.
MECRANICAL FEE
Int
emiatlai
bonding Iagrtemcmmply herebyuthrndcmmyad fiver ofend namlewer earn gm
city
buildingconstruction,mgend herebyrandanadraoses. 0vee of Ihie city tumor upon the
ebuv(We)-9. propartyfar ln
ALTER OR ADD TO MECII.
(CONSTRUCTIONTAX
and limpanan.
(We) egrte m cove. Indemnify std kap Irnnlese the City of CuPenim egetnn
IiaMlitiu I rnnend which may in any way accrue against ssiJ City
AIR IIANDLING UNIT TIO Im,,K111 CFM)
In COR M tit Ill.
AIR HANDI.I NO I INIT(OVER I(LOW CFM)
cn
��'
EXIIAUST IIOOD(W/DUCT)
PAID
/ /
3Ygnnue of ApPlic mmanmr Dem
HEATING UNIT (To 100,00(1 RTU1
Data Recalls #
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmudom mmeriel
n defined by the Carols Municipal Cale. Chaper 9.12, end the lfalth end Safely
'ICTAL
IIRA'1'INo IINI I'(OVER IIgs,1Np BI U)
CMA, Section 25532p1? 0 N /
❑ Yes n
VH.WFIIAI'ION PAN (SINGLE RESIDI
'
Will licammfutun auildin ossa amuse vi pment mdavy
pp g p
BOILER - C'OMF(JIIP OR 100,(Mp BTU)
ISSUANCE DATE
O dam air cmmeminann as defined by the Bey Aeee Air Quality Management
A Management
PFpct? ./
13['] Yee No
BOILER -COMI'(OVER IIgI,pp RTU)
NEW RESIDENTIAL. MECII. SQ, FT.
I have read the hmedms materiels rcqulamert, under Chapter 6.95 of the
Cdifmnie Ileallh At Safety Code, Section VU05, 2533) and 255M. I understand the,
if the building does not cutrenlly have • lens,, that It B my responsibility to nalify the
Clean of, ��ysdqut r n t rim lm nemeses of a Cmifiutr of
Occupmfy./
a
0 -is
,.rivner or Nominagan� Dine sm
ISSUED BY:
TOTAL:
OFFIUL