27730APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUMMING I,.LkU pRICAL
"'UMBING MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT r� BUILDINGPIROJECI IDkN I [FICA LION
PFRMITNO.
27730
BUILDINGADDtSS.
(!!!:0P__1EF LOT#
SAN] IARY NO,
APPLICA I EON SUBMIT] AL DA pE
OW . AMF
mv � � f "25
HONER
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CONTRACTOR'S NAME: IC
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NIC
CONTROL #
RCHITI]CL/filsGINEER: LTC NO:
�,DDRJFSS
-'7 A
CONTACT: PHONE:
r
Urry ELECTRIC PERMIT 17EE
BLDG ELUCT PLUMB MHCH
El ED 13
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARA I ION
I hemby affirm that I am licensed underprovisionsorchapperg (commencing with
APPLIANCHS - RIESIDIENTIAL
JOB DBSCRIPTION
Ono
Section 7000) (if Division 3 of the Business and Professions Code, and my license is in
but I force and affical.
PANELS
noo
z 8 -�?4
OZ—Q
Li .... rcl.,,Oln _Lx.#_
Date C4 60211) Connote
'M,ARATION
UPT02WAMPS
201 - IGRAMPS
, — ARCHHTC7S
I understand my plina.h.11 1w used as,mAic records.
wsss�
OVER TOM AMPS
S(dFjpFLOORARBA
$)SQ. FL
SIGNS F.LbCTRICA/
Licensed Professional
gg�<
X�:�
0"
OWNER-BUILDpR DECLARATION
I hereby affirm that I arm exempt from the Commences License L. far the
follmainEinecoo. p3mlio. 7031.5, Business and Professions Code: Any city�, ecanny
SPbCIAL ClRgtf/M],SC.
I I1.MF,;vWfER.0R
which actimms a permit to continuum, alter, impmve, demolish, or repair any stricture
Inior 1. it, issuance, ad ....... loss the applicant for Such permit to file a signed statement
1� R DEVIC
WHO
le. E
in., he is licensed palmoren to the prooliallax of the Cinatonalm', Lirprose Lrow (Claitam
9 hournmearin with section 7000) of Division 3 of the Busines, and Proficanio, Core)
VALUATION
�0111
��:Lo
or than In, 1, c.capt thenloon and the basis for the iffle,rdi,.ampt ... r. A., smmitam 'if
Smile. 703 1 �5 by any for a peard, subjects the ,,carm to. civil Penalty of
ma me than five handled d.1 mrs (S500).
C3
will do the work,andthe structure is not interadesdorofficamil ficarrale (Sm. 7T,Eu, .1ne,
sGUTLf 9- TCHF F1 ES
IDENII I, , !CTR 10 SQ,pp.
STOKIES
WPECONSIRUMION
.,,it Prufcoilam, Cade: Thc Conararna'a Liecuo, Law does a., Epply to - --act o
,roperry wimbuild,minapreves themor.and ishcohne, such work himself., 'hoinighthis
own employees, provided that such improveracaus, ancommoodedorofficial forsall. If,
OCC. GROUT'
BUS. UNITS
TOTAL:
however. the building or improvement is sold withinum, yearnfrompiciam, illeouvoic,
builder will have the broten ofpmving thin he did not build or improve for Purpose of
QI N11—AMBING PHERMIT 17EE
Y'
"Ic.).
0 1. loowi ofthe mEaAy, am exclusively contracting withfictioned conammors to
FLOODZONIz
APN
minimum he prople, (Sm. 7(MU. Business it Prod.sairmis C se., , - a..
Limpse Law does not apply loan owincrof,imparty who builds o� imprmo,�, th,Zon,'aral
PFMMITISSUANCE�
who contracts for such prijects with arpouramons) licensed pursonat to thi, Contractor's
Lican'o [.a,.
ALTFR - DR,MN & VIThIT - WATER (FiG
FEE SUMMARY
0 1 am exempt under Sm. _. 13 & 1) C for this reason
BACK FLOW PROTECT. DHVICE
0 U 171 51—Mf �S
SANITARY Y —N_
0." Date
DRAINS � FLOOR. ROOF. ARHA, COND.
RECERF#
WORKMAN COMPENSATION D17CLARATION
SCHOOLTAX Y _N
1 hereby offirrin that I have a cianifirme afrournscat to self-insum, or a certificate of
�Wmlkamx Compensation hisminammin. monfled copy th .... f(Sm. 3800, Lab C.) which
RBCEIFp#_
FIXTpURBS - PFR TRAP
7ARK VPB Y _N
enriployce's under this peraiii.
Policy # t
GAS-VA.SYSTFM-I INCAOUTIAI`pS
RI:CEIIrl'#—
BUILDING DIVISION FEES
Company
GAS - EIA. SYS IEM OVER 4 1
PLANCHECK FEE
vi,
0 Crimped c., is hereby famished.
[I Carfifird copy is Tied with be city inspechim division
GRBASIVINDUSTRI, WASTE! INTUMCEPTOR
GRJ,DING FLF
CIzRTIFICAI H OF CXFMPTION FROM WORKFRS'.
GREASE7 TRAP
SOILS FEE
COMPINSATION INSURANCE.
SHWISR - SANITARY - SI ORM b. 200FT.
17NERGY EER;
(This section need not be completed ifthe pramit is fortune hundred dollars ($100)
Fees.)
1A,1, 'A WIVEIST711LECIR
I recrify that I. he palficarmaree flix, walk bar which his peopit is issued, ].hill]
it... cruIP4,, in, .. in any amons, in, as to Invariant, subject or the Workers
PAID
z
Cmp,mxmi.nI..sofCa1if..i.. Dan—
Applicant
&T S>1TC.WRBATING
Date Receipt #
C)
z
NOTTC12 TO APPLICAN r: If, after making Ellis Certificate (if Exemption. you should
NBW RESTDFNTIAL PLMIL —SQ. Frp.
I EITA L::
>
become subject to the Workees Compensation Provisions of the Labor Code, you must
f this di emptily with urh provisions .,,his accord, shall he emitted ... ked.
BUILDING ITS
SEISMIC FIFIR
U o
1, 5
0
CONSTRUCTEON LCISDING AGISNCY
1 hereby affirin flumilhere is a construction lending binary for the Performance of
he work for whirdflai, Exermi, is issued (See 301U. Car. C.)
Leadar', Name
Leadve, Address
ULECI RIC FIB7
Q'I'Y. MECHANICAL PERM IT FFF
PLUMBING FEE
W
gL
I reatit, Ill., I have lead this application it state he, he rdsove information is
carrom. I agoo, to comply with all city and county ordinances and stale laws mining in
PflRM1TTSSUANCR
MECHANICAL FIER
is mk
E,O
U �;
building consummion, and hereby radiance repmsentativesc,fthis city to enter upon the
iduave-onatimical Ennitre", for inspection purposes.
I
CONSTRUCT
.1 10�1'A
—
ALTISR OR ADD TO MECH.
lWe) agree, to save, indemnify and keep warromess The City of Cuparlan against
—
liabilitice,judgments, costs andiapences which may inanyway seeme against Wd City
AIR HANDLING UNIT (TO 10,00th CF?vH
line Cr ()I flot granting of this Permit.
AIR HANDLING ON] I FOVpR I Bodo CIM)
PAID
S z 'ore U ATEII
71IAZ'AlRD'vmJ,S
BXHAUST HOOD (W/DUCI)
HBATING UNIT (TO Ipsy" BTU)
MATERIALS DISCLOSURE
1)
Wiliffir.pIplimen or firm. laildingum.part,tine or handle bacanka, material
as defined by the Culucifirm Municipal Code. Chapter 9,12, and the Health and Safety
HKAsTINO UNIT(OVER 100.000 BTU)
rJ . i__
0
VU241 ILATION PAN SINGLE BESIDE
�Cudr,Smflru,25532007
11 ye, 0 No
HOILRR- COMPLEHPOR 100,01(JOBIT)
ISSUANCr DATE
Will thetipplicannorfman, which ran . I
BOILER - COMP (OVER 100,000 BTLT
hareadours air contruninarts as defined by the Bay Alm, Ail Quality Management
Distinct?
PAID
Cl Ye, 0 No
NEW RESIDIRITIAL MEECIL—SQ, IT.
I have read the brosurdince nalarnirx nerlainernents aide, Clispar, 6.95 of the
California Health As Safe,, Coah. Seminars 25505,25533 ad MS�. I maderstrundflam
DEEC
if be hmlmh,doa� I mocall, have. remain. that it is my rx,,mi1m1hy to amitflia
mention of the requirements which must Fe met prior to issionace of a Certificate of
Occupancy.
C/ V
Owarriainiffluni,ed rigam Date
TOTAL
OFFICE