26175 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.- . . PF.RMITNO. 26175
CITY OF CUPERTINO APPLICATION/PERMIT PLUMB; ;-MRCIIANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLRATTON SUBMITTAL DAT:
J o l 4-4, Da-y oF+^- w 2 —l�
UNRx LOT
OWNERS NAME'_' IONS CONTRA ggS NAME: LICNO:
CD"ro--1 O3 o33z ft�}vL !�^S'• eo �elz36t° NC CON.oI.x
RCHITECTjNGh% A- LIC NO: ADDR!rS L p� A,r `ry.rF, Lry�- ❑
CONTACT: PHONIC (�U I f"^r__- 7"t, T^'Yobn
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ECf PLUMB MECH
PERMIT ISSUANCE "►
LICENSED CONTRACTOR'S DECLARATION APPLUNCES-RESIDPNIIAL
p0Z Ih7")aff tslon3 lispBusinesand! aud'lhCo&.an m yboars,wish LOB DGSCRIPI'ION
�r400 5«lim)OWI of DIVIsIm JNNe Business Rofmswe Code.W my limlx ale PANELS
yr�F full foe¢mxl eHm. 3p2 3Sf
ICGI-.. UU 4ccnm ,u Lic.M UP T02W AMPS
y Q y talk
Dalt -IT�� on. 201-I"AMPS
ZOtoz ARCHDECTS DF.CUARATION OVER 1000 AMPS SQ.FT.FLOORARFA 3/sO.FT.
O Z-O I mtdee.land my plus,shall be used m puNk tenad.
P=n1_:1 SIGNS ELECTRICAL
<y�,�j Licensed PrOfeaimul
r,w< OWNER-BUILDER DECLARATION PECIAL CIRCUR/MISC. Lat
KO pW,F 1 hereby.Rens lean I con esvnpt frau the C.Ommor',License Law fa Ne
trf3ta.,a followmg ewwn.(Sunim]0315,Hoinem and Professions Code:Any city O coorty TEMP.MEIFR OR PVI INST.
u 3 which requires a perm,to cmmuct,ahe,impose,demolish,Or repair any structure
f Y7 pr lm to its ismoome,Jon tryuim Jc.,licun fm,uchpnMt to file.signed nate, POWER DEVICIRS
< thapt he is licemcd mum to the pOsisions of the Cmnoaimel Lwcme law(Chapter
XaXo ff 'J(cmmmri,ing with Sntimn7")of Diviilm J of the Business artd FOfmiaa Code) SWIMMING POOL ELECTRIC VALUSTIpN
W^ athu her is exemp,tamfmrtt.nd the b.ds fu the alleged exaoptimn.Any violeuan of
CZQn
n
-FIXTURESSol nit mbjauharnOIRLEIS-SWRff
mmor,mun Eric hundred dklla ($500). I CJC�
NEWRESIDE ALELECIR _SQ.FT.
K ❑ I,arweteo(lhcgnpmY.amyemployen wimwagmm Neuw4msnpatatioo, RIES FF. NSTRUCTlO
y3� willdodcwas;Cout:The ,urti,nmimendeoLaweed lorale(Sec.Tan owner
w Pmrcaiam cone:The�naxta a.cense law dons not wplr m m rwner rr
pmPn^YwN,builds-impnwes Ihcrton,.nd who toes...hw. orcefathmughbice
cmptoyccs.pingoe tMtsmM1imps"wivartm,inteMedmpLeued(a stn If,
.GROUP RFS.0 1
Mwevn,dleio,e the
o,mvin E.OWwithin Oneycu ofrnmpinim,the of
t.fc). will have the buNen of poving Nu M1e did ort WiMmimprvc for psvpo,c of
x0 QTY. PLUMBING PERMIT FEE FLOOD LO APN
❑ L.,owecrof the lnromY,ens eaclusivelyctmuaming with licensed cmvanonw
cavuun tae pojem(Sec.7N4,Bussona and Pmfcuimn,Code:)TO,Cmvamor's
Uccosc�wdocs not apply toenvwocrcfpopcny who buihtsa bnprovmtboomo,and PERMRISSUANCE
whocommet,I'trr suchpwjccOodb.cmr umt)l icencedpunualtm Nc COmne.,
Lcemc Caw. ALTER-DRAIN&VENT-WATER(LAE FEE SUMMARY
❑ I son cacmpt undo Se. ,B&P C fm Nn scamp BACK FLOW PROTECT.DEV ICE SANITARY Y N
el. Date DRAINS-FLOORROOF.AREAGONDRLCEIP O
, , . .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihcrtby atfrm Ow lluvcacmifiu,e ofmmen„o.df-Eumc,aacetifcuc of FlXNRES-PFR TRAP RECf!IPI'g
Wakcrs'Cmnpenationder Nisceroill.edcupy Nerm!(Sec.Jggl,L.b C.)which PARK FEIi Y N
coscra all entpiny¢',under Ni,pnemlL GAS-EA.SYSTEM-I INC.4 OUTLETS REIMS' x
Policy Y BUILDING DIVISION FHS
Company GAS-IA SYSTEM-OVFR 4(FiM PLANC+IECK FFF 2
❑ Cetified rnpy is hecbY famished.
❑ Cmified rapy ins filed wtiN Ne city inNcctim dvi,lm GRIEASE/IN'DUSTRL WASTE INTFRC-EPIOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETAAP I�
COMPENSATION INSURANCE
nNs section need nm ed cesnpined inns,permit u faomn handed duchan($iW) SEWER- 'IARY- O FFEI
a lm)
I certify than in the perfmnlance of the work for which Ni,pmmlt is iauN,1001 WATTR ABATER WN
ew employ any porn to any orm to au to the Workers'
O z Com ins Uw Calif a 11 r-1 � WATER SYSTEM[I[BEATING se Receipt#
Applimust A r_
z 2 NODCE TO APPLICANT:If,Ne making N.Cenfimue aExastplian,Y.sbmuld NEW RESIDENT+ PLM.. TOTAL:
UO becmrc subject to the Workers ComFermahm provisions of the Labor Cede,you must
famhwiN comply wort such"A.m.Or this pandt shot be resented revoked. BUILDING HF t
y O
CONSTRUCTION LENDING AGENCY SFISMIC HL'E
I bmsby affirm Nat tam is a mn,mxvm lending agency for the pefmtwrvs of T UECTRIC FEE
U O
the wma 1m which N,permit.Lased(g ,309+,Clan.C.) i
1<rdcr's Name
O lender's Address; QTY. MECHANICAL PERMIT FEE PLUMBING FEE a—
I certify Nat I Irsvn mad Nia appliw,im and sate but Ne above infi.im I.
�" OJ cornet,Iagrte to romply wiN all ei,Y and evml,Y adinarem and ttuelawaseladn8 to PEBbdu ISSUANCE MECHANICALFBB �•
(- y buildingLm,wntian,and hereby authaiu sepvmtatives ofdDcity to enter upon the CONSTRUCTION TAX
VZ aMwementimed properly fonnq¢climn prryavm. ALTERORADDTOMECII.
(We)agrte to ave,indcmniry cold keep harmless lee City of Cupem,to against
Iisbilitic,judgmr.,command cxpcmca which may in any wyamuc against said Cry AIR IIANDLING UNIT(TO JO."CFM)
in easmqueoce a rhe gaming Of Nis'com,
AIR HANDLING UNIT(OVFJt 10.000 CFM) EI
Si,fmum of Applic.nUCmoucmr Due EXHAUST HOOD(W/DUCD
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW."BTU) Date Reccip x
Will theaWlicwt or future Wilting oavpant store w handle hvydous material LIEATING UNR(OVER 100,000 Bf1J) - TA
u defined by Ne Cupnulo Mmicipal Cade,Chapter 9.12,estd the Health and Safety
cmx.s«am zssJz(.)+
❑Ya VP,NTLATION PAN(SINGLE'MID)
ISSUANCE DATE
Will
cs ars marramfuvuc builder BOILER COMP(3HPOR 100,000 B'ITU
pp garupuu uaccglupsrn,ahvtmwllichcmit ® p
hnmdom air,a.uantimma m dcflrcd by be Pay Arta Air Qtulity Mmagcment BOILER-COMP(OVER IM,"B'IU) • M ' D
DiAoim^ ❑Yes
NEW RFSIDENf1AL MECfI. SQ.FT. 21 199
1 have rtnd the hamdpu S, cJool,rtC5,255nta under M. I ear mi of me �wJ�{W/m�l q
California Halm&Sefcur code.orve ala esm,h t it Is and 25534. 1 mderr ff Not Y
if the bm of t done,not currently have•mrb,.Nan it u my responsibility to notify Ne
mnnrlarlt mr Nn rtgair e n must x mer pior to ia.�na rr.cmi0o,e of Cll Y UY LI�IN�
a" n�f a
Owner aomMen,riacl ngDue IggUFJ>.Y:
OFFI