26237 (2)_Fe
r_
APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO` -
BUILDINDIVISION. APPLICATIONIPERMIT PLUMBING-MECHANICALb
G
3'R.}y}Y1fl`ASY; BURMIN P8010IDEWUPICATION4,$x^PiJ,$i; s'L
- PERMITNP.
237
BUILDING ADDRESS /( I'I'/A�)
z/ ' J c UN'a 1^' L01
SANI'1'ARYNO.
APPLICATION SUBMITTAL DAIS
J
O%V ti NAN I I ONE:
CONT ACT'OR'S NAM
N/C
CON I'ROLu
t1lr.:m1,C1/ENGIN :'T, LIC NO:
ADDRESS:
❑
CONTACT: PHONE:w„•.var•
�F
i T :4r vl
QTY J^EL8C7RIC P8RMIT.a"r+FtF88a"?BUILDING
u � roti .a kat }1t • ... xc t
ro PERMIT INFO
BLOC EC PLUMB MECH
PFRNfIT IgSUANCE
�3B 4
LICENSED CON1RACfOR'S )ECLARATION
1 hcrchy affirm that I stn licenmdunder provis onsof Chepter9 (commencing with
ppPWANCES-RESIDENTIAL
JOB DESCRIPTION
Section 7") of Division 3.f the Business and Professions Code, and my lie. is m
PANELS
�1
full force and effect.
\
License Class Lic.M
UPT0200AMR5
�`
/
201 - LOUD AMPS
Data Contractor
ARCHITECTS DECLARATION
1 undemm�d my plans shall be used es public rccmda.
OVER IU00 �
SQ. FT. FLOOR'jR -
.
S/SQ. FT.
SIGNS ELF.CDtICAL
�1 ui
`IVL.I`
Licensed Profcaional
OWNER -BUILDER
SPECIAL CIRCl1IT/ADSC.
1 hereby affirm that I for. me
exempt from the Cussima is Lianas law farco Ne
1 Cade: My my cowry
following reason (Section ]0315, Business andove,
TEMP. METER OR POLE MST.
douonz
which rtquira n permit o cons; the alta, improve, demolish, fi repair ed seedcase
s
priorwits Issuance,rrore9utro the applicantfarsuch fileee Lx zurcment
POWER DEVICES
Contrtmitto
that (commencing is liavd purtumt to Roc provisions of thethe Badness License Lew (Chaeta
or met heisxemithheeuon]andthe basisnn3ofthe Badness mad Rofasioa Code)
or Nm Wei31.5 bytmerefrommdthebaank s Neallegedeacmpi to Myvioldonof
Section ]03).5 by any applicant for a permit subjects the applicant w a civil penally of
SWIMMING POOLELECTRIC
�� VVALU!(�ryON
OR69
C.J V
UTLETS-SWITCHES-FL\TURE9
not mom Nen five hundred dollen ($500).
❑ I.uowetaofthe properry,mmyemployea colon wegaathe'uwleromperwtion.
NEW RESIDENTIAL ELF.CRt _SQ. FT.
STORIES TYPE CONSTRUCITON
will do the work, and the zwctur s i s not intended of o!fared for sale (Sco. 7f 104, Rosiness
and Professinsts Cole: The Contractors License Law does not apply to son owner of
� r,i n II A
1 r. •7 II
property, wholmIdsorimprovu thnean, and whodoas such work hdmselforthroughhk
a
ownemploye,providdar thsuchimpmvementzmenot intandedmoffaed fmale.If.
however, the building or improvement u said within one year ofcompletion. the owner-
C. UROUP"
--P"N 5� f�a
'^ 1 \ / I✓ I h I�
builder will have the burden of proving Nat he did not build or improve for purpose of
nnasst as'.:n[.J•.�vn{Rv'ac;.wix.xswttc@^y�N�r
. fa ? 'Jxrt'.vwiG x�r. 1'S.+�'.`vial at `.�e "♦
Wi
❑ I.m w afthepmpmy.=n clusivelyeontns Zwith =) ac=
romraee the project (Sec. 7044, Resines and Profusions Cade:) The Conpacem'e
license law doer not spar y ct an owner of proPmy who bud Ids m improve tlteeon, ad
DiiTE Dz
PERMIT ISSUANCE
whoc acafmwch pwjau with acontrazPoKs)licensed punuantwthe Conoactors
L
U. Law.
ALTER - DRAM & VENT -WATER (EA)
_wr�}"tj°�17",„c7•"_.FEE SUMMAR_Y,C'gy>,�.r-'Pei
❑. 1 am exempt under Sm. , B & P C far this sawnD
BACK FLOW PROTECT. DEVICE
SANITARY YN
RECEIPfM
Owner Dae
DRAMS -FLOOR, ROOF.AREA, CONI.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
_P Ihembyaffimnwlbaveaandfiuuofwttacntwwlf-inm¢,oracandflcateof
W'mkesi Compcmation Lssurmwmeanifidcopy thucof(Su.7B00,lab C.) which
RECEI a
FIXTURES - FEB. TRAP
FIXTURES
FEE Y N
coovers all employer's under this pemdt.
Pulicy.N
GAS - EA. SYSTEM.I WC.4 OUTLETS
RECF PTR
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
[ICcrtiftd copy is hereby famished
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the riryinspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FE
COMPENSATION INSURANCE
SEWER.SANITARY - STORM EA. Jul
ENERGY
(This section need notbecompletd ifhe permit is fossa handraddollars(SI00)
edeas.)
WATER HEATER W/VEM'/ELECM
I certify that in the pafamunceoftbe work fm which this pcmm is issued,I shell
are emplay my person in any mmner ao as to became rubjece m the Workers'
PAR)
Compenaoonlawsof Calif rad. Data
ATERS IEMRREATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If. affect, making thus Certificate of Emerilmon, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become mbjaa m the Worker Compmation provinom of Rose later Cde, You must
forthwith comply with such provisions or this Permit shall be demand revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a contraction lending agency for the pmfmmence of
the work for which thus Permit is issued (Ser. 3097. Civ. C)
ELECTRIC FEE �.
Lenders Name
Tameerm Address
1 certify mat 1 have read this mpldcafion and mute mat be above information is
correct. I r,om to comply with all city it county ordnances and sort laws reladngto
--se.' crass .••. .^..v^:.-• ::_e,<f,"tL 'Na'^"�
QTY.?rv' 1MECHAMCAL PERMIT.;",.«;�: y�:; FEES;:
:"ode AT�,4a.1w ere:. we,•s,.....:nv..e,Rv.•> r *.. a. ... .
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEF
building construction. and hereby authority mpreanutivcs of thus eery m enter upon the
move -renamed progeny for inspection purposes.
ALTER OR ADD TO NIECE.
CONSTRUCTION JAX
t W e) uprec m save, indemnify and keep harnlesm me City of CuNmr..'mou
limit jufroicon.costsvndupens swhich may inmyway wcrueagdnstsvd City
AIR HANDLING UNIT(TO 10,0(IOGFMI
in to at mace . c ing fthis it
tAA
AIR HANDLING UNIT(OVER MOB() CFM)
Signmure of AppbeonVConnaaor Date
EXHAUST HOOD(W/DUCf)
PAID
HEATING UNIT (TO MWO RTUi
II AZAR000S MATERIALS DISCLOSURE
Dmx Hcccipta
Will the uppbeem err lumre builJmg necupunuume or handle humrJnm on art, ul
as defined bythe Cupenoo Municipal Code, Chapter 9.12. and the Health and Safely
HEATING UNIT (OVER 100,M) BTU)
TR'I'AL:
Cde. Section 25532(v)7
❑. 13 No
Will the applicant or Brute building occup5nmw Nuipmcmordevice, which emit
ISSUA DATE
VENTILATION FAN (SINGLE RESID)
BOLER-COMP(3HPOR IM." B7D)
BOILER - COMP (OVER IDp,fgD BTU) .
Instructions
Dtqair conuminants as defined by the Bay Area Air Quality Management
❑Yu ❑No
I. '♦ ..
p
^' N' b -
NEW RESIDENLNIECH. SQ. FT.
M
I hove teed the haurdous materiels requirements under Chapter 6.95 of the
California Hrdth&Safely Code, Sections 25505,25533 and 25534. 1 understand the
if the building doe nm cormfly have • extant. that it is my rapmoubili y to notify the
APR �,
ii r1W
_
. wcupmt of the rcqudremenu which must m met prim in m umce of a Cendfiure of
Occupancy.
Coy
ISSUEDBY: t\ Ilia • a'IIryV
Ownermeuthmird agent Dau
OFFICE .