26401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO APPLICATION/PERMIT PLUMBING-I.LE AICAL PERMIT NO.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26401
BUILDINGADDRESS: 1 rJ v �2«� SANITARY NO. APPLICAT11ONSSUBMMI�IT'AL DATE
UNITM LOT# ��I�I�I
WNFRS NAML PIIO E CONTRACTOR'S NAME, LIC NO: 1. P l
NIC CONIROI.a
RCH Cf/FNGINEPR: C y LIC NO: AD El)NTACT: PxDNF( )�oqQTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
%9--ZOO(/3PFAMff ISSUANCE, '� BLDG EI PLUMB
LICENSEDCON'IRACTOR'S DECLARATIONAPPLIANCES-RESIDFFJST JOB DESCRIPTION
1 he")ofi), IM1mI emlicensorurker pmvisiauofOCosle, cony beme with ^
�Op Smuion]00(1)nf gvium3of the BusireasW Pmfessioru Code,and my Br<nae 1.in PANELS
C full face wI,�.d.cIfmt.
F�N LiccnR Com ITP T0200 AMPS
fn �' Die Cantn D �i ]01.1000 Af.1PS
Z c,,— es"I b,mads DECLARATION OVER 1000 AMPS Ti REA 5/SQ.FT.
O Z—C� l udaslnrd my VBos sM1all be toed as public road+.'Qy SIGNS BLECIUCAL¢� Lionised Pmfau{md0W OWNER-dieniN Jt ilia Contact SPECIALCRtCIRf/hfl O aV 1 ngm m aflonn.(Sa IFat 1 wn eaemp frim de Cesdomsra s:Any Law co the so (ollowine rtason.(Scmim]0313.Husitess ark Rofeniau Cale:AnY miry acowtY IEhSP.MGIFR OR INsr. D14�
4' g which on turas a Permit m cansoun,cher,imlwvc,dcmdish,or 1,any avunoc
f'ty3>7prow units issuarcc,also rtqu'nes the RiFicmu fasuNpermitto file asigred ausemeat TOWER DEVICES
WnaC) Lha he is licemal pursuantm the povi.amu M the Cmvrrals Lidense Law(Chapin SWIMMING POOL ELECTRIC
d e� 9(conurrreing with Savm]000)of Div idon3ofthe Bu+iaa and Rokviom Code) VALUATION \
❑,� or dal he is esempt thcrtftan and the basis(«the alleged cxnnption.Any violation of
5OSoon 70111 If wy aWlicim Ra alermil sobjmts the appicvnt to a civil faulty of OUTLETS-SWITCHES-FIX'NRES I �I
not more then five hundred dollus($500). NEW RESIDFNMLELECIR SQ.FR.
❑ I,uoweraflM1elaopaty,ormyemployeeswiN wgmulharmkc STORIES TYPECONSTRUCI N
will dotheamok.arta Lha he Coeiotw's Id dao8ertdfaode(Sec.]000`Bus'wr
ab Pm(esdan Code:The Cwuncmrs IJcenu Law dao not apply m as owner d
property afro builds m impove IM1crton,ark who doss ouch wort himelf a through hu
cmpbycp,pnvideJlhatsuchimpmvmenu erenot interdM oaffmdfaula.If, OCC.GROUP RFS.UNTfS
bowcvm,the huildingor improvement is sold within oa yevofcompletion,t etrviar-
bmcl will huvcIo,burden of povin,that he did rw build or impmve for pmlwe of
m cJ.
❑ I.uowtrroflhe poopeny,inn eacluvvclymwxtin�wiNlicemedcatraaoum QTY. PLUMBING PERMIT FEE F LDNL APN
cotuma the Mjea(Sm.7030,Btviaas ab Pmfcviau Coda,)Tie Cmuaaars
LEceree l�wdmna apply orae sworn(propnty wM1a buikaaimpovmdermn,end PERMIT ISSUANCE
who cmtmcufasueh projects with a emwcw(s)licensed pursuant to the Cuoramds
❑cense Iso. ALTER-DRAINk VENT-WATER(FA) FEE SUMMARY
❑ I am exempt under Sec. ,B A P C fa this rcanm BACK 11-OW PROTECT.DEVICE
SANITARY Y N
Owvea WORKMAN COMPENSATION DECLARATION DRAINSFLOOR.ROOF.AREA,CONI. SCHOOL TAX RECEIPT*
WORKMAN
N
❑ Ihmebyaf Bwl Nveacenifiweofmnv blit-imure,aac fi d FIXTURES-PPR TRAP RECEIPTa
Workeri Cornpemamon hismaa<aaamftad cop,tcdsonf(S .39)0,Lath C.)which PARK FEE Y N
cannot all end loya's under this permit. GAS-PA.SYSTEM-I INC.G OUTLETS RECEIPT Is
Policy* BUILDING DWISIO FESS
Company GAS-FA.SYSTEM-OVER G(HA) PLANCHECK Ftire
❑
5y'Cvtificd on,is Elect with the dy inopadim division. GREASEWNDUSTRL WASTE INTERCEPTOR GRADMG FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASET1tAP SOILS FEF.
COMPENSATION INSURANCE
('Itis vcn nerd m
tiorot be ctplctad ifthe permit is for me hundreddollus($100) SEWER-SANRARY-STORM EA."I'T. INERGY FEE
o lwJ
I comify that in lheperfmtunceofthe wart for which 96,crnd u issued,l shell WATIR HEATER WNEN'(EI.F.CIR
oa cmpby,any person in any rammer m as b become subject m the WakenPAID
z Compenamian Laotof CalJamu Due R WATER SYSIFJAAATING Date Receip0
QQ NOTICE TO APPLICANT:If,after meting this Ccnificate of Eamlptim,you anduld NEW RESIDENTIAL"B. SQ,FT. TOTAL
ate.., temasubjea to lie Workers Canpenaatlm rovisims ofmc LaborCade,you mots
fonhwith canpl,wiNsuch povisiuo or but pcmm ahJl he deer dreviled. BUILDING FRE 14
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
O
I notchy affirm pusn
Oe u•canuw:lim, ..ng agency fa me,Pa .a OTOTAL: ELf:CfRIC F13E,
Oa,wofor which this p
rk ermit u ia.ucd(Sac.309'1,Los.C.)
enders Name
OPLUNUUNG PER
leder,Addrtn QTY. MECHANICAL PERMIT FEE
1 inanity that I neve read This applicalmri and ante that the above refomudm i.
dot. Iua
gm to mtply with da
l city end aunty ordinance wnl
and ewe laws aing to PERMIT ISSUANCE MECHANICAL ITB
m<
building omsuucuion.and hereby+ulharixertP¢senutivaofthiantywmtu upm the CONSTRUCf10N I'AX
V Z above-memimed pod,y for iron netim purposes. ALTER OR ADD TO MECII.
(Wer)agree to save,iMemdfy ab keep huminr tie Cy of Cupcmw again
Iiabilidm,judgmeno,cosuM aexpeamuhic
which may many way acmag
e a ist sak Cly AIR HANDLING UNIT(TO 10,000 CFM)
in crosegxae of the fpaeth g of th'n fermi
AIR HANDLING UNIT(OVER In."CFM)
net 'sot Cmur vtx 0.te EXHAUST HOOD(Wfl)UC11
PAID
AZARDOUS MATER At 9 DISCLOSURE HEATING UNIT(TO 111(%0(X)BTU) Date R ,s#
Willthc applicant or Julart building vpuu awe or handle malarial HEATING UNIT(OVER 100.0008111) TOTAL
u defued by the Cupmtiw M *Code.Chapter 9.11,and the Heats and Salley
Code,Smtion 25532(e)? VENTILATION FAN(SINGLE RESID)
❑Yes 999 Na
ISSUANCE DATE
WiIltMopplicentmfuuurthuildingaculwnuuxeyuipanuordeviaawhichetrtit BOIIER-COMP(THP OR I(N),fXl0 BTU)
hamNwts air contaminants as fitN by the Bay Arca Air Quality Marugennent BOILER-COW(OVER 100,000 BTU)
ni
❑Yes o NEW RESIDENTIAL MECII. SQ.FT.
I have rad me,hvardau'materials rt,moddents under Chapin 6.95 of tie rJUN —6 1994
Cdiranie I homh A,Safety Cada Scatiau 25505,2559]aril 25534. 1 understand!Idem
if Na,building docs not cvrrcnfy have u talent,that it ismy m=ibiliy to nmify
neuu�f the regairvo nos which now be and prior to i.uavca aRa Catifoate of COY i• `f� (n° 11•�'/LO,/
owaraauthodzm ago Due TOT L ISSUED BY:
oFFICE