26997APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B11If:Dlasaw— ExcTRTr.At-
APPLICATION /PERMIT PLUMBING - MP.CHANICA11
BUILDING DIVISION BUILDING. PEOJE(n' IDENTIFICATION
PERMITNO.
26997
BUILDING ADDRESS:
SANITARY NO
APPLICATIONSSffUBMI//T�IAL DATE
CITM
LOT#
y a�
OWNERS NAME: PIIONB:
CO NT
Cf0 'S M e LIC
NO
N/C CON IROh4
RCHITf:CDIiNGINEER: hIC NO:
b G
AU
'ONI CT PHONE:
QTY,
ELECTRIC PERMIT
^
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MiiCH
I/pe }s, M
PERMIT ISSUANCE
ZWZ
1400
tC U
&;WE
F'Z m
m,Q, y
OZ-0ARCHI7ECI'S
OZ-0
FY�
Irate/'
ia` Jam►
EN OR
LICSED CONTRA 's DECLARATION
Ihereb firm thetlem licensed unae
Yo rprovisionvd Chepmr9 (urmmcnoingwhh
fatf:dadefDivision 3ofthe Bminess end ProPoSSions Code, and my licenm is io
full force and etfec
Liden�Cmro
Uwe G CTS D
DECLARATION
I understand my plans snort b< used us public records.
APPLIANCES - RESIDENTIAL
LOB DIi5CRI1'130N
F -
F
ppprBlg
UP TO 2M AMPS
201 - 1000 AMPS
OVER 1000AMP5
SQ.tn'. FLOOR AREA
E /SQ.IT.
SIGNS ELE IC
6
•
licensed Professlnnul
peK6
KOa,
u13 a -rn
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contra, is License Law for the
falluwin,misoa(Section 7031.5. Business and Pmfnsi s :sae: Any city or county
SPECIAL CIR IS
TEMP. MMIR
NO �
YE
did z
p' oLL
W_N
Za
C t_-�
a3—
which mquind a Permit to construct, alter, improve, d olis or repairany ftmcture
prionoitaismena ,also requimsthe appliamt for su permitofileasigneasmtement
that he is licensed pursuant to the provisions oft .moan Li,cmaLaw (halter
9(donaancing with Section 7") of Divism ofthe BUSlnea and Professions Code)
a, her he is exempt therefrom a ad the b ordaml,lml. tkm Anyviolationof
Section 7031.5 by any applicant f md".hj.t,Ihd.Pplice Doncivil pena0y of
not nmmthan fivo hand,, ars ($500).
❑ I,as.wnnr mp <ny,ormyemployedwithwagemetheir lec.mperrvtion,
willdn the and the atrunureisnm intendsd ororferW forsele 0s 7044, Business
POW ER DE S
SWIMMING POO .L
VALUATIONdO
OUTLETS- SWITCHES-
NEW RESSIDENTIAL EL' FT.
STORIES
TYPE GDN$TRGCf1GN
and Protects ms Coda "fh< Comm,mr Licmee Law t apply o an owner of
pmpenywnr bwdamimPi.vea mere n,ona ^ltd rmaelrorthroagn His
mPdye , pmvidWthatsachim LO 'ware rdmoffulO�orsNe. If.
OCC. GROUP
R&UNDS
hnwever.theb 'I ding nr improvement ill it n ycm.fmnipl ticn,theownen
holder will hav he Hurtle of provist�I t notbuild nrimpmvefortnrposeof
vie.).
❑ Lasowrcroft Imp sivelyrnntractingwithli <enseJ COn.umoretn
the yfoj„teke. and Professions Code:) The Commetor's
TO
Qom'
PLUMBING PERMIT
FEE
FLOOD ZONE
MN
Lmatrua
icenselawdcesnot ap to ernfpropcny whobuildaorimprovesthereon ,end
PERMIT ISSUANCE
whocour ctsforsuch pro ets it, contra tar(s)hrrt, dpursuanuothe C.nnadams
License law, c/
ALTER - DRAIN & VENT - WATER (EA)
FEESUMMARY
❑ [a exempt under Se . , B & P C for thii ress.n
BACK FLOW PROTECT. DEWICE
'f Il% `P.
SANITARY YN
RECEIPT#
Owner
GRAINS- Fl.00R, ROOF,ARIiA. COND.
WORKM COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Iherehyafr,.,hat l h ve a antithetic nfc.nsem to selGinsure,oracertificme of
Wmkeri Cnmpcnvtion lnsu arecenitied copy thereof(Sm.38W. Lab C.) which
RLCLIPTp
FIVURES - PER TRAP
PARK FEE N
GAS - EA. SYS9'EM -I INC. OUTLETS
covers all employee's under, rspemit.
Polly#
1: 1'fp
BUILDI DI ISIONFEES
Company'
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCIICCK FEE
-
nifi Cy is hereby fumishrA.
❑ Ce M try
GREASE(INDUSTRL WASTE INTERCEM OR
GRADING FEE
❑ Certified colt is fled with the city inspection division,
CERTIFICATE OF IiXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER- SANITARY -STORM FA. 200FT.
ENERGY FEE
or less.)
WATER HEATER W/VRM'/ELECR
I,edify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner s. as to become subject to the Workers'
PAID
z
Z C
Compensation Lawsof Corifomia. Data
Applicant
WATER SYSTEMITREATING
pate
NOTICE TO APPLICANT: If, eOe, making this CenHE.td.f ExmrNmn.you should
become suhjer 1. the Workers Compensation provisminaofthe labor Code. you must
NEW RESIDENTIAL PLMB. SQ, FT.
TO
t94�Fl
?
forthwith comply with such provisions or this permit shall be deemed rvoked.
BUILDING FI7E
aQ
CONSTRUCTION LENDING AGENCY
SEISMIC 'EF
ZIhereby
L)
O U
affirm that them is a construction lending agency for the Performance of
the work for which this Permit is issued (Sec. 3097, Civ. C.)
Lender's Name
ELE R
Lender's Address -
QTY.
MECHANICAL PERMIT
FEE
I TEF
U Z
1 deniry that I have read this application and state that me above information is
correct. I,.,. damply with all city and countyordinances and state lawsrclitang to
building construction, and hereby authorize representatives ofthls city to enter upon the
above- mentionedproseny forinspecti.n
PERMIT ISSUANCE
-C IC ,FEE
ALTERORADDTOMECIi.
CONS UCI ON TAX
(We) agree to save, indemnify ecp s the City of Cupertino egwnn
w
liabilities' nB.coaEmdcxpe - 'ch any way accrue against said City
AIR I IANDLING UNO(TO I Q00B CPM
eeo granting of 1.
AIR HANDLING UNIT (OVER IDWO CPM)
-
rgnawreu untracmr Date
EXHAUST HOOD(W/pUCp
PAID
HEATING UNITGO IW,000BTUI
I IAZARDOUS ATERIALS DISCLOSURE
DaIA Receipt#
Will theappli,ant.r future building acropom atom., handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
BEATING UNIT (OVER IW.(IWO 1)
Code, Section 25532(.)?
❑ Yes ❑ No
VENTILATION FAN (SING .RPSIU)
Will the .cormorants re building by the Bay equipmen Quality Management it
.thous air c.maminantn m defined by the Bay Area Air Quality Menagcment
�istsin7
BOILER- COMP(3111' 100,000 BTU)
ISSUANCE DATE
^ A
1'� '
BOILER SCOMP ER 100,000 BTU)
i ❑ Yes ❑ No
i�pV r
NEW RESID i TIAL MECH. SQ. FT.
1 have -read the hazardous materials oa uimmems under Chapter 6.95 of the
California Health & Safety Coda Sections 25505, 25533 sand 25534. 1 understand Ihat
I a46 8 19��
it budding does n.l curcmly have a adman, that it is my respmsibility m notify the
occupant of the requirements which must be met prior to issuance of a Cenificam of
I v f •yk/!-
upancy.
ISSUED BY: _
Owner mauthorimd'agem Date
TOTAL:
OFFICE