26075 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO F1 IHMING-ELECFRICAL - PIiRMITNO
BUILDING DIVISION APPLICATION/PERMIT 1'1,UMBING-MECHANICAL 26075
I BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO APPLICATION SUBMITTAL DATE
z2s6I Pc�.� DE o,e . 3—��
UNIT# LOT#
/OWNS[ N//k�Mli.r' PHONE.Z.F kllL �CON'I(1}� OR'SNAME s 1ICN�}\rAi `'r/],N N/C CONTROL#
ARCH(IE T ENGINEER C NO HPSS
U
CONTACT: PHONE:
�t '7 [' IQTY. ELECTRIC PERMI'PE BUILDING PERMIT INFO
�JOaN IC.A CS��'1 L�J �G.� IZ - I BLDG am PLUMB ME❑CII .
LICENSED CONTRACTOR'S DECLARATION PERMIT ISSUANCE APPLIANCES-RESIDENTIAL
M`Xz Ilmw1 ffinngm han1icenved unJCr jOB DESCRIPTION
F100ya and Prmmof Chapter and mmenangwnh
ti100 Sccuoa]Ond3ofectviaon3of the Business roil PmfessinnsCdc,and my license ism I (PANELS
Fps U F Luc force and effect. UIP i~is d Datcmc Class Ciarioncw- 201-1000AMPS
I-yZ ARCHITECTS DECLARATION I I OVER-1 I AMPS _^ SQ.FT.FLOOR AREA $/SQ.FT.
Z O'20 1 understand my plans shall be used as public p,oNs OVER LBW AMPS
oz"M
F=S,F-W1 (SIGNS ELECTRICAL
S,7, 1.¢enscA Professional
V OWNER-BUILDER
from he Coal.ION I SPECIAL CIRCUM/MISC, 'y
iry5, 4 f- f hereby alfnn ilia am eau...from the Coal ro e:Any Law for the B Ism.
following reason (Seaman]031.5.Business end Itofesaons Code:Any city or county TEMP.METER OR POLE MST.
J which reyunes a pennn m conswn,alter,improve,demabsb,or mepar any ama t E I n
Qn prior na resonance,also requires the applicant for such Permit RlensigneA s(Chapter mmcnt (POWER DEVICES �n r�, h\. ] r'�I p '7j... Nl
1y_Op the he is licensed Pursuant to Provisions of the COntrecmr's License Low .0 --I0J)
d�o� 9(comm<ncing wnhSwoon]OWIof Drvman 3ofine Business and Pm(essiaw Code) SWIMMING POOL ELECTRIC I VALUATION
y)_y or that he is exempt therefrom and the besets for the alleged exemption.Any violation or
�ZQ Section 71131.5 by any eppLennl for. arardloilj.h.the applicant o civil penalty of OUTLETS-SWITCHES-FIXTURILS NHIE'
WWnot more than five hundred dollan($5W). NEW RESIDENTIAL ELECFR _SQ.FT.
W pw ❑ I.mownerofthepmpcny,ormycmployee wtNwMesastheirsolecompensatton, I STORTES ---oa TYPECONSTRUCFION
will JO the work,nnA mestrumumsnotimmdalnnnfercdfor sale(Sor7044,Busmess
and Professions Code:The Contractor's License Law does not apply m an owner of
property who builds onmproves thereon,and whodotaxich wodrhmmselfonhnstril s
own employees,providelthat such improvements suction intended oroffered forede.if, OCC.GROUP RES,UNITS
however.the building orimpmvementis sold within one yearofcnmpletion,the owner
budder will have the Warden of proving that he did not build or Improve for purpou of ^'(
sale) TY. PLUMBING PERMIT v
❑ La.the project(Smporry,am cxclusry an rontrassions eda)The Contraia's IQ FIiI. FLOOD ZONE APN
construct the project apply oorno Business end Professions Cale:)The Cantmcmnd PERMIT ISSUANCE 1
Licensetraw,for nit pplyioznowncrofpropcny whnbed pursimproves thereon,end
whose Law. nrsu.hpnslcclswith ucnn0annrlsj licensed pursuant the Contmcmra ALTER (EA)License Law. FEE SUMMARY
❑ I net exempt trader Sec. B&P C for this reason I BACK Fj PROTECT.DEVICE OU t HIDE FEES
Own,, rate f SANITARY Y N_
DRAINS-FLOOR,ROOF,AREA,COND. RECEIVE'N
WORKMAN COMPENSATION DECLARATION JSCHOOLTAX 1' N
• W Thereby affirm atast... ttnrficam of consent to self-msnre,oracmificate of FIXTURE$-PER TRAP '_ RF.CEIPTp
Waken'Compenwoon lmmm�ee orucemOeJ.npy OmrwffgecJtlW,Leb CJwhnM1 1PARK FEE Y N
covers all employee's trade,this permit. (GAS-G.SYSTEM-I INC.40VFLETS I RFCEIPP#
or
./P�o�liTic�yp BUILDING DIVISION FEES
• lJ t.'er.fld copy is hereby fa famished.
ymspecuun division (GAS-EA SYSII::M-OVER 4(EA) PLANCI IHCK FE — -
GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHTRAP SOILS FEE
COMPENSATION INSURANCE
(This swoon need not hecompleted ifine permit is for one hundred dollars kHigh I (SEWER-SANITARY-STORM HA.20017 ENERGY FEE
or less 1
I certify Eliot in me pegonnanee of die work fm whmh this penntt ms issued,I shall I WATER HEATER W/VENT/ELECfR I not employ any person in my manner an ex to become subject to the Worker' 1 PAID 1111
O z Comlmnsnoonl.owsof Celifnmm. Dar. WATER SYSTEM/TRGTING )ate Receipt#
O Applicant
ZZ�-1 NOTICE TO APPLICANT:IL after main,this Certificate of Exemption,you should ) NEW RESIDENT IAL PLMB. SQ.FT. I TOTAL-
become subject to the Worker's Compensation provisions ofthe Labor Code,you must
11a" ; frawith comply with such provisions or this pemdt shall M deemed revoked (BUILDING FEE _
a (� CONSTRUCTION LENDING AGENCY I (SEISMIC FEE
1 hereby n1 Erm that there is a construction lending agency for the performance of
U O the work far which this#anon a matured(Sec.3097,Civ.C.) TOTAL: ELECTRIC EYE
Ixndcea Nor-
C) PLUMBING FEE;
U 1<nnIc Addr.h IQTY. MECHANICAL PERMIT FGIi
U I.cagy that 1 have mod this city and county and stem mot the stave owe odi information to 1 MECHANICAL.FEE
mmng—roo to comply hereby uth and rounrymdmeneesand stem Iowa 'PERMIT ISSUANCE with r�-rZ huddmgumatruaomert M1otinpulhonmrepreeenauven of this city roamer upon the CONSTRUCTIONT'AX
U z above-menaoncJ property ldemnif it ke q,l cs. ALTER OR ADD TO MISCH.
1 We)agrees save, and expenses end keep hsmrlessthe Ory its .nim again
liabilities ' ems,costs xndexpenses which mayinany way azcrue egarnstssid City LAIR HANDLING UNIT#010,01X1 CFMj pry n
,e gOtyhnR fit. 3�z/9 4— I
AIR HANDLING UNIT IOVL'R 10,1100 CFMI
'SlmUUreolAppllanVCodmch( Data EULNUST1I001)(W/DUCD PAID `e 199
HAZARDOUS MATERIALS DISCLOSURE I I HEATING UNIT(11 IIX1,BW BTVj e( F n. Rcc/nypt p
t e applicant mfuture budding occupant rare or handle hazardous material DEATING ON['[(OVER 1110,00001 U)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and me Real and Safety
Code,Secuon 25532(ap VENTILATION FAN(SINGLE RESIDE
❑Yes ❑No
Will air contaminants re burlier occupantay Area Air Management
ant
BOILER-COMPOHPOR IW,01N10TU) I ISSUANCE DATE
Dolowous err ammmmums its define)by the Bay Area Air Quahry Manegem<nt BOILER-COMP(OVER 100,W01HU
Drnnnl I ) I
❑Yea ❑No NEW RESIDENTIAL MECH SQ PT. �pI��/
I have read die hmanlous materials reyunemeas Under Chapter 695 of the NAR -8 1994
Calilomia Health&Safety Code,Secuon,255115,25533 unit 25534.1 understand Nat
occupant not which e, that it my respo a Of. tonaufy the I Cl7Y ur
occupant of the rcynvemem.whmh must be ion poor io issuance of n Ccnificam of (;UNth
Occupancy. I
Owner or authorised agent Data IOTAL: ISSUED BY-
OFFICE