26439 ICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
5'OF CUPESIONR.11PFxmn No (�
BUILDING DIVISION APPLICATION/PERMIT .:PLUMemc-MECHANICAL. _ .7
_ BUH.Hulc rooted H3BrrWicAnore;,:r-.,::.. N'
LDING ADDRESS: RAY Cu SANITARYNO. APPWCATIONSUBMITTALUA_TE
U�l..r Tl r.(j l...Q,
N LOT# ' �� - •• I-
'NIMSNAME: PHONE. CONTRACTOR'SNAME: 'LIC NO:79
Ip4C CONTROL#
s ^CTM12JGINEER: I V N LIC NO: ADDRESS:�O L off,}' 'srW,...•. ❑
COt PHONE: Cif u1r'eur."w• + LL
.--.� ��. V'1a..5f!`n,fy $0 �' �✓Yl. ieu:, e. ;' 3yi '�4"'yF'4 .r•'FHUH.DH'7G PEHh9T IrF0 .. ".!
,Av�aS,: FEB'. .
O PiiT�9�ML - BLDG ELECT PLUMB MECH
s/C Cr- e2 i PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
1CZ Ihembyaffirm Nat l am licensed underprovisiomofOmpter9(commencing with / �"
100 Section70DB.f Division 3of,he Business and professions Codcense e..nd my liis in PANELS �(/-1: � CLL4."s-sa.._y/
'Is)IF-�. full forte and effect
Z� License Class,-C.1-Lic.# S 1.-zR:m UP TO 200 S <-IC
-6d Dore I" —'i /� �"I•-Seedy 201-IDDBAMP
�yZ ARCH.1 ECI'S DECLARATION OVER IOOOAMP SQ.FT.FLOOR AREA S/SQ.FI.
.'? I understand my Plans shall he used as public records.
F-m SIGNS ELECTRIC
,2:1 Licensed Professional
7=6 OWNER-BUILDER DECLARATION SPECW.CMCUrr SC.
JyU 1 hucby affirm Nat 1 em eacmpt foam the Cmaamors Lice.law for its,
2 a
toa following rnson.(accusal 70313,Business and professions Code:My city or county TEMP.METER OR M Sf.
vOiJ which requires a permit to construct,duo,improve,tlemolish,or upsirany sounme
.'j}� prior mo its issuance..Iw requires thaepplicant(mruch pemutmfde asig dsurement POWER DEVICES
p0 that he is licused pursuant to the provisions of um Cmomrars Licmre law(Chaps SWIMMING POOL C
9l commencing with Section 7000)or Division 3af Ne Business and Pmfessiam Code) ) VALUATION AA
�_•y orthathe isesemptthemfromand Ne basis for theulleged exemption.My violaum of OUTLETS SWIT s8 ( Sas �u
-ZG Section 7031.5 by any applicant for a Permit subjects the applicanm t a civil puWry of
not more Nan five hundred dollars($500).
7 ecompem.um.
NEWRESm AL _SQ.fT. STORIES TYPECO STRUCTION
, �� ❑ I.esowneroftheproPerty,ormYmnployeuwiNwagesulheirrol
�3— will dothewor,endl:The tum isnot isLt...Law closes;
so G6,owner
of
end Professions Code:The Conwcmrs Liave law dao ml apply m an owns of
properly who builds m impmves thereon,end who dao such want himul f or through his
C GROUP M.UNITS
_
cmploya;providW Jprove impis sold nuerene iearofe amplleered for We.a.
however.the have
the
bur improvement is that
hei iinot build of improve for Nc o se,of TOTAL:
builder will hove the burden of proving Nal he did not build or improve for puryou of
sale.). a...v.-n-.s- arr;xser-r+tw.:..wwwn s ek"j•-Frsyi
;' ""- PLUMBAIG PPRMIT; , .�:._ • FEE FLOG APN
❑ I.ss ownmof du moPenY�amexelusivelyconu.ming with licmud contncursm �' �. ''(I�.ea-;...p,:gyt..,e>sr;a,tf: .rte a »,r�su'�* -
cmuvum the project(Sec.1014,Business and Profssaions Cade)The Conbenor's
License Law doesrmt apply m anownerofpropenywhobuildsm improvestherem,and PERMIT ISSUANCE
whocmutsfanuch poects wiNaconamrte)licenuprsuanuo re mvos
Law. ALTER-DRAIN&VENT-WATER(EA) Aroe is,'z. F• SUMMARYl ;'—n`
❑ 1 em exempt under Sec. ,B&P C fm Nis reason BACK FLOW PROTECT.DEVICEES
SAN TARY _N
-
Owner WORKMAN COMPENSATION DECLARATION DRAINS-FL ,ROOF,AREA,COND. SCHOOL TAX Y fPT#_ALN
.1 r'ffum dots 1 have a eenificau of carseat m self4rocum,or.certifrcne orRECEIPT«
,•o
2 oution Insurance ora certified copy mermf(Sm.3800,Lab C.)which FlXTIJRFS-PER PARKME Y N_
vert stIN-ro ce'r under this permit. GAS-EA.SYSTEM- WC.4O RECEIPT#
Polity N BUILDING DIVISION FEES
Company 1'-^ GAS-EA.SYSTEM-O ER4 ) PLANCHECK FEE
❑ CanifiMcopyishcmbyfumished.
Q CenifieA copy is filed with the city imparim division. GREASHIINDUSTRL W TE INTERCEPTOR GRADNG FEE
CERTQ-ICATE OF EXEMPTION FROM WORRIERS' GREASETRAP SOBS FEE
COMPENSATION INSURANCE
(Dtissectionn«drmt he compleud if Ne permit is far one hundred dollars(SIM) SEWER-SAN Y-Mt EA.2013M ENERGY FEE
or less.)
I arrify that in the performance of the work for which this permits issued,l shall WATER H RW/VENTIE F.CIR
not employ any person u�(�any manner so.s to bec9rQe ub'at tq the Workers' PAID
Compemetim Lews of Califame.s Date 3 {{r �/ 91/ WATER SYS TING Dau Receipt#
Z APplout TJ T
0 NOTICE TO APPLICANT:If,afar making this Cvrificau of Facmptim,you should NEW RESIDENTIAL PLMH. SQ.FT. TAL:
) .fir becane eubjem m Ne Wmoss. pmssrim pmvisimuof she Labor Code.you must
forthwith comply with such Provisions or this permit shall he shamed revoked. - 0 BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
O
Ihereby affirm that there is a construction leMing agency for the performance of TOTAL: ELECTRIC FEE
j the work far which this pernut is issued(Sec.M17,Civ.C.)
r lender's Name '-t. ��y]a;va.;ues'venu:wv.+a._.es.::%t-e'.'}" ,:t
lenders Address QTY. 3d.=^c MHCf1AI%CALPHRFHT,-.C•I�e `V'?FEE k.,;,
LQ PLUMBING FEE
I certify Net 1 have rted Nis epplicetim and suis Net Ne above ufomuum is ii1"°/v^• ""Si._rs.
CL correct. IegrcetocomplywiNOlcirymdcountyordina mmdsuulawsrelaungm PERMIT ISSUANCE MECHANICAL FEE
In building construction.and hereby authosise representatives ofthis city menterupon the CONSTRUCTION TAX
I Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)spree to save,indmmify and kap huml.ss the Coy of Clpenim a,at.,
hosinla...judpmuts,emuand expenses which may inmy wryacerueapehoasaid City AIR HANDLING UNIT(TO 10."CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIADVER 10.0130 CFM)
Sign..of Applicans/Contractm Dau EXHAUST HOOD(WIO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100. Dale ReaelpN
Will lheopplicantorfuture building oecupmt store or handle herardous material HEATING UNIT(O W. BTU) TOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and she Health and Safcly
Code,Section n532(.)?
❑Yu 11 Na VENTILATION (SINGLE IDI
ISSUANCE DATE
Willheapolicmtmfuwmbuilding=upantuwNuipmen,orae iaswhichemit BOILER- (3HPOR IW, TU)
Grund a' inants..s defined by the Ba Aces Air Quality Management I
Y Y g BOILER-COMP(OVER IOO,WOB ,y
C1 No
No NEW RESIDENTIAL MECH. SQ.Fg. �0 a
I have sad the harmdour moterials uquimmcros under Chapter 6.95 of the V 28
Califomu HuIN&Safcry Code,Saxons 25505.25533 and 25534.1 undemand Nat /�
if Ne building does not cummly have a unset,that it is my responsibility to notify the eoY i)r J
acupem of Nero uiremcros which must be met prior m ismana of a Ce tificau of L/Y
xeapnty.
NU
Ownerorauamired en Dam TOTAL: ISSUED BY:
OFFICE