26350 f APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO -ELECTRICAL- PERMIT NO,
II` APPLICATIONIPERMIT PLUMBING-MECHANICALCT 2 6 3 5 0
BUILDING DIVISION BUILDING PROJEIDENTIFICATION
BUILDING ADD ! i LOT# SANITARY NO. APPLICATIONSUBMIITI,AALL\�DATE
III OW/JERSN E' PHONE: CIUR'S NAME: LIC NO: ��
) L NIC CCONTTRR�OOLL##(=](�%
RCHITECT/ENGINEIR'. LIC NO,. ADD S: El
ONfACf: wI OUE QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
LDG LCr FLU# C
PERMIT ISSUANCE r
LICENSEDCONTRACIURSDF,CLARATION APPLIA CPS- ID L
p.z I embysffmt than l am l'acn,ad aldermovisims Of Cliaqu 9(comencencing with JOB DESC ON
�00 Section 7")of Division SarNCBminm,and Po.hrinces Cade,and an,liccnw is in PANE
C
full force eM cRcel. PTO /�
tGF.Z Cn,License Cla"s Lin.M
yD 6atc Gmtnnm 1
z 8N`_s O I SQ.FT FL AREA 5/SQ.h7'..
vsZ ARCHITECTS DECLARATION
�N�❑ Imdusatal my Plans shall rix usW as public rturtds.
T
NSE [CAL l/9 UV
QYF„s Licari Pmfexsinrul
K��Q OWNER-BUILDER DECLARATION SFE AL C1RCUIT/MISC.
0.XOaU 1 hereby affirm that 1 am emmM 's front the Comma Limnse I.w f
W 31r-vFi following tcuon.(Scnim]U31.S,BusiteseM Pmfccvans Cadc:AnY city TEMP.METER OR POLE INST.
Er�p� which reclaims a permit.rnn,wn,eller.improve.aemolnfn.m repair any im -
prior Loins issuenwelso tepuites note applicrnt torso hpenmh rofk.si®ted rn1 POWER DEVICES
a"KMp Oat he is licassul pum,uunt to the Prawn, ottifnhe Conrtn
aor's Lican.Law(Chapter
.9(commencing with Seoino7000)of Division 3 of the Business uxaio
l Profcru Code) SWIMMING POOL ELECTRIC /S VALUA O
'Z, Seen.
ee7031.5
031.empt any
plicarnfees permi,m bja .theitfic.,wn.AnylPartam of {v( 1 ��
FZQ Scnwn]OJI Sby any opplicnntfmepertnit wbjccu tM1e applicant toacivil perulry of Ef5-SWITCHES-FlX'R1RE51{
�_O mol mom than rive hundred inflame(SSW). NEW RESIDENTIAL ELECIR . . STORI TYPE
C� ❑ 1,a5 owrcofthe propeny,mmY emPlaYe�-,with wa8ee'vs thcirsolernmpemetion, S FT
Q CONSTRUCTION
p�,�� will Bothework;Code:
The Cor isnot Lu ictic"Law
10 an wemevf
and etyvelPrifeadma OMB:The vesmemon, n wcm taw ane not hionn if1.an Deana or
own
wnem loycesprovid d tmve.Ih imm,and won arcs sten work hitnseemcl through his
rntployccsgmidcd that each impmvrntrntu am not imcndcdm olfcrtd fm Nell, .G OUP RES.UNITS
however,the building or iarfsaw ett is sold withinma year.fcvmpinion,the owner-
budder
wnwbuilder will have the burden of proving Thu he did rrtt build or improve for purpose of
sale.),
❑ I,oawrcrof thn prapmy,am cxclusivclyronvxtingwithlicemed conlRenUSta QT' PLUMBING PERMIT FEE ELoGDZME APN
mn4run date project(Sec.](YM,Entities,and Profcato.Code:)The Contractor',
fAmuelaw done,tat apply to an ownuof prapepYwMhuildsarimpmvec 0suesq end PERMIT ISSUANCE
ucrnae l
wM1msLaw.aces fm such pmjccns with aamtradm(s)licrnsed purstanuo Bc Contradoie ALTER-DRAIN&VEWATER(EA) FEE SUMMARY
❑ I am exempt order Sac. .B&P C fm thio tenon OUTSIDE FEEN
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owns Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSA NDECLARATION SCHOOL TAX Y N
,] IMrebye amthstl have acmif a oto xlf-ineme,txa artiriate of FIXTURES-PER TRAP R Pr#
oRrn'Compnw--inion lnsurumc area ' thvmf(Sev3800.lab CJwhich PARK FEE Y N
mall employee's under plan pemat FA.SYSTEM-1 1 OUTLETS #
Policy# .DI O DI ION FEES
❑Continennttifed copy is hereby GAS-EA.SYSTEMOVER4 ON PLV1CHE
❑ Cueifed copy is E1d1 W ty ion. GRPASEAN STRL WASTE I CEPTOR G
r
CEI(TIFICATEOF OMWORKERS GR - A -� S .S
COMPENS O RANCE
(This seeminn�not be completed ifihe Prorm is for one hard! Buf($IW) JE =SANITARY,- 2WET"s ENERGY FEF.
Or Ices.)
I cutiry lnal in the peHmmarc<o[IM1e woh for whlcM1 tii,gamin is l ea,l,tell AIPR HGA
non employ any Penal in any manner en ae b reverter eubjeit to the Workai PND
Canpctsetlon Lawsof Caliromia Dam— �'s5 A Y TWG/ Duc R ipt
0 z Applleson
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,your EW
NR IDENTIAL PL9MSQ.FT. TAI:
(� haeme suhjcct to Ute Workcfa Canpcnuim pmrisiaro of the labor Cnde,ym mu,
foMwith canply with such ptovisionimthis pennit,M1ell bedmrred mevaked. BUILDING FEE
SEISMIC FEC
[] ma them —commUCTION mm.lanLENDING AGENCY
1 touchy affirm the then i,a intim tim krding agency for 0e pufomtmtre or
U ZO otic walk tar wman tnulmnit i,i.anm(sec.3B9],ci..e.) i. ELECTRIC FEE
Lanai Name
0 F LeoderSAmum_sc QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that I have read this application and made Pan he above infermat ire is -
FM1W. ctmect. l agree mrnmply with all city and coamy aNitarrn amnd, ro n.mluin,ni PERMIT ISSUANCE MECHANICAL.PEE
_ building onsomuction,and hemb,audanaeoremesentuiveof Ni,city to anter."the CONSTRUCTION TAX
U 'Z above-mentioned Proton,An inepectim peopme. ALTERORADDTOMECH.
(Wa)agnea IonavcJMemniry anal keep harmless date City or Caperton ainv
liebllinia,jud,mnts,costs and cxpnu'cs which may in sty way exotic apt=find City AIR HANDLING UNIT(TO 10,"CFM)
iter uerce of tee granting of this pamdf -
AIR HANDLING UNIT(OVER 10.000 CFM)
Si Curt of A,licem/Contranm Date EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTLE Doe Receipt0
W II me a,liaam on future building oavpam note Or hurdle nevrdotu metmsl
ac defined by the Cupertino Municipal Cade,Chapter 9.13,and the Haetth and Safety, HEATING UNIT(OVER 100,000 BTU)
Code,Sa025533(¢)?
11Y No VENTILATION FAN(SINGLE RPS[D)
❑ ❑
TE
Will the vconcwt mfmare building by the Bay
Ares An Quality which creno
BOILER-COMP QHP OR 100,000 BTU) ISSUANCE A
trier, av contaminants ss def tied by oho Bay Arca An Qaeliry Mutegement BORER-COMP(OVER 100,000 BTU)
I sln<t?
El Yam
Ya W P
❑No NERESIDEN'F AI.MEC L SQ.FT. % 1f)
I hsvc read be h mardous andenals recuimnemes ander CM1epra 6.95 of the
Californiaulcelo&Safety CWy,ave Sections 5,25533 ynaspomfi 1ardentud lMl AUG -8
Ctheiaing ealth Safety
nsveions t!)5, it ismnd 1553uibilitymnotify the AVG Y
I occupum of me ma,miumants which must be met poor to Wuantt of a Certificate of
Ownicrmauthonied agent Dater TO 1,: ISSUED BY "�'jryy
Q
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