26628 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-El: RICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT, PLUMBING C'l IDENTICAL 26628
IIUIhI;ING P120J6(YI'IDENTIFICATION
BUILDING ADDRGSS: - -, 1 . ' SANI'T'ARY NO. APPLICATIONSUBMI//TTyyAI,DAIS
�J V\ �
W UNIT# LOT# �_2'y�►�
OWNERS NAME: PHONE: CON'IRACI'OR'SNA LIC NO: —` l�
NIC CONTROL
•ARC]II'I'ECI'/BNGINEI312: LIC NO: ADDRESS: ❑ �g /
CONTACT: PHONE: BUILDING PERMIT INFO
ZQl'Y, ELECTRIC PERMIT FEC
Lp IlQ EI ' P M UMECII
PI?RMD'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IOIi DISCRIPfION
ptyZ I hcrehyaffirm Nal l um licensed under pmvisiomofL apmr9(cotmnencingwith
IY00 fullSection
rceand)nf Division3 of the Business and Professions Code,and my license is in ppNE1S
FyZW fullforceClad effect, UP I'0201)AMPS
<< t� License Claus Corm ROD
IOD. Date Commcmr 201-I"AMT'S a
Z ONZ ARCHITECTS DECLARATION SQ.FE FLOG AREA sfSQ.FT.
OVER 1000 AMPS
OZ O 1 undersmnd my plans shall b,used as public records. 1
F� W� SIGNS ELECTRICAL Licenxnl Prnlessionel - a/1--111+1'
a OWNER-exempt ?R n the CoATION gPEG1AI.CIRCUIT/MISC.
iCO0F I hereby affirm that 1 urn exempt from the Qssions ra License Ism for the
:yl
which following rtaua.ermit to construct,
Business and Professions or repAnyair
city or county POWER
ETER ORVICES M]LF.INST. #�Q
j=�yM poor
to Is tisane.alsomconstheapmr,imfrsuchcmanifttmrepeig enYsmctum
f Y� pdurto stn issuance.also requires the applicant for such pclmiuo fileasigrrW statement
POWER DEVICES
µ�j p Thal he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
d m cmmencin th Suet on 4000 f Division 3 of the Businevsand Profeeslam Code) SWIMMING POOL ELECTRIC
9(u -
Wou, bwl )o VAI.UATION�
yYjtim
Seor ction
hciaexempt
any applicant
f the bmiefomhetsflicalleged exemption.Any violation of UTLES.SWITCHES-FIXTURES
�ZY Se home.h. iv eanaeddrmlfmapermit subjects the applicennoecivil penalty of
not more than five hundred Anlims(f3110B.
K
y3,2 w ❑ 1,a;owneroDhepmpeny,ormyemploycawithwegesustheirsolecompmuation, NEW RESIDENTIAL ELECIR _SQ.FT. STORIP TYPE CONSTRUCTION
will doahework,and Nis
e structure notI codedornffereAfur eale(Sec.RHq Bminem
uod Profesaium CMe:'I'he Cown.Ur'e License Lav,does not apply m an owner of
property whobtildsorimprovcsthereon,and whodoessuch work himselforncrtmgh his OCC.GROUP RFS.UNITS
wnemployees,provided that such Improvementsaremot intendedoroffcredforsate.If,
however,the building of improvement is said within one year ofcompletioo,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owner ofthe pro)mny,am exclusively contracting with licensed contractors to QTY' PLUMBING PERMIT FEE ITOOD ZONE APN
constrict the project(Sec.7044,Business and Profession;Cale:)The Contractor a PERMIT ISSUANCE
License Lewdoesnut upply m on ownerof property who buildsmimpmvcsthercon,.d
who contracts forsuch projabwith v contractors)licensed punn
uano the Commences ALTER HEA)Liatru Luw. ( FEE SUMMARY
❑
In exempt under Sec. ,B&P C for thin moron BACK FLOW PROTECT.DEVICE. OUTSIDE ''
SANITARY Y N
Owner Dare DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT#-
WORKMANCOMPENSATIONDECLARATION SCHOOLTA% Y N
❑' Ihemhy nffinn thntlhnveacenificme nfconunt tv self-insure,Ura cenificete of RECEIPT
Workers'Compereation Insurance or acertified copy themof(Sec.3800,Lab C.)which Fl%TUkFS-PER TRAP I
� PARK FEE Y N
coversall employee's mndenhispermil. GAS-EA.gYS'IEM-IJNC,4OUTI.IRS
Policy# UILDI G ISION FEES
CompanyCe" GAS-EA.SYSI'EM-OVER al IRA) PLANCHF �y
❑ GertlfiM copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASE INTERCEPTOR GRADI
CF.RTIPI A'I'I?Olt CXEMfTtBiFROM'WO KE7R� GREASE TRAP S i
COMPENSATION IN -FRANCI?
('ITisaectiouneMrnl be completed if the permit is fornne hunSEWER-SANITARY-STORM EA.200FT. ENERGY FEEorles.)I ceno'ythorn th perfomamceofthe work for which this perWATER HEATER W/VFNT/ELECI'R
.at employ any per, in any manner a ax.to become subject to the Worke PAID
7-. Comprnsmion Ltwso Culifnmia.
Data WATER SYSTEMITREATING Date cccipl
Applicant
Z 0 NOTICH1OAPPLI NT:1 after hs c of Exemption.you should NEWRESIDENTIALPLMR, SQ.Ff. OTAL:
F V2
becomes m the o o - a he Lobar Code.You mist
a 7 forthwith comply wit s or this permit shallMdeemed revoked. BUILDING FF. —
VL11 (� CONS R CTION LENDING AGENCY All, SEISMIC
Z Iht forvi is Oa he eco dttRd Vr)ey rjle#erfonnun of 1' L
O the.,,,it Name ch rmi Is issu e[!'�U9 1 J
Lenders Name D
Q U t<nd Address 'v QTY. MECHANICAL PERMIT FEC PL IN I EEE•
I certify that have read This application ly state rhat the obo-e�
r1^ W
correct.lurecm m l Ih ail cit Jwwm nNinancm and etble roma rclatio to PIiRMTTISSUANCE �. MECHANICAL
y n pyhe yon Y 8
'U Z Tiff
buildingcanetred n, ill for im nthorizpmjp eourives of this city upon the CONSTRUCTI TAX
L) z abov Wimioned pony forinxp41»putlmua. ALTER OR ADD TOMEC#.
(We)agree w comfy and keep hmmleu N<City of Cupertino agaimt
Fabilities.judgmence,cost,and flxpen hich yinany weyoceme agninsuviJ City AIR ItANDLING UNIT(TO 10,0Ltl CTM)
rnming of 's panto wg AIR HANULINGUNIT(OVER 10,UWCFM)
IQ ✓2
Sig ammo(AP1Ji—bConl nor Da EXHAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0(10 BTU) Dm t _� Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 p'fU)
ride- d by the Cupertino Municipal Cale,Chapter9.12.and the Health and Safety
Code,Section 23332(e)?
11 Ycs ❑Na VENTILATION PAN(SINGLE RESID)
Will the uconta manus its defined
by me
tuy Area Air Quality Management BOILER-COMP(3HP OR I00,f#10 BTU). 11 'HANCE ATE
huzardnu.v air contaminants its defined by the Bey Area Air Quality Management
Dlsttlfl4 10 BOILER-COMP(OVER 1000BTU)
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IT. A B
I have rend the hicoSafety
Coe motion,reyuirtments under Chapter1 vas 6.93 of the �'9
California Ileahh&Safetyently 25505,25533 it sand,lumai 1undersand That (f�; q
ifthe huilof the snotwrtemlhich mushave a t
be nice ois to issuance
Cedrto ionthe /y /M�
Occupant of the reymirements which muss he ren prior m ixsuunce of a Cenificme of
Occupancy, n..,.
Owner m mithonzM agent Date TOT ISSUED BY: C _
OFFICE