26283 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO KICAL PERMIT NO.
suTLDTNc DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C O r
'hi'L`-':p',Psf BUII.DBid PROJECT IDENTmcAmobiAtirtR 5ryrl,( � o oZ
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMf ALDAI
Na U I� � /j �/ //vy�
sslu rT'�/•� UNIT» g LOT ��7 lLT
OWNERS NAL 4 cd66 PHONE: CONTRACTOR
ti4.L bQNICNI Y+" lafiK NAME LICNO:
b NIC CONTROLN
RCHITE ,ENGINEER: 'LIC NO: ADDRESS: ❑
T VIA'
o 17 s-1 l .
ONTACT: PHONE: 'Dn fLy��t 'SnF' .Amur" -.a.a«^xrs W..+ 1+igY' �fiSa &.tt".q?u�jIBUII.DING PERMITtINFO '"yri'y
ELECTRIC PERbll7'it a t'� + FEE
6C S.W�h?:r. r.€e,. l •I... �' ._ r. �t P UMB MECH
kA ? 66 311
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
=.zIherchy ufrom than lam licensedmdcrproviAcm,.fChupter0(cammencing with TOB DESCRIPTION
?OC Section 700))o1 Division 3 of the Business and Prefeuiuns Code.and my licrnsen in PANEISSjtl'
'-y+'1- fail force and dct
fe . ��•��rr
BZW License Class Lic.N lIPT0200 AMPS
Ly Q e- Date Contractor. 201-I"AMPS
O SQ.FT.FLOOR SISQ.FT.
Z ARCHITECT'S DECLARATION pypg TOO,Agog
I understand lhll my pans sabe used a public dc recors. ^
-u1 SIGNS ELECIIOCAL �e O
Licensed Professiond
=zx2 OWNER-BUILDER DECLARA7lON SPECIALCItNIT/hUSC.
yCaO I hereby affirm that I nm exempt from the Contrenors License Law for the
J3 tv.y following mount.(Section 7031.5.Business and Professions Code:Any city or cowry TEMP.METER OR POLE MST.
which requires a Permit to common.alter,improve,demolish.or mpa'v my structure POWER DEVICES
pyY� priorm in issuance.dm rtout.Weapplicont far such permit m fileasigrdsoumenm
C G that he is licensed puuano the provisions of the Contractor's License law(ChipsdSession%MC nn
9(commencing with 7")of Division Sof the Business and Pmns fessisCade) SWIhA1ING POOL E1ECfRIC VALUATIOryw�y-
y-y or the he is exempt thoofromand the basis for do alleged exemption.Any violnion of
FZQ
Section 703 L5 bymynpFlic.mfar.pormilmljecu the applicant at a civil porosity of quTILErs-SwIrcm-FIXTURES O
E=� not more than Eve hundred dollars(S500). NEW RFSmFNfU1 EIPCIRSQ.FT.f4F ❑ I.asownerof theproperry,ormyemploye«wiNwagaathrirsolecompcauion, STORI TYPE CONSTRUCTIOf
a3$ will
and dProfessionsooProfessionscswsioons Codec noCustomer's teLicense
e Law dosnor apply to an owner
xv
of
property whobuildsorimproven thereon,andwhodoessuchwmkhimselforthmugh hu
own smployees.provideddwsuch Improve......ins«dedaoffered hostile,If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year incompletion,theswar.
builder will have the burden of proving that he did raw build or improve for puryom of
..-rrsx vsx olvv_ui.srs' •.tfi.
sale.). x. avt
❑ I.wown«ofthepmpeny,amexclusivdymntzacdngwithlicemMc =11.rsto 9' �' HW iP�WK:'a'r' 'xt FLOOD ZONE APN
convect the project(Sec.7814,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License law do«not apply m.own«of,spon,who but Ida a improve Hereon.and
whocontmcta for such projau with aso m enums)Beamed pursuant to the Cwonica s ,;yt.v:a+'+• - -- -- -
LicenseLow. JDRaONS.FLOOrRIDY-ARE�,�qN
E FRES
LTER.DI`AW@VENT-WA7FR(EA) sT.t,M •,g,;yiry FEE SUMMARY. ��rs
❑ 1 am exempt underSec. .B&P C for ills reasonACK FL W P SID
a's ANIT Y Y N
Owner DateRECEIPI'N
WORKMAN COMPENSATION DECLARATION CH LTAX Y Nh'Cmpcfmmdonlmeveacertifiwco(consym mf(-39,o,a C)tw chIPFWmkcn'Compewtion lvuonm orecudfidcopy thereof(Sas.JB00,lab C.)which PARK Y Nit o
coven all employee's under His permit . YnaBW,DIN ION FEES
Policy NCompany AS- PLVREASFIINDUSTRL STE IMERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' REAiSTRAP SO
COMPENSATION INSURANCE
('Phis radon need not be completed if He pemtit is for orte hundred dollon($100) SEWER-S ARY-STORM EA 200FT. MOY
to less.)
I cenify Hat in the pedormuteeof the work for which lids For u isusd,Tshdl WATER TER WIVENTNI-ECTR
not employ any person in any muter m as m become subject m the Werlori PAID
Compensauonlawsef Cdifomia. Dem WA SYSIF.M/TRFATING Dau Reasons so
O Z NOTICE
Applicant RESIDENTIAL"B. SQ.FT. TOTAL:
Z 0 NOTICE TO APPLICANT:ILafser reeking His Certificate of Exemption.you should
IA became subject m the Worim's Compensation provisions of the labor Code.y—...
� forthwith comply with such ons or this pssm,"I be dcard rtvokrd. BUILDING Ss �n
,o
W Q CONSTRUCTION'LENDING AGENCY SEISMIC
a.� Z Ihertby of that there isoconnucdve lcMing agettry,f«thepdomoae of ,O,� ELECIRI FEE
U O He work for which this Permit is island(Sea.3097,Civ.C.) k"i �-
Undoes Name 11 Y ✓pNWMygpYAN:tY:Y!'., Z i.
IT. �"^& PLUM G FEE
ONF• gMECHANICAti PERMIT- F�✓}t '+t
LendersIcertify that 1 have read His application and wu dist du above infomudan is Y r 'Y" `�` 'z'aw+.'+x rnvua +�iunY ^»s+r
W correct.la ancom I with all cit and court rdinances and some laws relaun to PERMIT ISSUANCE MEC AMCAL FEE
gree comply Y county B
U Z move-nomawedve.wd barely audience representatives vuof this city menta«open the CO U ONTAX
UZ abovememtigree property far mnify and Jump
ALTER OR ADDTO MECH.
(W)agree m save,indemnify and kap my in the City e f Cupertino against
liabilitiee.judgmenu,cosu.dexpens«which may in any way ucrveageinrm add Ciry AIR HANDLING IINIT(T010,000 CFM)
n cansryu of granvng of - .
1/. � AIR HANDLING"IT(OVER 10,000 CFMI
•S outc f ApplicanUConuxmr Date EXHAUST HOOD(WMUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Due Raei,» 1
Will the applicwtor loom building oocup.umu or handle hawdom material HEATING UNIT(OVER 100. TU) L:
a defined th applicant
ns Mwicipd Cade.Cha,tt 9.12,sal the Halth and Sdety
Cale,Section 25332(ali VBNT7{,ATION FAN(S LE RFSID)a r
C]Yea ❑No
Will theapplic.m or future buildingaacup.mseex,ipmemordevice whichemit
BOIIFR-COMP POR 100.0(10 BTU) ISSUAN ATE
hazardous air comuninunms us defined by the Bay Area Air Quality Management BOILER-CO OVER 100,000 BTU)
Dilute!
1:1 Yet 11 No NEW RE FN IAL MECJL SQ.FT. fl ,{
f ry '
1 have real the bawdnus materials reyuirtmcros under Chapter fi 93 of the
Califnmm Ilcahh&SafetyCWe.Sections 25505,25533..1'_5530. 1underu..1Har fS R
ifthe building does notcunendy have a tenant,that it is my ropoaibili Yon
mib the AP
occupant of lite requirements which mart he met prior to issuance of a Cenificau of
(Xcupancy.
Owner or amhoiizrd anent Dote TOTAL: ISSUED BY:
OFFICE
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