26294 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •.1oL I MAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
26294
rw,fd+�`t;:$ BUILOBVO PROJBC4. CATONPFura%18V"
ILDING ADDRESS: SANITARY NO. APPIJCATIONSUBMITALDATE
O ✓ r/IPI\ �/ . UNIT# LDTN I�^y ✓T
OWNERS AP NE: CONTRACTOR'S NAME: LIC NO: 1
�_O NIC CONTROL as
.RCII /PNGINE•ER: LIC NO: ADDRESS:
u� r F S
CONTACT: PH- ON�� ea.m xuW"' r, ro - •+ yf
C4� { swa?�:BDDnBaaPeulDrwFo
�5( '°" a'i'✓v k+ ig' g"' }�,w'sitF�?J ELECT PLUMB MECH.
f/L/J ► O W'L, 1 PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION IAPPLIANCES.RESIDENTIAL LOB DESCRIPTION
IWz Ihereby efOntM
n ,l em licensed and,rpommm
visioruofChaprm9(cocing with
400Section]000)of Diviai a( a Business and Professions Code,and my license isin PANELS
W full force end cRecL
:Zw Llan s Lic.N UPTO200AMP5
16 rn Contranac 201-1000 AMPS �—
y. 1'IF.CI'S DECLARATION OVER 1000 AMPS SQ. .FLOOR AREA $/SQ.FT.
C, 1 un me pl s ell beJliCdae pub'
yi_-W c WP�WL
Q
.$W Licensed Pr Y �� � t1O
C OW - ULL.DER DECLARATION
3iU 1 herby dfmn that I am eamryt Trace the Conuuwls License law for she
'wFi following tawo.(Smdm7031.5.Busirou and professions Code:My city or county .
y which recover a pemut w common,alto,improve.dmmlish,ac repair any s ncwts, L
35`2 pia to is is.,alw rsryiro the WE.,for..pmts to fit...i®td amemmt
GO Nat he is licensed pursuant to the provisions of the Coarses s License law(Chapin
;o�i 9(rommencing with Sectio]000)of Divuim 3ef Ne BusEsss std Pro(mimu Code? VALUATION
jay or drat he hi.m ptherefom ad the basis for Ne alleged,mrapdon.MY vi.letion.lai - ./^�
.ZQ Section]051.5 by my applicant for a Perini,subjects the applicant w a civil penWry of ITTLETS-SWITCHES'FIXTURES l/V1
,2 not mare thin five hudrid dollen(5300).
�C$ ❑ 1.uownenofthepoperry.amyanployecswiN weguuNeirwlerompenution, NEW RESIDENTIAL ELECIR Q.FT. STORIES TYPE CONSTRUCTION
-3� will do,he Work.Code:
The Cure U.Law
does
We(Sec.]U14,Buaimof
41d Pmfdainm GdC:The CmlmKlnra LI RIme LOW daJ nn OPp1Y w N OWMf Of
pmpenywhobuil&wimprova Nereor,mdwhada suchwoAMi lfmdu ughhis
woemployas,novided p
thwwchimovemensuerw,imnMa
WoRcsd Tarsals.If. OCC.GROUP RES.UNITS I
however,Ne building m improvement is sold within one year of mmpl,tion,Nee"..
builder will have the burden of proving that he did not build in improve for posPose of
We.). rrtw r('6tii EEO
:�.r �cma.��u'..ir.^�sd"�Na"
❑ 1,uowmrofNepopeny,emexclusivelycm=m ngwiNlicensedconlnnmaw �'yrp(,-f,,, t O 1 si ji,�y"t5s'-] 11m,
FLOOD ZONE APN
ronswn the project(Sec 7044.Business and Pofessie s Code:)The Cantracwls
UnermLewdoueoapplY tomownerofpropertywhobuilds acimpoves dormer.andPERMTf laS
U.law.
whocmtnesfacsuch prnjecs with a contractor(s)licensed pusumt w the Conu nars .�_b.� ...�r.;,. _ I
ALTER-DRA IAt - A!!L + PEE SUMMARY/' L •'v s
::4;11-�ra'aX+� _ u.:dki.:?'iF i'�'''
❑ I un comp,under Sec. ,B A,P C Por is reason e:. d ,
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner WORKMAN COMPENSATION DECLARATION DRAUJS-FLOOR ROOF.AREA,GOND. EC6IPTN
SCHOOL TAX YN
_ ❑ Ihcrtby alfitm tlwlheveamdOw,ofsnnsent wself-insure.are anifcuc of p�yRFS-PFJt.1.RAP RECEIPfN
Wwtni CompewtionlmurmcemacertiBd copYNerco((Sm."DO.lab C.)which PARK FEE Y_N_
raven ell emplayme's uMer this pemdL GAS-EA.SYSTEM-1 INC,4 OITHETS RECEIPT N
PaEry N BUILDING DIVISION FEES
Compmy GAS-EA.SYSTEM-0VER 4(Ek) PLANCHECK FEE
❑ Cmifled copy u hereby(untishd.
(3dropy'u fJd with Neriryimpcction division. GREASE/INDUSTRL WASTE INTERCG
EPTOR RADINGME K
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE 02
COMPENSATION INSURANCE
This sectiouncd notbe completed ifthe permit is feroneheadtd Mtm,(SIOO) SEWER-SANITARY-STORM EA 200FT. ENERGY FEF
mleu.)
I ttrtifY dist in Neperfomm�a of Ne work for which Nis penmit is issud,ISIWI WATER HEATER W/VENT/ELECIR
not employ my person in my manner w as w bean...him in Ne Wodceni PAID
Compensation lAws of Califonds. Due WATER SYSTCM)TREATBJG Data Receipt N
Applicant
O NOTICETO APPLICANT:If.after nuking this Caditcetecf Exnnption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
.LI).t bamnewbjactmthe Woher Compensation povidouof the Labor Code,you mut
' forthwith comply with such Provisions or this permit shall be dated revoked. BUILDING FEE (ov,51
w,J
j Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
tI hereby afMN
n at Nate is s casmutia
cn lmdirg egmry for the perfacmma of
t O she work for which Nis pemtit is issued(Sec.7097,Civ.C.) T FlECTRIC FEE
Leder.Names,t,.«• �yx7lraeRao+xv[cet.'nr'@ �-..l :nr,:.w
'`I a } PLUMBING FEE
Leader's Address t,f:: MEOMNICAL'PERMIT y� T•. fes,
I certify Net 1 have red this application and cum that the above infamratim is �' '' S!?:'Cl-
6.Uj correct.l spree w comply with a 11 city and cowry mdinences andsuo laws rtlatin". PERMIT ISSUANCE w MECHANICAL FEE
fn building cim ucdon.and herebyeuthaclu representdva of this coy,, t,,.,n the
i Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. / CONSTRUCTION TAX
(We)agree,o rave,idvmily and kap herridess dte City of Cupctino against
1 bilitin,jdgmms,ecesendespmseswhichmey in my way uctueapainat said City AIR HANDLING UNITITO IO,OWCFM)
Co. Ne goadaNraFYsiI pe
\ C� AIR,HANDLRIG UNITIOVER if"CFM)
jilIEtturcofApplittent/Contrectur Due EXHAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Data Receipt p
Will the the Cupertinor o
futurebuildingCodec Chapter
moor handle Health and Safety
BEATING UNIT(OVER IOOAOO BTU) TOTAL:
u defend by the Cupmino Munidpal Code,CTepur 9.12,and the Health and Sa(ery
Code,Section 8512(11)? VENTILATION FAN(SINGLE ESSIG)
❑Ya ❑No
, `^
IS J,144CETIATE
Will dosppliantafuure Wildirs occuptuseequiptacdevttwhicht BOILER-COMP(3HP OR 100BTU)
`t t fj
hermdous air comeminms as deMd by the Bey Area Air Quality Manegnum, BOILER-COMP(OVER 100.000 BTU)
)tamed?
❑Yen [3 No NEW RESIDENTIAL MECH.—SQ.FT.
UN a 51994
1 have reed,he hareNous metenisls recuiremenu under Chapter 6.95 of the
Glifamia Hg N&Safcry Cede,Sections8305,855Jmdns215atSM ilhndarmalfdy e, LVrCnlll
if the huildin docs not cunmti haves wnanL Net i,lam
Occupant of Ne requ'vemens which must be met prior to issumce of a Cutificau of
Occulsncy.
Owner car sudwrired eget. Data A ISSUEDBY:
OFFICE