26989 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES"USE BALL POINT PEN ONLY
CITY OF CUPERTINO HU¢DiNG-FULL I'RTC tPERMITNO'
BUILDING DIVISION APPLICATION/PF,RMITPLUMBING..MECHANICAL, n C n p n
IIUILDING PROIBUIT IDEN'T'IFICATION G v J O J
>.DDIIINN/O AADDRI3g5: ��///J�� �/uy SANITARY NO. APPLICATION SUBMITTAL DATE
V3 ,MSP' �• UNH'll LOT#
NEMS NAME. P ONI3: 0 CONTR / E: LIC NO: - c
Rilll'fECf/BNGINEER: ....._....._..�._. .IC NO ADOBE S: IF
❑
O1/NTA QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO
BLDG ELECT PIAMB MECII
........._._..........:.::......: :..:L.T.:..S. -.!. .. . . PERMIT ISSUANCE �. ❑ . ❑
LICENSCD CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I Lerch fEnn thml um licensed under p gwi B SC PION
OCZ Yar provlelo snfCTa to 9�(mmmmin with
Pis00 Seminn]OB0)oPtlNisibn'J M1fdi4Riauti&7icaSAiekssinns Code.vnd mylicenu is in PANELS „J
z,t roil force and effect.
IQ„Z' License Class Lica# UPTO2WAMPS
wjy Dam ^ traetw•--• - 201-H#O AMPS
ZOyZ ARCHIfff.0 SrT'UiRAT1(lN. OVER 1000AMP5 SQ.FT.I- T.
.00R AREA $/SQ.I
0 P-, 1 undersm ul my plans shall be Lsed tt
as public rorJs.
pwF� SIGNS ELECTRICAL
Licensml Pmfessriuj_?;,;,;-;;:;;—y' — -
d`aa'6 OWNEMBRUER'OFCURATION SPECIAL CIRCLTEMISC.
OaU I hereby alfrm that I am e;inpt from the Commetors License Law for that
Say following mason Section 7031.5.BLsineasand Pmfesei.ns Cattle:Any city nr county TEMP.METER OR POLE INST.
�_1 which requires a Permit t0 construct,alter,improve,demolish,or repair any srmtmrc
}$ prior to its issuance,also requires the applicant for such p arraitto file a signed statement POWER DEVICES
that he is licensed pursuant to the ErpyHqui p[Ihe Cmttrauats License Law(Chapter
9(commencing with Section']000)'01T)NI556K3 orIff"mahEsi and Professions Code) SWIMMING POOL ELECTRIC VALUATION
�r^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-f WITCHES-FIXTURES
I-ZQSection 7031.5 by any applicant for alermit subjects the applicmd m a civil penalty of
$SD no marc than five huWWtVah W350=a'=2:_:':.. NEW RBSID[.NTIAL ELECfR _SQ.FT.ElI;asowncraRhepmn rty,ormyemployaswithwagesastheirsolecompensation, STORIES TYPE CONSTRUCTION
will do(lie work,and thestrucmre is not intended or offered forsalu(Sec.? 4 ,Business
and Professions Code:The Catatnmwr's.Liceaxr6awdres not apply m un owner of
propsnywhotiuiWsorimpmves thereon;endwhodaes sued work hitnselformayugh his
own employees,provided that such lmpmvenamtsure not itnendedor offered fmsele.IL OCC.GROUP RCS.UNITS
however,the building orimprovement is sold within o_eyeUgfcgpcplabon,the owner-
builder will have the Kuillof prbaiiffixSMid,mn pudd or improve for Purposeof
sale.). .-..•..•- -.
❑ Las owner(it(Ile prulerty,not exclusively counracM1ng with Hcensedenmmmmsit, QTY, PLUMBING PERMIT NGL; FLOODZONE APN
construct the project(Sm.7O14p Rsmnm We:)The Concentrates PERMIT ISSUANCE
License Law doeanoo apply roan ownerofpropery wbobuildsor impmvesiltereon,and
who contrasts forsuch pmjccts with it contractor(a)licensed purauanuu the Conlmcmrs
License Law. ALTER-GRAIN&V13NT-WAIT?R(HA) 1$B SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this nation BACK FLOW PROT[CT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. krrTifor
WORKMAN CMUTN=a1ZDECLARATION SCHOOLTAX Y N
❑e lhco, '. muhatl bnveacenifiwte nfconsem rat selGinrure,oracenificated FIXTURES-PER'I'RAP RECEIPT#
token'Composition lnsmnce,.1.certified copy thereof(Site3800,Lab C.) inch PA RK FEE Y_N
rs all employee's undglbis.petWil„�Ny.....•—�•-• GAS-EA.SYSTT:M-I INC.40TTLITS RECEIPT#
Policy# BUILDING DIVISION FEES
Company3C
❑ eti GAS-HA,SYSTEM-OVER 4LEA) PLANCI IVCK FEE
mified copy is hereby famished.
❑ Cenifced copy is fled wRh'X1Ii j.WP;Zeir'di�= GREASEINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FARMPTION FROM WORKERS' GREASCTRAP - SOILS FEE
.COMPFSISA2]LNANSUMNGC -
(This section need not b'ecompriiTll'W'pinnit is!aeon hundred dollars F$100) SEWER-SANITARY-STORM P.A.20O17. ENERGY FEE
or less.)
I certify that in rhe performance tfthe work(oSwhigbdltisPcntsit is issued,I shall WATER HFATER W/VENT(ELECI'R
nor employ any person in any rMOAerLN:#sar:.beam2euhjeu-to the Workers' PAID
Oz ppl cam tion Luwe of Culifnrniu.'DetE”" WATER SYS'I'13MtTREATING Dam Receipt#
O Applicant
NOTICE TO APPLICANT:If,after making this Certificate dExmaption,you should NEW RESIDENTIAL PLMIL SQ.FT TOTAL:
Fi/1 become subject to the Worker's Compensation provisions of the Labor Cole,you most
forthwith comply with such provisions nr this pcnnit shell be deemed revoked. =MECHANI�L
EE
W (� CONSTRUCfION'CpYprRGAOF.NCY
5 1 hcrcby nffmt thanherc is a cnnstrvetinn lending agency 6r the performnncdof
U 'he work for which this permit is issued(Stt.109],Civ.CJ E '.
O Lender's Name . ..........�.,.., v..v a--
OU. P' Lender's Address - QTY, MECIIANICALPBRMIT FEE
W I certify mar 1 have read Nis applicatirm and some mat the above infmme e.is L iE
>' a cancer. lugree memmply wire,atkcilyandsoum ,a tltn.,encexnd stntehws mlmfng to PERMIT ISSUANCE
H r,C build,.,coadmJ(io.r.WIieieb'y'uutlummeoepreshmemvee ofthi.4 city to enter upon the '1ON'TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree ire,in mnify am0 keep haomlms mCM g[ pert o against
Erbilities,judgn Its, os,a iH-pp"-" -trey rvayac gait tax City AIR HANDLING UNIT CEO 10,000 CIM)
in nacyuenc dth grin ing'�tsl x
{Eir AIR HANDLING UNIT(OVER 10,0X0 CFM)
Signuturo of Al dicant/Coomm44 !"t. Dat f IAUS'r HOOD(W/DUCG
PAID
HAZARDOUS MATERIALS DISCLOSURE ATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant score or handle bavardnus material -
asdefinedbyOmCupertinoMunicipalCode,Chapter 9.12,and the Health and Safety 11 TING UND(OVER 100.000 O'I'U) TO'T'AL:
Cade,Section 25532(a)? VENTILATION FAN(SINGLE BESIDE
11Ycs -❑ NB`;:.ti�._fL�......_..
` HO11.13R-COMP(JHP OR 100.0,H)RTU) ISSUANCE DATE
Will theapplicant or furorebuildingacuPant use equinnu mordevices whichemit
h1and'm air cnmaminems as,dafmW,by.h.,B,,Aoeu;Air Quality Management BOILER-COMP(OVER 100,00OBTU)
❑yes 11 No~' NEW RESIDENTIAL MECIL SQ.IT. qq
/I have read mm hazanloaF uiusWvaiL:wyitirerrwmw under Chapter 6.95 of the �� W �•
Collf.mia Ileahh&Safety Code,Sections 25505,25533 and 25534.1 understand mut - 4/
if he building does not currently have a tenen0 mat a is my respatmaibility m amity,the �
ccrio nt critic mquheamnts.whic8Q
ls,moat M mm#pitrmisavancaof o Certlfute of 19 o
Occupancy.. . .
Owner of manhood aed agent Datet
T'O'TAL: ISSUED BY:
OFFIC
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