26828 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINOI IhDI .-6L
1, ,TR1 AL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 26828
BUILDING ADDRESS: ef4epa�'[ SANI'T'ARY NO. APPLICATIO��1N SU//UBB��,MITTAL DATE
� a�'S �L L UNH'p LOIN &:2> s
OWNERS NAME: /�� /N,rJ pPHHOONE: CONTRACTOR'SNAME: e!t&LIC NO'. lll���JJJ NN'F �.
T&
_fyy_- `!&M -kms+ 2v'-27 iJ 5 V, 1i� . ._��` SIC CONTROI,N
ARC111t'GCI'/1iNCHil LIC NO: !rJ ADDRESS: ���VL. Q, rs_ MI, /�Ld�
i Z ktat2kc e.lo Ls23Z S+F %, P4I� Tet b7-�� U-(q
TAR
NTACT: PHONE:all QTY. ELECTRIC PERMIT FEE - :BUILDING PERMIT INFO
steel� �. d7�� SLUG 1..LECI' PLUMB Mf:CH
�k 1i 4 —S—W.I , PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DISCRIVOON
Zxz Ihereby affirm that l am licensed unterprovisions ofatipter 9(commencing with
�00 Second 70W)rf Division 3of the Business and Professions CWe,ond any license is in PANELS
W full force and effe}c..� --
F,ZZ ac License Cloves Lic.N 157-1 N'?S UPT02M PS
vfGy One Contractor 201.IOWA
ZONZ ARCHITECTSDECLARATION OVER IOW S SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0
1 undemanJ my plans shall be uxd os public records.
m SIGN. E AL
Q� ',...�)) Licensed Professional
d'ky.CQ OWNER-BUILDER DECLARATION IA CUI ISC.
N,F 1 hereby affirm That 1 um exempt from the Comm mrs License Lues for I
� followingmromr.(Senion 7031.5,Business and Professions Code:Any city.,county TE .METE RPOLEINS'T.
y which requires a permit 10 conslNcl.uher,improve,demolish,Or repair any swcturc
KWQFto its issuance,also re the applicant forsuch Ito filen grindatalemem OWER DEVICES
pont quires pp pemtie
y)K�pC that he is licensed pursuant to the provisions Of the Contractors License Lew(CM1apter
,L 9(commencing with Scemon7000)o(Division 3 of the Business and Rvfessin is Code) WIMMING PoOL ELECTRIC VALUATION
W_,ret or thin he is eacmpuherefrom and the basis fanhe alleged exemption.Any violation of
�zQ Section]031.5 by any applicant forapemlil suhjects Ne applicant m.aivil penalty of OU'I'hETS-SWITCIIIiS-FIXTURES
not more than five hundred dollars P1500).W NEW RESIDENTIAL ELECTR _SQ.FT.0 ❑ [.as ownernflhepmpeny,array employees with wngesastheirsolecompcnsation, STORIES TYPE CONSTRUCTION
a will dolhe wmk,nnd the smsalure is nor intended orofferW for safe(Sec.7044,Business
and Professinm Cade:The Comment",License Law does or apply to an owner of
property who builds c r improves demand,god who does such work himxlf Or through his
own employees,provlded Nm suchimprovemems srenot lntendedoroffered forsale.If, OCC.GROUP RPS.UNITS
however,the building or improvement is sold within oneyearo@ompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ LmowncrofNepNpenY.emexdusivelycommctingwiNlicenaeeconwnorslo QTY.. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7344,Business add Professions Cede:)the Contractors PERMIT ISSUANCE
License Luwdnesdm apply For ownerof Innipa dy vembuilds mimproves thereon,and
,memntmers Rnrdch projects wiNaaommctods)licensed pursuanuothe Contractor's ALTER-DRAIN @VFM-WATER(IA) FEE SUMMARY
License Law.
❑ 1 nm exeunt under Sen. ,B @ 1'C for this reason BACK FLOW PROTECT.DEVICE 011'1:IDI.I Im,
ANITARY Y N
Owner Dale RECEIPTIt
DRAINS —ROOF,AREA,DECLARATION
Ihereby affirm lharlhavencenificnte of conxnno xlGinsurc,ora unificateof RECEIPI'p
FlXTURFS-PER TRAP
N'orkcrs'Cnmpensarion huumnce ora ceni6ed copy Nereuf(gec.3800,Lab CJ which PA Y N
s ? covers all employee's under this Permit, GAS-Ea.SYSTEM-1 INC.4 OUTLETS RF.CF.IPI'N
wao
Policyp ❑URDING DIVISION FEES
Company
Cenifed copy is hereby furnished. GAS-EA.SYSTEM-OVER 4(EA) LANCHLCK FEE
❑
❑ CerdfiW copy is filed with the city inspcainn division. GRHASE(RDUSTRL WASTE INTERCE R GOADING FEE
CERTIFICATIi OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPHNSATION INSURANCE
('this auction need not be completed Him Permit is for One hundred dollars(1100) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE
.1 last.)
T cenify that in theperfnmmnce of the work for whichlhis pennil is issued,l shut) WATER HEATER WNENT/E1EC1R
not employ tiny person in any m as Ira become subject to the Workers' PAID
Z
Compensation Lawsof California. Dare so WATERSYSTENUTREATING Date Receipt It
Applicant DO NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RFSIDENTIALPLMB, SQ.FT. TOTAL:
a-, account,subject to the Worker's Compensation provisions of the Lahr Cot you must
7 Roosting comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
Lt1 Q CONST RUCTION LENDING AGENCY SEISMIC FEE
Fz I hereby affum that there is n construction legitimating ency for the pedornance of ^�
U C) the work mar which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE51
Lender's Name PLUMBING FEB
0 U Leader',Address QTY. 'MECHANICAL PIiRM17 . FEE
1 certify that I have read this application unit state that the above information is
>i k,
correct.l agree to comply with all city and county ordinances and suite laws relating to PERMIT ISSUANCE. MECHANICAL FEE
F-' building construction,and hereby authorize representatives ofthisciry to enter upon the CONSTRUCTION TAX
V Z above-mentioned propery for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnity and keep harmless the City.1'Cunndin,against
liabilities,judgrtienls,cosrs and expenses which may,to my way,sccmeagainst said City AIR HANDLING UNIT(TO 10,000 CFM)
I.amoviumee of he gmnring of this permit.
pp AIR HANDLING UNIT(OVER 10,0110 CFM)
Si w a p V ammcm! Doc EXI IAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Recaid#
Will the applicant or future building meaning store or handle hazardous material
as defiand by the Canadian Municipal Cale,Chapter 9.12,and the l lealth and Safety HEATING UNIT(OVER IOOOOO BTU) T
CWC.Section 25532fu)7 VENTILATION FAN(SINGLE RFSID)
11 Yes El No
BOILER-COMP(311POR IOLOOO RTU) ISSUANCE DATE
ham,air
applicant or Poore building by the ay equip menmuality Management ) W
hazardous air conHminanls as defined by the Bay Arca Air Quality Management BOILER-COMP(OVF:R 100,000 BTU) If LLY
niamiclr
❑Yes ❑No NEW RESIDENTIAL.MECH, SQ.17. /I�N� '/
1 have rend the hazardous materials 5505,25533a under Chapter 6.95 of the AVG /994 y
CaliforniaHealth&emadtSafety Code.Sections 25505,ementand 25534. 1understand that
if he building does at currently have a tenant,that it is my meponsiailiry m notify the G/Y Lil-
c as of the requiren0enrs which must be met prior m issuance of a Certificate of
O ` (
Occupupancy.
Owner Or outhorizW agent Dote TOTAL: ISSUED BY:
OFFICE