26703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Q1�-�'-FI'��' TERM[ NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26703
BUILDING PROJECT]BEST'IFICAI ION
BUILDING ADD'RESS':: /� I� F/ D SANITARY NO. APPLICATION SUBMITTAL DATE:
ZOT `I 1 9C/_ OPEI,, �f UNIT LOT � ��
OWNERS NAME: ^S F/uCclisa �+��'��OJ
CONTRACT MB: LI l
/.l ✓ L O(� NIC CONTROL#
•ARCHITECT/ENGINEER: LIC NO: ADORE S� All,
ST �Aul�O^� ❑
CONTACT: PHONE: •{s t <s , / O�q r 1 ., J
���nn�•f //–���I/� 9 QTS. $ ELECTRIgERMIaT' .� - - FEE BUILDING PERMIT INFO
�V/•t / J / sem' gml /p/ -60 O PERMIT ISSUANCE BLDG ELECT PLUMB MI:CH
❑ ❑ ❑ "IF
LICENSED CONTRACTORDECLARATION APPLIANCES-RESIDENTIAL
p y�y Ihereby uflirm that am licensed undcrprovisiovidenrsofCheumr9(commencingwim DESCRIPTION
DCRIPI'ION
FJ0p�0F Section](100)of Division3 of the Husincsx end Rvfeui.m Code,end mylicerlse is in PANELS
y Uk3 full force and effec
ayzW Licemc . �_`0 Lic.N —`""' r `� UP TO 200 AMPS �k„�ysa� ��
y?y Date�Cram q 201-IOW AMPS
y FO,Z ARCHITECTS DE A TION OVER 10110 AMPS SQ.PI'.BOOR AREA E/SQ.FT.
O z„ I understand my plains shall he used as public records.
FyF� SIGNS ELECTRICAL
Licensad Professional
89 C�6 OWNER aimmo IRtome CmATION SPECIAL CIRCOIT/MISC.
ip�,OyU 1 hereby serif ml mm 1 am exanpt Inatome Canuecmr's License Lew for the
t iN following reamn.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Bioon s which requires a permit to construct,alter,improve,demolish,or repair any etNclum
{f{vo�rM prior to its issuance,also requires the applicant for such permit to rile asigned statement POWER DEVICES
m K G m that he is licensed p r aten t.the provisions of the Contractor's License law(Chapter
L 0111
4 9(commencing with Section]00()of Division 3 ofthe Business and professions Code) SWIMMWG POOL ELECTRIC VALUATION
X,_y .,that he is cxanpnhated in andmi,basis for the alleged exemption.Any violation of OIJTLITfS-SWITCHES-FIXTURES
Cys Section 7031.5 by any applicwnfar a permit mbjedslhe opplic.t1.a civil penalty of
not drrethoa five hundred dollars($5W). NEW RESIDENTIAL ELECTIi 5 .FT.
W a ❑ 1,asowneroftheproperry,ormyemployemwilhwagesastheirsole compensation, Q STORIES TYPECONSTRUCTION
d will do lbewmis.andmesnicame sort numdedoroffercdfmanle(Sce.1044,Business
and Professions Code:The C.mmcn.ra License law does not apply to an owner of
property whobuildsorimpmvesthemon,and wh.doasuch work himselforthrough his
ons n employma,providW that suchimprovementsarenol intended oroffered forsole.If, OCC.GROUP RES.UNITS
however,the mildingorimprommcnt is sold within one ymr fc.mpbhmn,meowner- TOTAL:
builder will have the burden of proving that he did not build or improve for product of
anted. QTY:;1 .e.'PLUMBINGPERMIT : FEE, ROOD ZONE APN
❑ L<ownpojectepmpeny,am rosin sive)it Prof ssio.CWa:)The nnadmam t '
Incrust the oosith(Sec.oat thro sec end Professions Crimp The Contractor'.and PERMIT ISSUANCE
whocIncersaIawdfnrsuc to,rplily ctauawneradirmtony whnsed punsds improve Contra,end
who contracts for such projects with a contrnenor(s)licensed pursuant the Convenor's
License law. ALTER-DRAIN&VENT-WA'T'ER(RA) FI713 SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,ARFA.COND. RECEIPTp
• co WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm that l have acertificam ofcomand to self-insum,orn certifeam of RECEIPTp
FIXTURES-PER TRAP
Workers'Compensation lnsumnr<orocenifiW<opy mcmuf(Sec.38W,Lab C.)which PARK PEE YN
rs all lnyyy��� gel t ' GAS-EA.SYSTEM-I INC.4O RECEIPT p
Pulhyp Y1'l BUILDING DIVISION FEES
Party C GAS-EA.SYSTEM-OVER 4IRA) PLANCIIECK PLC
Certified copy,is herby famished.
Candied copy is fled with the city inspection division. GR12ASFJINDUSTRL WASTE . CIiP1'OR Iis, GRAVING FEH
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifine petmil is for one hundred dollars($1010) SEWS .ANITAR -WBA.2( ENERGYFEH
or less.)
I certify that in the performance of the work for which this permit is issued,l shall 'NJ /EL'CTR
not employ any personany manner so as to hachure subject it)the Workers' PAID
Compomaunnlawsof California. Dene WATERS EM EATI Date Receipt#
0 z Applicant
z 0. NOT ICE TO APPLICANT:If,after making this Condit.&H.cmption,yorosWmld EW REST TIAL LMB. FT TOTAL:
(rV) Normae subject tome WarkersCion,cuionprovisinnsofrhe laborCWe,youmust
P4 > forhwith<omply wilhauch provisions mild.pemmehell be deemed revnked. BUILDING FEE
6i Q CONSTRUCTION LENDING AGENCY SEISMIC THE
Vz Iherebyaffima mut there iso cansnucni.n lending agency for the perfomtanceef TOTAL: ELECTRIC FEE
Q the work for which this permit is issued(Sec.3097,Civ.C.)
Ixnders Name - ''
Leaders Address QTY..; MEC NICALPERMIT;' _ NEE PLUMBING FEE
C) I certify then 1 have mad this application and state that the above information is
coned.l agree to comply with all city and county ordinances wad state laws mining'. PERMIT ISSUANCE MECHANICAL FEF.
building construction,and hereby modmize repteserimsesofmircity no enterup.n me CONSTRUCTION TAX
U Z abave-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
IiabilidecJudgments cosisand expenses which may in any way ala against aid Oly AIR I IANDLING UND'(TO I II,00d CFM)
in<.nr uquenlc)eofthe torn Troia permit )/11 /9S
Dl AIR HANDLING UNIT(OVER IO,00)CFM)
Sipunflareof Applican Contractor I Date EXI IAUST HOOD(WB)UCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO hio,"B'TU) Data Receipt#
Will the applicant or far.building occupmn atom or handle hi audous melerial I3EA'fING UNIT(OVER 1 W,OW BT-U) TOTAL:
as defncd by the Cupertino Municipal Cade,Chapter 9,12,and the Health and Safe,,
Coda,genion 25532(a)P
11 Yes ❑No VENTILATION FAN(SINGLH RP.SID)
W ill the applicant or future hulldingnecuponn methimpment ordeviecs whiehemlt
BOILER-COMP(311P OR 100,000 DTII) ISSUANCE DATE:
hazardous air comaminvns as de0ned by the Bay Arca Air Quality Management BOILER-COMP(OVER I00,000 BTU) !1 p
District? T M
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 have mad the Immolate,materials requirements under Chapter 695 of the JAN 18 199
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that
it the building ores not currently have a conal,that it Is my responsibility to notify the
necapant of the requirements which must W mer pd.,to issuance of a Certificate of 'CI I Y Ur l#Ut'C
Occupancy. _
Owner or amM1odssd agent Data T ISSUED BY: