26872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B IL)ID G: EEE i'RICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MI:CHANICAL
BUILDING G PROJECTIDENTIFICATION 26872
BUIL ADDRESS: SANITARY NO. APPLICATION SUBMrITAL DATE
cd 5" O ES uNITa ora �� "l
OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO:
L,� 2C ys �y ��� /��� N/C CONTROLp
RCHI'IECT/ENGINEER: LICJNO: b ADDRESS: -'t ❑
3Io Se .oro dl L14 BELL
is CONTACT: PHONE: BUILDING PERMIT INFO
' QTY. ELECTRIC PERMIT FEE
BLDG EL/'—'\ PI.IM{ M[CH
PERMIT ISSUANCE �� IKEEl
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ��
tF
Matz Ihereby affirm that l am licensed underprovisionsof'CTapter9(cummencingwith
VJ00 ScHma7(m))ofDlvidon 3 of the Basineaa and Pmfea0was Code,and my Horrou is in PANELS
K� full ford erica.
pQ,Ztu I-Elf Cl sem{ 25 Law, A UP T0200AMP5 /►� ``/ {��x•{ y�.�
mI-6y Daley\YS_Cnntmca\ 201-1000 AMPS
LFNJ ARC ECTS DECLARATION OVER 1000 AMPS - - SQ.FT.FLOOR AREA S/SQ.FT.
UZ_Q Iundefs�armJ tgkTlan. nil bcrecnrds.
r4lp tW ((// ' SIGNS ELECTRICAL
Liconsell7meal
ty 0.'Q OWNER-BUILDER DECLARATION S1117CIAL CIRCUI`DMISC.
�x'OyU I hereby affirm that 1 ren exempt from the Contractors License or the
1a1 t0. followingrenson(S.Hma7031.5.Business and PTnfic.iom Cale:Any city., my TEMP.METER OR POLE INS'['.
H,< which requires a permino cnnstrwn,her,improve,demolish,or repair any Siris m
3-;!(Y� PHono its ias.ance,ma.mgaircsthe applicant for suchpvmiuo Masai stem t POWERDEVICES
�a a 0z that he is licensed pursuant the provisions oft Convacmh Lima. w( npler
� 02 9(commmmcingwith Se000o90HH EDivis' .nOhe c an Cie) SWIMMING POOL ELECTRIC VALIJg9P3P.
W_rn or that he is exempt therefrom and the ha forme alleg un n,ti y lationof CC-.J���/
1-'ZQ Section 70315 by any applicam fora ,mics a 1 nnnguei pca.1ty.f UTI.ET$-SWITCHES-IlX'NRLS
not more than five hundred dollars( Iw). NEW RESIDENTIAL ELECTR S PI'.
❑ LmnwnernDhe property,nr employeesw: gesmh campnmwtlary Q STORIES TYPE CONSTRUCTION
d will do the wmk,amd the smamm i of intended or
df a .'A144.Business
and Professions Cale:The Cnm mr's Lice does n. ply to an owner of
Pmpmy wart nuilAs nrimpr.vcs th am,andh r' immlfnrthrough his
nwnemployees,providedthasudt m smart ed.rofferrdfursale.If, OCC.GROUP RES.UNITS
however,the building.,improve a ithinon efcompletion,rheowner- T
builder will have the harden ofo id not lm or improve for purma a of
role.).
❑ I,mowner.fthepr.p<ny, vendusi y nR mg wire licensed c.nhun.rsm QTY. PLUMBING PERMIT Flip FLOOD ZONE AI'N
.nstmct the project(Sec.7o44, nea de:)Pr sions CoThe Comd
ntor
m s
U,ame Law does anta,ply an ownerr imngwpIiRMIT ISSUANCE habuilasorprovesmere
a /
wh.comraas fm.such projects with.contract licensed pumaanuo,he Comructor's
License law. ALTER-DRAIN&VENT-WATER(NA) FEE SUMMARY
❑.1 too exempt under Sec. ,B&P C for this o mon
BACK FLOW PROTECT.DEVICE. SANITARY YN
Owner Dme DRAINS-FLOOR,ROOF.ARIA,COND. RECEIPT'.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm that I have a certiticam ofcomen to self-insure,ma certificate of RECEIPTp
orkcrr:Com,nodion lmurancem.,crtified arpy fhereof(See.3800,Lm C.)which FI%TURES-PER TRAP PARK THE Y N
coverstill employee,underthis Penni,. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT'a
PolcyItS 6 Ol _ BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PfANCHECK FEE
❑ Cenifiedcopyisherebyfumishrd.
Certified copy is Eli with the city inspection division GREASEANDUSTRI.WASTE INTERCEPTOR GRADING PEE
CER IIFICYI H OF EXEMPTION FROM WORKERS' GRBASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thit,anion need not nc completed Hun,Pemba is foram,hundred dollars(SURE) SEWER-SANITARY-STORM EA.20(t ENERGY FEE
less.)
I certify thatin theperfnrmoverofthe work forwhich thispennit isissued,l shall WATER HATER W/VENT/ELELTR
not employ any Parana in my manner so as to become subject to the Workers PAID
D
Z Compcns:pion Lnws.f C.lifumia. me WATER SYS'TEM/IRTATING Date Receipt.
Applicant
z�72 NOTICE!TO APPLICANT:TL after making this Cetificme of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
t� 00 become subjectto the Worker's Compensation provisions of the Labor Cie,you must
kKi . forthwhh comply with such provisions or this permit shell]In created revoked. BUILD]NO FE
W CONSTRUCTIONLENDINGAGENCY S E;fAC
z I hereby affirnm that there is a construction lending agency for the Performance of ky
O me work for which W s permit Is issued(Sae.3099,Civ.C.)
I cHders Name
0 F Landers Address QTY. MECHANICAL PERMIT It PLU ENG FEE
V I rainy that I have read this.p plication and stem it,., ]to above information a MF_,
� "J NHE
-' "J correct.Lgree mcomply with all city and coumy ordinances enJ smmlaws rclming to PERMIT ISSUANCE.
U1building construction,and hereby authorize representatives ofthiscity to enter upon the CONSTRUCTIONTAX
U Z. dw.-nanaioned inmpery for inspection purpaes. AUTE.R OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless me City of C.,rHan against
liabilities,judgments,costs and expenses whichmay inany way accme against said City AIR HANDLING ON]]'ITO 10.000 CFM)
in comequmas,of the gmnting of this pemtit.
AIR HANDLING UNIT(OVER 10.000 CPM)
namrt of ApplicantlCommcmr Date EXHAUST HOOD(WiDUCq
PAID
HAZARDOUS MATERIAIS DISCLOSURE HEATING UNEP To to,00n BTU) Date eceipta
Will the applicant or future building occupant store or handle mansions material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the E lealth and Safety HEATING UNIT(OVER 100,003 BTI)
Cade,Scctl 25532(.)^
ElYes No
VENTILATION FAN(SINGLE RESID)
❑ �
ISSUANCE DAT
BOILER-COMP(3E IF OR IHB,W0 BTU) E.
win me.ppnaam.r nnmabahiring.ca.pam ate egwpmem.rammea which emitBOILER ,
h tmand s air contaminants us defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 1011,000 BTU) I�
District'! I-4 /4
❑Yen WN
. o NEW RF:SIDENI'IAI.M[CH. SQ.M.
z 1 have tend the hazardous diamonds reyuin mems under Chapter 6.95 of me 110 1
7 a.
C.Iifand.Health&Safety Code,Sections 25505,25533 and 25534. 1 understand But /� J
(the bonding rine,not currently Inot.utsm,but it A nnymspomlbilltym notiOuna co
mcupnd of the mquiremems which must he mer prior to issuance of Certificate of (�
Occupancy. f
' r r
Ownermmfiarord.,an, - Date TOTAL: ISSUED BY: ,f
OFFICE