26407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOR°R'ISIN°-eI-erl'RIJ7A- Pr:RMlrlvn.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26407
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BUILDING PROJECT IDEN'IFIC-ATION- v (•{
BUILDING ADDR17SS: - SANITARY NO. APPLICA'HON SUBMI'1-I'AL DATE
UNIT# LOTH
OWNii SSe NAME: L PHONE: C MTRACTOR:S AME: n l LIC NO: NIC JJ CONrROLp
L. l�Q V D/2 1.Q�� T
ARCHITECT/ENGINEER: LIC NO: ADDRESS"
CONTACT: PHONE. BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLpG ELECT -PLUMB MICH
PERMIT ISSUANCE r�l(\ El ❑
mun
LICIaNSED CONTRACTOR'S DECLA atamr) APPLIANCES-RESIDENTIAL
eA
WCZ IhereM1y afOuhatiamlicenseJderprovisinns of'Cheptcr9(commencing with JOB DESCRIPTION
aOF- Sficection
ofDo,ahm 3 of the Business end Pmfiassions Cod,and my license is in PANELS � 1
UP
2031
rir6a Ddtensc Cl ss^ Contprecm��O � 2UIT01000 AMPS" �r l "'
F�yN A CHI'fI1C'CS DECLARATION SQ.FT.FLOOR AREA $/SV IT.
z 0 y OVER 1000 AMPS
O Z—❑ I understand my plans shall be used n public rcwtds.
PLtuJl SIGNS ELECTRICAL ' \
2J Licensed Prafesst...I ._
4�JYfi OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W 3 W u I booby affirm tont I um cxwapt&oto the Commcmr's License Low for the
m¢ followingreason.(Section 0031.5.Business and Professions Code:Any city or county TEMP.METER OR POLR INST.
F�03 which media'.permbu,construct,.Iter,improve,demolish,or ret any swcture
Y7 prior to its issuance,also requires the applicant friction p mnd to file a signed slatemem POWER DEVICES y
uull <O that he is licensed pursuant o the provisions of the Commoners License Law(Chapter
a0.o� 9(commencing with Section'10M)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTR - ALUATION -
W�,� or that he is ex mad dorafromanJ the basis far the alleged exemption.Aeyviolutionof
F-ZQ
Section 7031.5 by any applicantfor a permit subjects the applicator o a civil penalty of OUTLETS-SWITCHES-FIXTURES
t more than Eve hundred dollars($SOo). NEWRESIDENTIALELECIR Q 5 .FT.
� m n❑ LasowneroDhepreperty,mmyemployees with wMesutheirsolecompemalian, STORIES TYPECONSTRUCION
y will dp the work,and the structure is not intended proffered fouule(Sec.9044,Business
liel 11 lesions Code:The Commcon's License law does not apply to an owner of
property who builds m improves Merton,and who dues such work himulf or through his
own employ building
that such impmv sold
within
not intendedoroffered forrole.If,
OCC.GROUP RES.ON[
however,der ill have the burden
of improvement mAn!noneyew or improve
efor phe urpose f TOTAL:
builder will have the harden of proving that he'diJ not build m improve for purpose of
sale.).
❑ I,aaowner onneproperry,measelavverycomraningwmaieensed conwmersm QTY, PLUMBING PERMIT FEE. Fl.Oon zoNl? nPN '
onwct the project(Sec.1014.Business and Professions Code:)The Convector's
Licene Law does not apply to anownermpruperty%mbuildsmimpmves thermn,and PERMIT ISSUANCE
who Convects fursuch pmjews with remaryetmod licensed pursuant to the Contractors
License Law. ALTIiR-DRAIN&VENT-WATER(IiA) - FEI?SUMMARY
❑ I em exempt under Sec. ,B&P C for this renon BACK ROW PROTECT.DEVICE SIDE.F E
SANITARY Y N
Owner Dale RECF.IPI'p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION UECLARA'fION SCHOOLTAX Y
❑ Thereby alErm thwlhavc acerlificate ofttmum to sell-in surp.mitimtilicate of RECIAFI'p
FIXTURES-PER TRAP
Workerv'Compensution lnurancmrucerified copy Nereof(Sec.3800,Lab CJ which PARK PER YN
covers all employees under this permit. RECEIPT#
y GAS-EA.SYSTEM- INC.4 0UTL618
Policyp BUILDING DIVISION FEES
Company - GAS-EA.SYSTEM-OVER 4(EA) PLANCIIIiCK PEE
[I Caddied copy is hereby punished.
❑ CcrtifiW ropy is filed wiN Ne city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEL'
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASF.'IRAP SOILS HE
COMPENSATION INSURANCE
(I'hissection needumbecompletWifth<permit lsfofonc hundreddollarn($I0)) SEWER-SANITARY-S'I'ORM EA,21IIIFT. ENERGY FEB
mless.)
I certify that in the performance ofthe work for which this permit is issmil,l shall WATER II TER W/VENT/ELECTR
nm empiny an n in any ,one'so as to beTw�tteµ�'ect W Jtte Workers' PAID
Co .pay arm iCan D l L "K/ WATER SYSTEM/IREATING Data Receipt It
Q z pllram �� �
Z_ NOI'ICH T APPLICANT:If,oftermaking this Ceribcam of Exemption,you should NEW RESIDEWIAL PLMB, SQ.FT. TOTAL:
hecmme subject to the Woders Compensation provision of Ne labor Cod,you met
forthwith comply with each provisions of this permit shall he deemed revoked, ,BUILDING FEE
IJ-I A
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 ocrtby affirm that there is n construction lending egrncy for the d..ca of
the weak far which this permit is issued(Sao.3099,Civ.C.) EL=RIC FTE
V O Under'.Name
OE' Lender's Address QTY. MLCHANICAL PERMIT FEE PLUMBING FEE
UI certify that 1 have read this application and state fiat the above information is MECHANICAL HE
�" LA coma legree to comply with ell city and county nNinenen wtd state laws misting to PERMIT ISSUANCE
1-' W) building convection,wad hereby uwhodm reptuentativen ofthis citytoemer upon the
U z CONSTRUCTION TAX
abnv<(We)tineve property for inspection purposes. ALTER OR ADD TO MHCH.
(We)ugree to xvv,indemnify and keep ns the City of agcrtino against
liobililka.judgmcnls,costs and expenses whichmay may inany way accrue.Suint amid City AIR HANDLING UNI'I'('I'O IU,II(0 CPM)
in'amr of the granting of thin
pLr'O AIR HANDLING UNIT(OVER 10.1x10 CPM)
Signor ApplicunUCn br \7 [ Date EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt k
Will the applicant or future building recupant store or handle hazardous material HEATING UNIT(OVER 100,04)(1 BTU) TOTAL:
n defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(o)9
Cl Yes 11 No VP.Nf11.A'I'ION PAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicamorfumrcbuildingoccupaniusecquipmemordevicesalamb rd BOILER-COMP(JET OR 10,0100 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Disarm,?
ci! T A
Yes ❑No NEW RESIDENTIAL MIiCII. SQ.IT. p
1 have rad the hazardous mmeriWs requirements under Chapter&95 of the - �ypy 2 0 199
California I leahh &Safety Code.Sections 25505,25533 said 25534. I understand that
if the building does not currently have a meant,that it is my responihility to notify the
mcupunl of the requirements which mann be mol prier to issuance of a Cartlfic m of C�1
Occupancy. r•
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE