26546 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-hLECIR IAL PERMIT NO.
BUILDING DIVISION (•�
APPLICATION/PERMIT PLUMBING-MECHANICAL 26C /I6
BUILDING PROJECT'IDEN-1'IF'ICA'I'ION G J
BUILDING
ADDRESS: SAM LARY NO. APPLICATION SUBMITTAL DAW..
I�.38 V_tp-'– JikJ UJ
UNIT# LOT 11
OWNER AME•: PHONE: C R 1'OR" r LIC NO: '
Lu— T , .1 L,1 pn,a, �1 -Z� BIC CONTROLp
•ARCHITECTpiNGINEER: LIC NO: ADDRESS: FCJr J ❑
rife-s Q OT S'r
CONTACT: PHONE: BUILDING'PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG PLUMB MIECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, JOB DESCRIPTIO
0CZ I hereby affirm that l am licensed underprovisfonsof Chapter9(commencing with
00 Section"ad of Division 3 of the Business and Professions Code,and my license is in PANELS r
WW fallforce en i,ffc'
6uz Lima leas •/ Lic.p 3o �L –/ UP UO 2M AMPS94
y<y Dase Cunwctor_–E�- / 201-IW AMPS
zOy{ ARCHII'IiCTSD RATION OVER 1000 AMPS - SQ.FT.FTOORAREA $/SQ.FT.
O Z o,Epppqq 1 undemtand my plans shell be used as Public retards.
F.to SIGNS ELECTRICAL
ipyy Licensed Professional
< OWNER-BUILDFR DECLARATION IsPECIALCIRCUTIMISC,
OaU 1 hereby affirm that 1 am exempt from she Commaora Liccnse Law for the
W�tcar
R, following reason(Section 7031.5,Business and Professions Coil Any ciry«creamy TEMP,METER OR PO P,INST.
F' O J which requires x Permit to mnswcs,alter,improve,demolish,or repair any swcmre
5�MY7, pnor m its issuuncgaka requireathcapplicant for such psrmam filerim,ed smmmcut POWER DEVICES
K<pK that he is licensed pursuant to the provisions of the Comracmes License Law(Chapter
9(wmmen6 ng with Section 7")of Division 3 of the Business and Professions Gare) SWIMMING POOLELECTRIC PJ i� A UAt'1 1
p •^y or that he lsexnnpt ihereRom andlhnhnsls l'orthealleged exemption.Any violation of IT ., Imo', '--, ��� V
Y Section ID3LS by any applicant lor�,scrmit suhjecta the applicannoacivil,senahy of 017LETS-SWCHES-FIXTURES
G< not-.-,ban too hundredolle
dn($5M). c l FD
$� I,asowncrnOhe NEWRESIDENT1ALELECBW�7. jr uv T BS, P CONSTRU ION
�C$ ❑ properly,ormyemployeeswithwag<suath<iaolecompensminn.will do thework,andlheswctme beat imendedotoff"ed for sale(Sm.7044,Business E
and Professions Code:The Counrectora Liccnse Law does nm apply to an owner ofpm,omy who builds m improves thereon,and whodoes such workhimselfor through his ACC.GROUP _RGVJ NITS
n employees,provided thelauch improvements sem nm imendedoroffereA foreala.ILM1wever,the building or impmvenam is sold withinone ycarofcompletion,the owner-builder will have the burden of,shaving that he did not build or improve for purpose of
sale).❑ I,as owner reform pmmy,am exclusively contacting with li«nW contractorsI. QTY. PLUMBING PERMIF1.00D ZONE APN
consumer the project(Sec.7014,Business and Professions Cade:)The Contractors
License Law A«snot applyroan owner Mproperty whobuilAsm impmvcsthercon,send PERMIT ISSUANCE
whocomraaa lorauchprojects witlt acnntracmr(s)licensed pununntmthe Conwctnrs
License Law, gI:IIER-DRAIN&VENT'-WATER(EA) PEE SUMMARY
E] I nm exnnpt underSec. B&P C for ohia reason BACK FLOW PROTECT.DEVICE OUTSIDEIT
SANITARY YN
Owner Date RECEIPTN
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPEcamofmNDECLARA'HON SCHOOLTA% Y N
I hereby❑ err'Compensation
that Insurance
have aar iifcmeof cup,thereof asent to Nbnsure,or Lob C.)athe of
which FIXTURES-PER TRAP RECF.IP`#
Workers'Cnnspensmiun Insurance rent certified copy thereaf(Sec.3800,Lob CJ which PARK PIPE YN
covers all entpinyev'e under Otiy lgrnl o.��L�ys q� BUILDING DIVISION FEES
Policy#
IY L[.J [J GAS-EA.SYSTEM-1 INC.4 OUTLETS
Company r.G. Lai )7 GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
X Certified copy is filed with the eiry inspection division. GREASFANDDSTRL WASTE INTERCEPTOR GRADING REE
CERTIFICATE Or EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF,
COMPENSATION INSURANCE
(Thissectionn«dnm becomplctedil'nhe permit is forodshindreddollaa H100) SEWER-SANITARY-S'FORM EA.200FI'. ENERGY FETE
orlcsa.)
I certify that in the performance of the work for which this permit is issued,I shall WATER DEATFR W/VENT/ELECIR
not employ any p:aon in any manner are as to become subject m she Work. PAID
z Compenmtionlawsof Califomia. Date WATER SYSfEMgGRiEATING Dae Receipt#
Applicant
0. NOTICE TO APPLICANT:If.after making this Certificate of F,semption,you should NEWRESIDENTIALPLMB, SQ.FT. TOTAL:
s^ (q becnmeatbjecnothe Worker'a Cnmpensainn pmvisirtns of the Labor Code,you must
tF^' forthwith comply with such provisions or this permit shall he deemed revoked, BUILDING RC
0. CONSTRUCTION LENDING AGENCY SEISMIC PER
VZ I hereby affirm that them is a communion lending agency for the performance of TOTAL: ELECTRIC IEE
O the work fur which this Permit is issued(Sec.3091,Civ.C)
4. ,r Lenders Name
P Landes Add.... QTY. MECHANICAL PERMIT F813 PLUMBING FRE
0 LJ 1 certify that I have read this application and state Puddle above information is
correct.l agree to comply with Wl city and county ora nota and slam laws rending to PERMIT ISSUANCE. MFAHANICAL
f"
bail dingeo ata dherebyacthodre repmsentdives ofthis cirym enter upon the - CONSTRUCTION TAX
U z dame, ned p my for i lion Imports". ALTER OR ADD TO MECH.
agree save, fm
f and keep hartnlen the City of CUPertino against
awalitiea,3dgt is,cos adcxta which may in any waymcruexgoinso said City AIR HANDLING UNIT(f010,(gXCFM)
int nLq n' of the a gnfI prom" -
�— AIR HANDLING UNIT(OVER I0,II0#1 CFM)
S mama Applican/Comractor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO I00,00(1 BTU) Date Receipt Is
Will the applicant or future building mention store or handle heranlrua material
as defined by the Caperton Munici pal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER l0i BTU) TOTAL:
Code,Section E 25532(e)P VENTILATION FAN(SINGLE RISJD)
❑Yes Cl No VENT
-COMP(3HP OR 100,000 BTU)7_p ISSUANCE DATE
Will an co tames is as defirrngmwhenBay Auipmem nrdevicee whichemit �tJ p tp
District' air contaminants as delved by the Bay Aree Air Quality Ma BOILER IM,000 BTU) g'Y u
Dianna,
CI " 1:3SEP
VNo NEW RESIDENTIAL MECHFT
. SQ. .
1 have read the haeafdous materials requirements under Chapter 6.95 of the 1994
California Health&Safety Cade,Sections 25505,25533 and 25534.1 understand then /.
Hirebuilding does nm curremeats whichly must
be,,et o is my rsuance of a Co notify the C��y
O cupam afore requirements which man be met poor to issuance of a Certificate of `Vrrh�r�u
Occupancy.
Owner or mdoiiecd agent - Dote - TO L: ISSUED BY:
OFFICE