26946 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL CITY OF CUPERTINO PLUMBING. PERMIT"° 26946
I� BUILDING DIVISION APPLICATION/PERMIT
4 C. Ano fNRtivl
UILDINO ADDRESS: SANITARY NO. APIUCATIONSUBMHTALDATE j
NIT# IAT#
NAMN: O H' CO M WC O:
N/C CONTROLcfi ,
Cf/PNOIN LIC NO: ADD :���a
ONTACT: PHONE: 1 IF
'�(,P BI)ILD dap -. oa1r.
e BLDG ELECT PI. MB MECH
PERMTTISSUANC'E ❑ 0
LICENSEDCONIAACTOR'SDECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
QKZ Ihereby a(Brm that l am licensed under povisluruofChWa9(commencing with
L1s 00 Section 7000)of Dlvisim 3 ofthe Business Pmfnalong Code,end my license Is In PANELS
FFyy,,� fullfomxmJx 3 a
6FF..Z, Licen CIu4 c �Ic.N' r UPT02MAMN
=� Dene l D• Conlrutm WWII-10110 AMPS
AMPS
SQ.Ff.FLOOR AREA $BQ.FT.
Z80?. ARCHNEcTs DELLA TON
OZ 0 .- l und tmA my plus NJl W ueW u public resects.
Kra SIGNS ELECTRICAL
Liaesed Profeuiond
OWNER-BUILDER DECLARATION SPECIAL CItcurr
O 1.. 1 hereby.(firm that 1 am exempt from the Contractus'.Lice...Lew for the
a fi�j
following....(Section TWI.5.B.O.B..and Preload..CdB:Anycity.county TEMP. OR RINST.
(aJ m g which requires.permlt to=met,alter,Improve,demolish,or repair my structure
Y� piarolu luvantt,Blmrequim de applicant formehpennlltufileasigned.namem WER DE
Gp dtit he ie Ilttnsed punumt m Ne povlelom of de ConhatYml License Lew(Chapter
R� 9(co^uue^cing with Section L000).Mivision 3 o(me Bull.and Perf.we Cade) SWI NO POOL E VALUATION
y .that he lsesempr therefore ed the bulgfor the allegWe.empion.Any violation of EIS-Suit XTU
i SaOon loJ1.3 by any kppllcmlforapemiluubJau Oat
.1 11
pnWyof
nm morethen Bva hundmi dollen(f300). NE BSIDENTIA EL SQ,PT. R TYPECO TR CGO
❑ I,esowncr.d11st peny,orme,loweyeeewiffeend authel(See 7C us
us Be
will da the wark,and the guucwrt hero IntenJW eroRertd farssle(SaJ0/4,Businen
and Rofnsions Code:Lbe ConbutWg License law due not apply b an owner of
property who builds m i mpmva thereon,and who don gush woh N ruse If or through N e
ownemploym.pmvidedthBlauchimprwemmu ate nd lmendedmaRered fm We.IC .ORO P
howeM, eNildingmimpmvemmtlgmldwithinmteyurofempletim,theowna- TOTAL:
build.will have the burden ofpming that he did Be[build or improve re empo al oef
le.).
❑ I,u mynerofthe pmpcny.eneaclusively connecting with licensed contractonm > 00 ZO APN
construct the project(Ser.7044,Business.and Professions CW,:)The Coninctm'. s PERMIT ISSUANCE
Llcenu l w w dose noupply tu an own..f(mtperty,who hl lde nl Improver thereon,.nd
't wMcro a tx formch projects ailhatonlncta(s)Becomes".I bit.Contractor.
IlcmulAw. ALDER-DRAIN.VENT-WAT[A(EA) lkx- t0. iiNSaPBB-SUMMARY,.. F „
❑ 1 am nempr under Ser. ,B A P C far this reamer BACK FLAW PROTECT.DEVICE
SANITARY Y N
1 Ow°cr Dau °RAINS-M.00R,ROOR,AREA.COND. RCCF.IPTN
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
hembyafilmUhstlhmeice incateofemse ttoselLlmum,mame ficeteef FlXLVRBS-PPR TMP RECEIPTN
Worker(CmnpmatlonlnurmxmeaaiRW p^py awrrof(Sre.J80D,Lab C.)which PARK FEE Y�EI�N N_
covin silemploy t M. r tit 4/ OAS-EA.SYSTEM-I INC.4 OUTLET
Pulic.N BUILDING DIVISION FEES
CmmpenY -� 'L GAS-EA.SYSTEM-OVER 4(EA) PLANCBECK PER
❑ Ceninedcopy,U hereby fumiahed.
❑ CeniHW copy 1.filed with the city Inspection dlviaim. °REASE/INDUSTRL WASTE INTERCEPTOR GRADING PER
CERIGMATE OP EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(me.atim nead not beeompleud lfthe Permit is forms hundred dellan(SIM) SEWER-SANITARY-STORM EA.20UFT. ENERGY FEE
B,leu.)
I cenlfy that in the perfomunu of the week for which this perm6 is issued,lshall WATER HEATER W/VENTHR.ECR
our employ my person in my manner m as m became subject to the Workers' PAID
Cempnulwn Lamof CalirueB. Dae WATER SYSTEMITREATING Dale Receipt
Q Z Applicant
�zNj, O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. F TOTAL:
became subject to the Worker's Compenandon provisions of the Leben Cade,you must
forthwith comply with such provision or this permit.hall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there Is a construction lending agemy for the performance of
U O the work for which this permll Is issued(Sec.1097,Civ.C.) AL: ELECTRIC FEE
I ewles Neoax V,g MAW,
H)y, Cyt ,q r as
0 Lenders Addresss: frit y " PLUMBIN°FL•P,
V 1 cenify that 1 heve read thla application and.tate that the above Information b Mini, i` 'w'B' '' 'n'�'"'sStx
H-1 correct,I agm tocamply with dl city Bud county oninseca ed state law retaiing to PERMIT ISSUANCE MECHANICALFEE
buildingconstmetion.and herehy Butherine repeesentWvao(this city menterupon the
CONSTRUCTIONTAX
abov(WentimW popsy for Inspection keepmea. ALTER OR ADD TO MECII.
(We)qm nt save.indemnify and keep may In.the City er Cupertino.gainer
IIeFilllin,judgmente,cmlaand..peruse.which mryln my way acrua.geln.t Did City AIR HANDLING UNIT(TO IO,gp CFM)
I^wne ...of the gre^Rng of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Sigumreof Applican9Contracmr Dau PXHAUSTHOOD(W/DUCfq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINO MIT(TO 100 BTU) Oast ReceiNN
Will theeppllcem or mmre build) eccupmI toren handlehaufdomm.tedel IfEATINO UNIT( IW,tx10 BTU) AI'
u defined by the CLpnlne Munle Cede CbNer 9.12,and the Heaithend Safety
Code,Section 255J2(gT VENTILATE PAN(SINGLE RPSID)
❑Y. o
ISSUANCE ATE
Will theapplicuter were ulldin acupamumequipmentordevlmwhichemit BOILS COMP(JHP OR Io0Al10BTU) -
huudeu ab contuNoanu as depold by the Bay Am Air Quality Management BO R-COMP(OVER 100,010 BTU) r
DFeMctT q '
13 Yea a WRESIUP.NTIAL MECII. SQ.Ff.
I hive read the heurdoua materials r.Iulerem,under Chap,,6.93 of the NOv
Crile buil Hine!Sat e,Sectim.23300.uh i"and 23, si 1 understand that el �F}Ng -�
o Y J_Y7e
If the building docs rut cu ntly heve a leunr tiut It ie my rcyanalbllhy to ill i the
omp.nl f the r b-ss w4 met prem m ies of•CenlRuu of Vr
OwnerOwner mhW�igent UTerr TOTAL: ISSUED BY:
OFFICE