26866 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-EL IRi AL PERMIT NO.
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26866
BUILDING ADDRESS: s(/�J/ SANITARY NO. APPLICATION SUBMITTALDATE
D it LEwesL UNIT# LOT# 'I
OWNERS? CONTRACTOR'S NAME: LIC NO: `
NIC `CONTROL p
ARCIII'IECI'/ENGINEER: LIC NO: ADDRESS: ❑
[COM"ACT: PHONE: BUILDING PERMIT INFO
4V ,/ta� ��L— it, 7, QTY. ELECTRIC PERMIT FEF,
K BLDG ELGCI' UM MECH
PERMIT ISSUANCE
7T 0 LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL X10 r�1rv„s�
p n'ZIhercby affirm thatlam licensed underprovisionsof Chapmr9(commencingwith I . \ \Jil�lll/JgMMVyJ\�elll/\
WOOionMOMo'Divison 3 ofthe Business and Professions Cale,and my licenx is in PANELSF-_F� rmceandeffect. rt ,^_SOU UPT02(10AMPS ` Y �WJ�XJ��FZ Wnse corse bier ae Contractor 201-IBM AMPS
F,z ARCHITECTS DECLARATION SQ.FT.FLUOR AREA S/SQ.FT.
ZOvr— I understand my plans shall b,used as public records. OVER 1000 AMPS
OZ O
SIGNS ELECTRICAL
,s� ',...�.11 Licensed Professional
as
Ecwu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.XOaO I hereby affint that 1 am,exempt from the Connector's License law for the
W a W oo fallowing reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F which requires ii .if It conswa,a ocr,improve,demolish,or repair any suucum,
En}7 prior to its issuma.also requires theapplicem forsuch permit to Elea signedslmcmenl POWERDEVICFS
LLAO that hula licensed paruon ,,,he provisions oft he Commalor's Lianas Law(Chapter SWIMMING POOL ELECTRIC
aLoE4 9(conunencing with Section]WO)of Division 3 of the Business and Professions Code) VALUATION
,Zti orthat he is exempLS
therefromandthe basis Permit subjects
is Onedcsemant to civiny l
of OUTLETS-SWITCHES-FIXTURES �D�
FZa Section 703 LS by any applicamfor apermit subjwts the applicantmacivil penahy of
aszp not macthan five "y.ordollars(ympl NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
Ww ❑ LasawnemftheprvPeny,ormyemployaswith wagesus of (Solecompenmtiow
L will do the work,and the structure is not imcnded mothered far sale(SeeABM,Business
and Profession,Code:The Contractors Ikerne Law docs not apply to an owner of
proam,wholudidsorimpowes thereon,and whodaessuch work himsclfor through his OCC GROUP RES.UNITS
ownemployeepmmarc
s,provided thatsuch imvcentsnot immndedorafferedforaale.If.
however,the buildingor improvement is sold within one year ofmmpletion,the owner- a
builder will have the burden to that he did not build or improve far purpose of TOTAL:
pmvtn6 prove purpus
❑ 1,aanwnerof the propeny,am exdusivdycontacling with licensed comrannrs to QTY. PLUMBING PERMIT' FEE FLOODZONE /rN
construct the project(Sec.7(F4,Business and Professions Codc:)The Contractors
License lawdoes not apply taanownmofprn,amy who builds orimprovesthrea
en,and PERMIT ISSUANCE �-
whocontracLsfmsuch pmjectswith acontractor(s)licensed pursuant tothe Contractor's se Law.
License
ALTER-DRAIN&VENT-WATT:R(FA) FEF,SUMMARY
❑ l ran escmpl under Svc. ,B A P C for This reason BACK FLOW PROTECT.DEVICEOUTSIDE PEES
SANI'T'ARY - Y—N
—
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIMOf
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm lM1m)have acenifcme of consem to selLinsurc,oracmificem of FIXTURES-PER TRAP RECEIPT#
Workers'Compersationlnsumaceor a certified copy thercof(Sec.38M.Lab C.)which PARK PER Y N
` covers all employes',under this permit. GAS-EA.SYS'1EM-I INC.4 OUTLETS RECEIPT#
Pal,# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 TA) PLANCHECK FEE
❑ CenifiN copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING 113E
CER'I'IFICAT'1:OF EXEMPT ION FROM WORKERSGREASF.'1'RAP SOILS FEE
COMPENSATION INSURANCE
(This scaiannecdnot b,completed ifthe permit is forone huodrcddullaa(SIM) SEWER-SANITARY-STORM EA.20)FT. ENERGY FEE
Our leas.)
I certify that in the pedom,ance of the work for which this permit is issued.)shall WATER HEATER W/VENT/ELECTR
not employ any ,,an any romint,
s.o ax to became subject to the Workers' PAID
Compensation Lawsof Calilonaia. DateWATER SYS'IEM/TREATING Date Recupl#
O Z Applicant
zO NOTICE TO APPLICANT:If.after making this Certificate of l?xempion,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
1r become subject to the Wmkcr's Compensation provisions or the Labor Cale.you as,,
> forthwith comply with such provisions or this pemtit shall be deemed revoked. BUILDING FEE
h7
4 Q CONSTRUCTION LENDING AGENCY SEISMIC hili
O Z Ihereby affirm that chert is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.309],Civ.C.) L: ELECTRIC FEF.
Undars Name
U" F Lendds Address QTY. MECHANICAL IERMIT FEE PLUMBING FEE
mre
O U I emit,Nut 1 have nd this application and s.le that the above information is MECI IANICAL FEE
>" W correct.Lgrce mcomply with.))city and county ordinances and state laws relating to 11IiRMI'f ISSUANCE
building construction,and hereby utho` senrau es of this cit to entero the
_ gcans Ye y pan CONSTRULTION TAX
V Z above-memioned pro cec u ALTER OR AD O MECH.
(We)al1. demni keep the of Cm
pcn'no a6ainat
liabilitics,jud w 'N ccrue aga' sts id Ciry AIR HA ING UNIT(TO 10lNX)C )
in c sequence w saveays.m Gm1
9 A ANDIANG UNIT(OVER It)," FM)
Si w pp am Date EXHAUSTHOODDVMUP)
PAID
HAL ATF. %LS DISCLOSLI E HEATING UNIT I BTU) Uac Rxeipt p
ill the appli or fu ehuildin6 nccupam store nr ndle hazardous material t1EATING UN T( V �I ,I%NI 'A
m defined by th .peri Municipal Cafe,Chapter 9.12,and the Health and Safety
Kj
Cadeecunf.
❑No V r A ON FLAN(SI LFjIfCS
YK k ISSUANCE DATE
Will tM1ca )leant or tuwm buildin amuses mem ordevices wM1ichcmit ILER O (IO.B(q B
PP d by th quip
havardnux air comantinanu ns defined by the Boy Areu Air Quality Manvgemenl NOILER-C AM],(OVER 10I,I( 1'U)
Disvid'l
❑Ya ❑No NEW RFSIDEM'IAL MEC SQ.FT.
I have read the ha ardous materials requirements under Chapter 6.95 of the HUG 1994
California Ilcahh&Safety Code.Sections 25505,25533 and 25534 1 understand that
iflhcbuldingdnesnolcurrcally have a tenant,chat it is my ospnnsibility to notify the t. LII I OF ��•t.
occupant of the requirenrems which most he and prior to issuanm of a Cenifimte of `�
Occupancy. EE
Owner nr authorized,gem Date TOTAL: ISSUED BY:
OFFIC