26310 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOu. -hLEcURICAL PERMITTING.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHAN'CAL 26310
BUILDING PROJECT IDE\TIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUB/MIITTAL.DATE
N UNIT LOTH /t,��LI ,
OWN NAME PHONE CONTRACTORW
'S NAME —� C NO:
y9NIC _` CONBOLN 1•
A Hti. NGINE : LICNO: AD RESS: ❑
f el 64
CONT'ACf: O PHONE BUILDING PERMIT INFO
�) O QTY. ELECTRIC PERMIT FEE
BLDG
PLUMBME(AH
MIT
PERISSUANCELfr
LICENSED CONTRACfOR'S DECLARATION AWLIANCIS-RMIDENTIAL
'L I offnoidual emrnI
licunclio"visionxof0o,hr9loommencingwith
CiLOB DESCRIPfIDN
-0 Seat.Seat.7000)cf Division Softie Bosuces aM Prof.iom Code,end my l iaenx is to PANELS
IQV Liceme Clom LieN. UP TO 4W AMPS
to Qa Due Cmlr.ctm 201-1000 AMPS
1—yG ARCUIITCPS DECLARATION SQ.FT.FLOOR AREA 5/SQ.FT.
conn_ I undcrsomil my Plemxhell hcused w Public mcnrds. OVER IOW AA11'S
ON—O
Wu� SIGNS P1JiC1RICAL I l O
QygmK'] LicrnseJ Rvfasi«ul L
i0WU OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ydOd 1 hereby affirm than 1 em exempt from the Conv.ctors Liccnc I,,w f«the
W'3 LL
,~is
following..(Secsion M313.Bu,incu"Pr ic
mfi Co :Any airy« ams,cTEMP.METER OR POLE INST.
t�°g which taquites a Iferrnii to c«utmcl,alter,iml'tove.detouluh,on,repair any nnnute
prion to to isoartcc,alio rtyuimx tie aMlicam f«xuchlcmtit to fk a Bigad slntcmrnm POWER DEVICIS
,s<0 most he is licensedpu.. tto the encitionv of the Contractor a Liceme Low(Chirm,
za oLL 9(emmcncing with Smtiun]0(0of DivuinJof the Busng wed Rofeviom Cade) SWIMMING POOL ELECTRIC
VALUATION �+
_y onthethe isexemptlertfrmm vd the bests for lhedIRWesempdon.Any vidauonof
FZQ Secdon]OJI.S by any applkam f«apemdt subjmuthe appliant too nsilpmdtyd OUfLF IS-SWRCHFS-FlX'NRFS O _9
Q ..rolownfvehutdtcdddlys ymA NEW RESIDENTIAL EI.ECIR —SQ.FT. STORIE TYPti CONS UC ON
tYC� ❑ I.esmvnern to cY.« not o,coym with Rs eat,((Sec,.
cam.B son.,
arm will dothcwnn,Coe ne Contcooc stwv lntLi ornwdo ,i.n 1,1. gBm,of
wed Pt y w h,one Code The oentreetss'e Lia who
law don rot apply to en awns of
Wormy buildeaid!that sthereomW suecose,,nmchwM tieuelfor Wough his
wn cngloyas,providM Wv euch impoves«nuertminlcMcd«oRvcd f«e.Ie If, OCC.GROUP RFS.IR.TIS
however,Ile building orinterovemmt n mW within art.Y.of completion,the ow«r-
boildex will Moe tee hordes of Moving don he did cot build or improve for putlaae of
4 J.
❑ rsuan
I,mowrsdtheppenY.amcaclmively...toclingwim Bcenscdcommict.h. QTY. PLUMBING PERMIT FEE FLWD'LO I: AM
rero
construct tie pmjat(Sec.]844,Bnvitev and Pmfevimn Cadc:)The Ctmunctor's
Lim. Lii.daerd apply to wowterofpopeny who builds«intpmves tleemn.aed PERMIT ISSUANCE.
,,.ho cu for each poj vs with acronuxt«(e)IiansM put to the Con.mie
fucrose Law. ALTER-DRAIN&vFM-wA'RR IFA) FEE SUMMARY
❑ I am exempt uMer Sec. B&P C!m thu rmson BACK FLOW PROILCf.DEVICI?
SANITARY YN
Owns Date RF,CEIPf N
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX V
❑ cM ompeenmthmlhaveaartiBcetedmnxent to eeH-Inure,«eeertif¢of Fl%TURFS-PER TRAP RFri IPfN
Waten'Compcmation lmur.recmecadfcd cgs,thcrtof(Sa.3800.t..b C.)which PARK FEE Y N
coveo,Jl employa'B tmdan this permit. GAS-FA.SYSTEW.4LNC.4 OUDJH'$ RECEIPT'
Policy BUILD^DMS NIEES
Company GAS-EA.SY :M OVERk PIANCHECK Fti?
❑ Ccnifml copy is hcrtby fumlaltcJ.
❑ Cenifcdcapyufledwid,lMxatylnepecttlian dhoti GREAS NDUSTRLWASLE Ji OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS G SE SOILS FFE
COMPENSATION INSURANCE
(This rection teed not be rnmplcted iDhc«tmit is(«mchurdrN 641en(SlaO) SEWER WARY eiRmEA. qFT. INIRCY
cJ
I mty y in the penfmme mmetehework for Nwhich cssne subjetdt is the WIshal WATER TFR /Elk.
not employ.nY es.on in or Dere so an to baontc subjm to the Wmkm' PAI
Canpanuetian law of C.lifomia. D.te WA IjkAFATNG ReaipN
AMIO Z NOTICE
IDE LPLM SQ.FT. TOTAL
NOTICE TO APPLICANT:ILefin midlung this Crnifntc of Excmpion,y
becwne suhject to the W«krr'BCmm1'rn+atim pmvisionx of the laborCMe, t
f«thw'dh comply with Bach pimiem n,«This pcona droll bda
e mW rcvukcd \ BUILD
P4 > ING
W
F
CONSTRUCTION LENDING AGENCY SEISMIC
1 hereh afMn that there is a cmemedmt Irnditµ.grrtcy f«the pMoremrae
V O the wort fa which ttis Perrot u hued(Sec MD,Civ.C.) TOTAL: FJE C FEE
its Norte PI.0 GING FEE
F Lender's Addrtes QTY. ECHANICAL PERMIT FEE
O U L amify tlwt 1 have reud Nie uMlicetion and shoe Chet the above information Is ME IANICAL FILE"-F17 rnmcat lagrammmpy with ill city mil convoyoNlwttcn aM nuc law minting to PFRMITISSUANCE l
E" Cn building corutmctim,and haeby.uth«in rtpraenadva ofthis city m enter opoo the
gt
U Z olNove-mentioned prc,m,f«inspcnian ryosee. ALTERORADDTOMECH. CONS CTION TAX
(We)agtm to mv,irtdrnaify and kap hanmlaa the City of Cupstuo agioo i
liabilities,judgtrtmu.cost:aM expenses which may in my way.ccme eg.imn mid City AIR HANDLING UNIT(TO 10.000 CFM)
In cnnstyurnac of the nntin6 ofthis Petmh.
/ AIR HANDLING UNIT(OVER 10,000 CFM)
SigeyOre of Applleent/Cowactm Dye PXHAUSTHOOD(WIDUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO M."BTU) W. RcaipN
Will the the Cu i «future eirol C occupant nuc m hionand ilhe
hHealth s Safe l IIEATING UNIT(OVER 100.000 BTIH TOTAL.
as defnestS.by the 32(.)?nn Mwicipsl Code,Chapcs 9.14,and the)1e01th end Safety
Cdk,Smtinn 25534(0)^.
VENTILATION PAN(SINGLE RESID)
r ❑Yew ❑No
BOILER-COMPOHPOR 100,000 BTU) INSUAjJCj ATE
WilUhe appliontafumrt building«ev{wtuuequipment«devkawhichemit /'�I
s air canWinirwu v defined by the B.y Am Au Quility Mwgemem BOILFJI-COMP(OVER 100.000 HIM
suis?
❑Yn 11 No NF.W RESIDENTIAL MECIL SQ.FL'. AY 24 1994
rted
1 have the haum y
xdomai.H tequi ui uMn Chathe 1J57(F
per 6.93 of
Celifomu Hmlth&Sides,Code.S ions 25505.35533 and 255]4. 1uMmtaM that I Uf Luh„
ifthe building dm W c ly have asmuot,thin it n my tcspmuibility m codify N, With,
occupant f the mgo'v menus d prior to Ieanarre of Cm f lac d
Oce
Owrn«oath t ¢ A ISSUED BY:
OFFICE