26678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO •-ELECTRICAL PERMIT NO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL. 26678 6 6 7 o
8
BUILDING DIVISION BUILDING PROJF.CIIDENTIFICATION' L I
BUILDING A DDRFSS: LL _ 1 SANITARY NO. AAPPPPLIC/A�TIIOONSUBMIITALDATE
O 7,� UNITS LOT x;A
INNERS NAME: PHONE: ..1I���� CON RACIOR'S NAME LIC NO
((( ••7
M S -ZW- NIC CONIROLN
A IIECI'ry'N INELIC 11 WC NO: ADDRESS: ❑
DrrlpN
CONTACT: PHONE n.-y' Q.Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
gIy --2.U- f/^'f�O PERMIT ISSUANCE CT PL l 1.ME
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OCP Ihereby affirm that l am lian.xd milker Pi,skims rfaaptcr9(ammacncing with LOB DESCRIPTION
V]00 See,ion]000)of Division Sof dm Basin.and Profcai.Cosle,vW my license Is W PANELS
1I,WE full fora mid cffm. ��\'1
I<,,y) Li.CW Lich UPT0200 AMPS IT jT
Hour Cmmlmoor 201-I")AMEN
1-V,Z ARCIII'IYCTS DECLARATION SQ.FT.FLOOR AREA FT.
Z c1 i,i O I UMcmtud my plena mol lx axJ Y public mcavol, OVER 1000 AMPS '—
oz
rz-ou SIGNS ELECTRICAL
Qy a ucrnsM Hofeuimsl
6' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0 L I hmeby fim an Wet 1 am esenp from Be CanrYcmr's La.law Or me
003 Pry followin Stsuon]0315,Business,mrd Pminsiory Code:An 'TEMP.NEUTER OR MILE INST.
g swan.( Y city m aumy
whqulssapem u,econatrum,cher,imprwe,dem�lish,orrcpirsn"..
kWs
Sny2 prior In its issamn .also syuina Jc aPrd Ood for such Permit to rile a rn
fi'amustateenl POMT:RDEVICES
W<0 Thu he i.liccnsm pwavanl to IM povisiom of 0m Cmmandt Limue law(Chaper
yO y SWIMMING POOL ELECTRIC
aX� 4(eammnsrneing with Satinn]gp)of Dlvui«t3 ofthaBmirras ud PmfeviaW Cade) VALUA'110N
w-stn «this he is aerrmpl lhertfrom and rte buu for the alleged exemption.Anydoluion
r�ySap
4n«ctrirr--s] y f« lsubjccss Nc appliconl toucivil pcWlly of ,�-SWITCHES-FIXRES l
thamfivc hatched"ln(VKE0).
NEW RESIDENTIAL EI.ECIR _SQ.PT. NTURIF NICU SIR CI N
yycF ❑ Luown .imst pnpny.urmYeroommel'wiWwegnrslMinolecan.Busmim,
s� will doifewmsrk,erd,The turtuam's not Liomse Law ffinead
Yk(Sec.to molder of
ss
end Rofnsi«s Cade:The Cmmisnm's Lianx Law doe not apply to en owner of
pmperly wlso Mmild�«improvadlercun,mmdwhodoe such wed Nmulfathrough his
cnpbycn,pvvided tM1m YCM1 improvnrcnls era nolimrrded or MferWfnr Yle.11 C. RO P RFS.UNITS
however,We building w improvemem is sold within arc yea of cmtfliam,the owner- .Tri
Wics,r will have the burdrn of paving Thal he did not build or improve fa P«pme of
sale.). QTY. PLUMBING PERMIT FEE ooD zoee APN
❑ roo be srofdsepopenakI. exclusively anwcssio ,Cme)Tdcmnareealo
CVnMNCI be IenJIXI(NG:.]B36.BWIIICN WJ PIOIGV ani Come)The CnnlreelC/S
who
with a rolprepcny who Wild.«impova Jmwm.ard PERMIT ISSUANCE.
whncmnacts!«sucM1 pmajnts with oronvect«(s)Iiccrvcdpurwemlothe Cmtmclale AL�g BRAIN IA
liaroc law, (' ) FEE SUMMARY
❑ I am earntp under Sec. .B A P C f«This warm BACK FLOW PROTECT.DEVICEOUTNID
EFEES
SANITARY Y N
Owr-f Dalt, RECEIPI'N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR ROOF.A OND. SCHOOLTAK YN
Cl 1FcsbyeRrm NallhaveaceniFacnlrnnxnrtor lf-imuume,unaHiliaucofRI:CF.IfTN
• tm'Conpenwion lruurume m eanified copy 0mermf(Ss.3800.Lab C.)which NKTURPS-PER TRAP
Wor , PARK FEF. Y N
van ell employa't under Wit permit. GAS-EA.SYSTEM-1 IIETV it RECEIPT N
Policy N BUILDING DIVISION
C«nP^^y GAS-EA.SYS , (EPLANCHECK FlE 931 N-7 0
❑ Cmifcdcopyishcrchyfumisbcd.
❑ Cmi&d copy is fled wim B-aity irmepauon division. GREASF71 SISfia ACI3PIDR GRADING FELT
CERTIRCATE OF FXP.MPIION FROM WORKERS GRP IAAF SOILS FEE
COMPENSATION INSURANCE
Ohis ,sOma-cd trot be mnpleleJifd-permll is f«orshundreddoBus(SIM) WER A Y-ST EA.300E ENERGY FEE
or Era")
I an Hi thou in Weperfmmanceafthe work f«which Nispermh is issued,l shell WA Eb1T/ELE
not rnythny my person in any mere-r ao as to her. subjcet to the Workers' PAID
Cnmpeuelion Lawaof Cmfcmme Due WATER STES TNG pale
Q z APplicwlIs
z0 NOTICETOAF'PLICAM':ILo(IcrmeF:ing NisCmifxve of Esungioo.youYwN NEW RFSI PLM SQ.Pf. TOTAL:
bceane mbjea to has,Wasters Cmnpenutimm pmWslom ofd-,--Code,You muss
foMwith comply with each Provisions or ON permit"I be deeroel mavated. BUILDING FEE
4 CONSTRUCTION LENDING AGENCY SEISMICFEE
U O Iherby affmm thnlWere iso CCrIVNCIlOII tering ager-yf«d-perf«nwxx of TOTAL,: FISLTRIC FEE
me wmk fm which mis permit is ivucd(Sec.309].Civ.C.)
Lender's Name
C' F^ tender's Addrev QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LUI ani%Nn 1 have rad Nu.Ppl usa on"'one Burl We Powe irdormeticn is
Y2�
sn. T g xmrnm ywiNelcity der my ardor a Jtlue la mlm gm PERMIT ISSUANCE MEOIANICAL FliF.
t^ � building comualion,eM lncby eudmonsreprnrnluivnuf Bus city to enter upon Ne CONSTRUCTIONTAK
U z aMwc-mcmioncd praPcny f«mspccmm purp.xs. L'DiRORADDTOMF.CIL
^ (000 agree b uvc,imrnmify ud teeP humins the Cly of Cuperlim-erg;.,.
liebilirics,judgnw-m.,cusls ed esperea'wM1ich nmY inmmYwnY accrmw agdmWald Cily IR I IANDLING IINI'I'(TO O,gNICFM)
Inc urns Bo of prnNL
s AIRIIANDLING UNIT(OVER 10.000CF1,1)
Sig a EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(N I00,"BTU) Dem Recap N
Will the ii,takent or future buumng oevapuusms or hudle aNwu materiel HEATING UNR(OVER 100,000 BTU) TOTAL:
u defrr-J by the Cupem.Mama,]Cade,Chaper 9.12,W me Heelm and Safely
Cole,ScOi.21532(0] V�LATION PAN(SINGLE RESIDE
❑Yn ❑No
ISSUANCE DATE
BOILER-COMP(311POR 100.000 BTU)me aPPliantmt�lus beidmgeCCuPNluxequipmrnl«devimwhichemit pp�� p
A
homrdous air comaro m ,as def We d by Bay Area Air Quality Managerm-m BOILER-COMP(OVER 100,000 BTU) - r 1 p
District]
❑Yn ❑No NEW RESIDENTIAL MECII. SQ.FT.
I have read J-haysMous materials r,lomacm.,under Chapme 6.95 of the JUL 15 19
Cdifamie Ha1N A Safety .Cade,Seetimu 25503.23333 umd 25334. 1 urdefwnd Nu
B rbc building does out cumemly have a Irnanl,Nal it is my mslwnsibiliry to notify the
occupml of Ilse rtqui.ut which mall l-star poor m iss.of a Cerufi.of fin'Ur Port J
Occup y.
Oxoer«euNmvN agent Dem TOTAL: ISSUED BY:
OFFICE