26743 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CII'Y OF CUPERTINOUILDING ELECTFRICAL pCbMirr NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBINGMECHANICAL 26743
BUILDING PROIF.C7T IDENTIFICATION
BUILDING ADDRESS: /, SANITARY NO. APPLICATION SUBMITTAL DATE
TA NTA U V f�- UNIT. LOT �—t E- y
OW RS NAFIE: PHONE CO R'S NAME: WC NO: —\
A�1YJ�� awt S o-2z�-110 �� I[)-U7SU NIC CONTROL
1�1HH-ECT/FNGINE : LIC NO: ❑
CONTACT: PHONE TRBUILDING PERMIT INFO
TY. ELECTRIC PERMIT FEE
� BLDG LLECI' PLUMB MECH
PERMIT ISSUANCE El
LICENSED CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
thereby afeml thatd I un liaosuMugovisiors of Chaptu9(conm a nclog wit
01zo1— Section70(X))cf DivisimJofine Rmimv wd HofcaiaufC�ode,end my licemeis in pANyS
QVCto
lie CeW cffrrt. Lic.N V UP TO NIB
cc++ OQBOJ��J
tnDo' Datc Cnmroctm 201-IOOOAMPS
z O v-KARCI II11f]TS DECLARATION OVER SQ.Fr.ILWRAREA $/SQ Fr.
oz— lankrxtvxl�tty pious Wall nc nealmpanlb rtrards.
SI S
urenw Ih,rmhtal
055'N.e.etnr fi DECLARATION S //ASC
xdOaF 1 hcreM1y afhrm that 1 un exempt fmn the Cmuect«s liccme law for the
1+1'3 u..an followingrcnwa(Sa,fi.7031.5,Businmm
ituAlPrafessis A's :Anyeiy ty ORIE toconnNST.
t u'ON J which nA,iirm a permit to con...alta,hrtpmve.demohil,.en repay my svucuue
Sd`�>� poor to iu issuuxx,alw tory'ism Nc appli.ult fm surltpanut My
D�ty K<p Unit k isliccnwdpmwutt to me pmvisian of me Cmuecta's I,krns law(
' 9anmthercin SWIM Ci POOL PIRCTIUCX ( ,with Section7000)ofDininw.3ofthe Bum.ud PwfeWaVALUA'Il0'ty_,� or mat he is memp merefmm ad the basis far me alleged n.miiaL Atz,Q Section 7031.5bymy q0 icant for•permit subjects the eppliema m a civil pOUTLETS-SWr ICIiES- 1
not some than f ve hantdml ddlus(55(10). `
71
❑ NEW RESIDENTIAL ELECIR FT. STORIE9 TYPE N uCnON
a3°p wJl do the wort,ud ite,muentre I,not intended or offered for vk(S 7041.Bwnms
ud Pmfmsias Code:The Corn cAs License law does,not appy to sot owtr of
progeny who builds m imlvoves thermn,std whodoor an wmk himrelfm duough his
cmpbym.poviddthet wchimlvovmrntaanctxt intctddoroffvdf«WcIL OCC.GROUP RES,UNITS
however,the Wildingoe iniMtement is sold within one yesrofcomplcdos,the owtler- TOTAL
buider will hove the dudes of proving thm he did rot bald or impov<fm poTn,u of
sols,)' QTY. PLUMBING PERMIT FEE L DZONE MN
❑ I,vawneraf 0e pwpeny,amescluslvelycmvrting with licrn�edcmuectmetn
comeuct be"Jen(Sec.7044,Business ud Rofeulau Caere:)The Cmttvct«s
Liccmclawdoesoctapplytowownuofpmpcny wlwbuilds«impmvcs tticrtm,mW PFRMI'I ISSUANCE
whocmtmas forwch projass withecmlrulmfe)li<rnsdpwsuantwtM Contractnfs
license Lnw. AI;OR-URAINh VIlJ'r-WATER(FA) FEE SUMMARY
❑ I nm exnnit under Sec. .B A P C fm this rearm
HACK PLOW PROTECT.DEVICE S Y N
Owner De¢ RECEIPTM
ARA
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLTIONSCH .TA% Y N
❑ InCont affirmmatt'.orirateofcapcntmsu-insu31,),amtihrneof FI%'IVRFS-PER TRAP RF,CEI N
Waekert Compensetlonlntuthin oracenlfid copy themof(SS IgB),lab C7 which PARK IFR Y N
rn Vl cmpbyc2•undcr Nu permifGAS-f•.A.SYSTA-IINGL+
40VDIS RELEI N
Policy* BUILDING DI V IS
Company GAS.EA.SYST�M�OVER 4 EDO PIANCTIECK FEE
❑ cetErtd carr i.ltmebr ramimtea 1
1 ❑ Cmied a.py is ltd with the city impcctim Arisioo. GRFASFIINDU.STRI.WASTE INIFRCEPI'OR GRADING FFR
CERTIFICATE OF E%EMPIION FROM R GREASETRAP SOILS FEE
COMPENSATION INSURANC
(This section need not becompletd iftle permit is two SEWER-SANITARY-STORM EA 200FT. ENERGY HE
err kis.)
I cent Out in the perfunurhee of the woh for Lie, WATER HEATER W/S'ENDFLECTR
not ctnpby any pawn in my mminer w t to the Waken' JBUILDING
D
""'wen laws of Glifmnii Dua WATER SYSIF.MO'NEATPNG to iptN
DO NOf110E TOAPPLIGNf:ILaftm roakitg mie Tbteo enndoet,you mould NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
becnnns_bject to the Wmk«s Cmtpensatim s ofthe l,abar Code,yourrau
> fanhwith comply with ouch povisimisathispuntl shall be dstrsd rtvWd. HFE
Q CONSTRUCTION LENDING AGENCY
OI hcmhY affirm tlat therein a cmwuction lending agency far the perlmmrxs of TOTAL: CfRICthe work fou which this pcmtit is istoed(Sec.3097,Civ.CJCuter',None
Lenders Athl¢vs QTY. MECHANICAL PERMTT FEE UMBING HE
1 comfy dont I have rad this"llmtim ad mate flat the above,oformatim is MECHANICAL EFF.
cormct.la,ram comply with Hl cityud cowry mditwtvsud muelewamlatingm PERMIT ISSUANCE
F M1uiltingmneultctito,end bench,euthari.e tepranutiver ofthia city to entaupon tlrc CONSTRUCTION TA
(� z above-unt.imd Pw y far in,ec ion Wrpwea. ALTER OR ADD TO MECIL
(We)ague to Ove,irden riify ad keep huMms lite Cry M Cupenion Mitinst
Iiebilhim,Judgmrnts,costs ud mpemm which may in my way n ti,,ainst mid City AIR HANDLING UNIT(TO 10,000(7FM)
Inc quence Mmegrist'�of Nis 'L
(I AIR HANDLING UNIT(OVER 10.000 CFM)
S aurecer Date MHAUSf HOOD(W/DUCD PAID
IIA]ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Owe Racipt N
Will tie applicant or futmc building on,eu,mt sioe or batinfle dws murial HEATING UNIT OVER 100,000 BTU) TOTAL:
m defined!by the Cave w Munkdpm Code,Clut mr 9.12,fund ms Ilmlm and Safety
Code,Satlan 25513(.)7 VENTILATION FAN(SINGLE RESID) t
11 Ym C1 No
ISSUAN DATE
Willthe opplirattorfumrtbuilditg occvPentucequipreeNmdevireewhichrndt
BOILER-COMP CHP OR 100,80(I BTU)
evnlom dr contmninum m defined by the Bey Atte At,Quality Mmii coent BOILER-COMB(OVER 11)0,000 BTU)
sWa7
❑Yo ❑No NEW RESIUENIIAL MECfI. SQ.FT.
1 lave rcud Htc lb Tamm,,matcnals oo iirc oens under Chepu 6.95 of the f A 0
CWifom'm kWthS Sufcly Crvlc,Sedimx 25N)5.2553)end]SSM. 1underil dmat
if the building Mme'not,coolly have a teean,that it is in,respotsihiliry to notify dtc
ut of the rryaclhe
irnts which muus,son m erc
Ipnto iuue of a Cenifue
cn[ 1
( pwXcupwcy.
OwrAroreuthtni",ent Due TOTAL ISSUED ILYi'
OFFICE