26855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOaurrntNr.erpr.TkTVA, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROTECT[DF.M'Ih1CAT1(1N 26855
ILOWG ADDRESS,
- SANITARY NOAPPLICATION SUBMITTAL
L DATE
t02"10 TqLA V or UNIT♦ LOT
NB ME pLJM,61HONE CTOR'S NAME yaa .'01�`
�^ NIC CONTROL0
ARCH ALT GIN'R: LIC NO: D G ❑
CONTACT: PHONEQTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
1 ^ �/. ♦ / O/ MECH
,. 64 IY✓( y`�^B�12— PERM IT ISSUANCE j PLUMB 36
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDENTIAl
pWz I bcby.Rn Jrnd
ut l con licrundd mvWom AfChx Mer9(cmimmcmg with TOB DESCRIPTION
en
,1�v101-- Senim,todeIDlrlsianJMNe Boumsand Pmf Cycle and my licenrt uin pANrp�
QZ, Ucwcfull orte aM cRcm Esc# UPTO2WAMPS v`
FZL
r < Date Cwtrrmr MI-I"AMPS
y
ZSNZ CHITECTS DECTARA OVER IMAMPS SQ.FT.FLOOR AREA (�, 3/SQ.FT.
gz_o ypl eraser - 2� ? (53
_ SIGNS ELECTRICAL
�nd
�0,
Lice
that
OWNER-BUILDER from
DECLARATION SPECW.CIRCUIT/MISC. \�
xOsy I hereby affirm then 1 aft acmpt frsm Nc Cwum,Co Limue dLawry
for Ne
LL3LLy fallovimg rawm(.Smyim]0313,Buslrtas nml Pmfasiau Coder:Any my acowty TEMP.MITER OR POLE INST.
tS l.'lo g which reyuiov a penia to cmmrun,Wwf,iml+nvc,demaliah,m repair any nmmum
prior t<)its imuomc,el.,)mqulm_s Ne applicim for suchpermit to fik a signed atmertent POWER D@CES
p that he ie licetucd puruumt m the pm,ui—ar Nc Commecmr'e Lie.Lew(Chapter
LLqx a 9(cormsncing wish Section 7000)af lbvisim 3.r be Bustin.and Prnfeuioms Cade) SWIMMING POOL.RLECTRIC ^ VALUATION
W_y or thin he is excmlx therefrom and the Lams tord,e tlegd eaemptim.My violation of OUTLETS-SWITCHES�PI%TTIRCS O/^� —().1(/�` L•{./
tZa Section 7031.5 M1y umy oppliumd for alerr it wbjmu the oppliant dr.civil Pertly d'
rat mere Nen five husdrw doles("M.
NEW RESIDENTIAL Fl I= —SQ.IT. TRIES TY
❑ I,uownt."ts, lu,nmyemttended]withwegeanNei(s 7o .B aJon.
B:— willdo(be wort.ande The
CureismtinteMdoroffmEf«sok(AyW an Btuinra
ed%rfeasians Ct.k:The Cmnrvnor's IJcena Isw doe not epp1Y m w owntt of i
pmpeny who bui Ids or improves Nefam,vol who,seer such wok WmaDa through his
own employees,provided Nat such imrovemenuue rot intrndcdaoReld far We If,
OCC GROUP RFS.UNITS
toxcrcr.Jc building Wimpravcmrnnis add wid�iu meyeer afrompledon,Jtcownm- Lk A.
builder will bti a de burden of proving slut be did not build m improve for pupae of `k
aide.).
❑ I,as owmrd'dhe propmty.wn<acluslrclycmtramNg with licxnadwnvzmnm QTY. NG PERMIT FEE L APN
«metfuct the fumed(Sec 7041.Busi.and Pfolestoa Cade:)The C-..—,u,
I.icvxl�w Jma mtepplymwowrrrofpspvty who buidsninrpmvo dhefcaruafd PERMIT ISSUANCE
wln«ndrxufm e�chpmjmu wiNamtm.color(.)licadud pvnuant do doer Canuacmis �.ER-DRAIN&OEM-WATER IEA) FEE SUMMARY
License law.
❑ I am caemp wrdm Sec. .B&P C fm Nu denim BACK FLOW PROTBCT.DEVICE IDE
SANITARY Y N
Owmr WORKMAN COMPENSATON DECLARATION DRAWS-FLOOR ROOFP40
COND. SCHOOLTAX Y��# N
❑ Ibucby affirm dhetl have accnifsane ofcmacnd da self Inure,«•emir uof FDTURM-_ RECEIPT'#
s� Wookmi CmlTcnsation launn¢m a anifid copy Ncrcof(S .3M,Lid,C.)which PARK FEE N
vcra.ltcmldoyee'stsde Ni ,crunid. GAS-EA.Sy PT
Policy 0 BUIL 'D1 )N FEES
C—Famy GAS- O9� E
PLANCHECK O
❑ Cmifdmpyishcfebyfmnit t❑ CemAedro isftkdwidhJucityim,edimdiviuor, GRPAS STELGRAD `WC ICERTIFICATE OF EXEMPTION FROM WOR KERS' REASE SOI COMPENSATION INSURANCE
(Tbieeatirn teed nit he complmd ifNe permit is for m,e htmAed dalWa(SI W) WER-SANITARYEN' GY FEE
mlm)
I cmify that in dine parr«frencs of the wwt fur which this pvmlt is lsswd,I adi w ITA IuiATI➢t w/VIIlI'mu:
ma empkry any pnsun in any m we to bccmm wbjmu to Ne Wid ers' PAID
Cmnpwuatim lawaMCalifami.. Due WA RSYSTEM/TRPATIN Dene R« ilia
NOTICE TO APRJCANT:If,aOm meting dhls Gerrit to MExcmptim,Yw should NEW ESIDFNIIAL% B. SQ.F`C JMTAL:
F_ wnri im wcormatmn dum
; mnhitorwith
�pooeniasarhtslnlIW cdbotdr dl
BUILDING FEB1 `51 saisaa,
WCL. SEISMIC FEE O
Q CONSTRUCTION LENDING AGENCY
Z I hereby sff on Nat dome is•comm lion Iuding.gcmY for the perforauree of - ELECTRIC FEE
V 0 the wok for which Nu permit is iasuid(S.,30]7,Ci,C.)
1.7. Ietdel.Num PLUMBING FEE
c) Ladd.Address QTY. MECHANICAL PERMIT FF.E
1 cenify Wt 1 h.ve read this appb atm and awe Nat Ne ebo,e information is MECHANICAL FEE
conei l agree to comply with all dry surd uumy mdinafce ed suer tt seDung noPFRMIT ISSUANCE
E" WiNimg«nwuctim.and hnebyaudoriu epeumativu ofmisary toduer upon rhe
(,J Z .bore.mrntraN Popery fn mpr
emim pnpr.". ALTERORADDTOMECH. CONSTRUCTION TAX
a 4:21
(Wer)agree to u,imlenmify am keep a Ne City Cityof Cupertino agtmt
dl ia.jdgtmhacosts aml<xpema which rtuy in.nyw.y scenic agnimtsaid Ciry AIR HANDLING UNIT(TO 10.000 CFM)
r degu m i /(k� AIR HANDLING UNIT(OVFR IOAOO CPM)
igrmn Applium/Cmtrcwr Di E%HAUSTHOOD(W/DUCII
PAID
L IA]ARDOUS MATFRIAIS DISCLOSURE HEATING UNIT(TO IM."BTII) Dane Red,',
Will Ne appli=t m forme building occupant store n MMle harmdnss mount I /� T � .ro
u deriod by de Cupmtim icipd MwCade,Clupw 9.12 and dhc Health ad Se(ay HEATING UNIT(OVER 100.000 BTU) L
Code.Sed.25532(.)7 VFNHLATION FAN(SINGLE.RISID)
❑Ya ❑No
SUDATE
Will JcepPlwandnfuturebuildingecupenduacyuiPrmmmdevicmwhich amid BOILER-LOA1P(311P OR I(p,fKtl NTD) OCT 'ISAN§{{��/J
�aM1a>efJow air conumimmis m defimd by fle Bey Area Air Quality Management BOILER.COMP(OVER 1 W.000 BTU) 011 4
Ur fur
❑Yo
El N. NEW RISIDF] IAL MECII. SQ.FT. tilIINC)
1 bavc sod Nc hazaN rtuncriaN rd,umments uMa Chapter 6.95 of Nc
Ctifomie I lralnh&Safety CW c,Sttuiam 25505,25577 ad 25534. I underswd Net
i fthe building cg .non cu my have uiwann,that it ix my n ,,omiulity to waify(be
mcupenn of tine rspulrcnwins wM1ich muga M con prior to i.aunmc of a Ccnifiam o[
fXcuWwy. 1
Owmer or amMdad egam Dve ISSUED BY.