S 2026APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
_.._.—
BUILDING - ELECTRICAL
PLUMBIIS;- MECHANICAL
PES
PESIT NO2�^^
L Lb
BLDG IEI.ECI' PLUMB MBCH
BUILDING DIVISION
APPLICATION/PERMIT
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL: '
❑SFDWI. ❑KI'fCHF.N REMODEL.
❑ AUDI TION ❑PLUMBING R17PIPE
❑AfU1.TLUNIT ❑STRUCI'11kA1.
MODIFICATION
❑ PIT 17RIOR 4;@f MTZF.Y REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH RF.MODEUREPAIR ODEMOLITION
❑ 01 PER
'/
lqfnl�_
PERMIT ISSUANCE
APPLIANCES-BSIDEN'1'IAL
1'ANF:IS
Oil TO2W AMPS
re W
C
3O y V
1x. y
,
M9
y o y
Lirenecl ProfYsionel
OWNER-DUILUIEIt UIECLARA7"ION
1 hereby uffinu that 1 an esemt from the Catharines License Law for the
following reason. (Section 7131.5, Business and Pmfessions Cale: Any city or county
which requires a permit to eonsnnct. alter, improve, demolish, or rcpoi, any sure 0
prior In hs issuance, also requlmxthe npplisnnr lin such pern.i, to llleasignedsm¢menl
that he is licensed pursuant o the previsions (if the Contmaor's License Ca.
(commencing with Scalon 9(MKI)of Division 3 Of the Business ane Profusion, Codc)or
that he is exempt therefrom and the bras lin the alleged exemption. Any vio lmioo of
gal-Isd AMPS
OVER I"AMPS
BUILDING PROJECT IDENTIFICATION
TEMP. METIER OR POLE INSP.
J
C SO i)\ IA
❑ NEW BLDG/ADDITION ❑ DEMOLITION
BUILDING ADDRESS:
Stereo 9031.5 by any a,plicam Porn Peri anbjects lheupplleom mnclvll penalty nl
not more than five handrail dollam ($5W).
❑ Lo the work, the progeny,(itmyemployeeswith Bred fostheirsok compensation,
will dotMwork,Cand
e:ThemrcisnmiLicensorawercoes not apply 911 N. Business
Code: The Cntnmcmrs License Law does not apply outsell un owner of
and ,ly who
pmpeny who buBtls nr oided th thsuch i end who ansa m n tinte sdOffamd gh
his own employees, provided that such vre not intended m nffcmd far
POWER DEVICES
❑THNANT ❑FOOD SERVICE
IMPROVE)dENT
DOTTER
SWIMMING 1'001 ELEC'I'kIC
011'TLETS- I'rCBES-PI%TURES
SANITARY NO.
NEW )P 'I'IAI. BLP.C'I'k SQ I'I:
APPLICATION SUBMI'PI'AL
DATE
WSQ. FT.
S h%
sale, If. however, the building or Improvement I% sold within one year ofcompletion. the
e mens I% old w
owner -builder will have the burden af,mving that redid not build m improve for pur-
F_`( 9 I
T
OWNER NAMH:
PHONE:
CONTRA(:I'
OR'S NAME:
GrG LIC(1: N
NIC
❑
C(1NTNOLA
I/ xJ
Y T
IARCHITE 'IF,NGINEER: hIC NO:
ADDRESS:
OFFICE
CONTACT. PHONE:
BUILDING PERM1'1' INPU
❑ Consultant Fees Paid by Applicant (Initial)
BLDG IEI.ECI' PLUMB MBCH
W
WOO OO
F w.+
VU
�n6w
,, o, n
pZ
LICENSED CON I'RACf11R;S DECLARATION
I hereby infirm that I wn licensed ander, provlson of Chapter 9 mmirriencins
with Section 7") of Division 3 ofthe Business and Profession, Code,and my license is
in full lone nnJ cQc t. 3
Licun.c �.W L Llc.p
One-(s/--.�—=�G}.y-Contmomr
V AtiLftITELTS DCCLARAT1oN
1 understand my plans shall he used m public reatNs
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL: '
❑SFDWI. ❑KI'fCHF.N REMODEL.
❑ AUDI TION ❑PLUMBING R17PIPE
❑AfU1.TLUNIT ❑STRUCI'11kA1.
MODIFICATION
❑ PIT 17RIOR 4;@f MTZF.Y REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH RF.MODEUREPAIR ODEMOLITION
❑ 01 PER
'/
lqfnl�_
PERMIT ISSUANCE
APPLIANCES-BSIDEN'1'IAL
1'ANF:IS
Oil TO2W AMPS
re W
C
3O y V
1x. y
,
M9
y o y
Lirenecl ProfYsionel
OWNER-DUILUIEIt UIECLARA7"ION
1 hereby uffinu that 1 an esemt from the Catharines License Law for the
following reason. (Section 7131.5, Business and Pmfessions Cale: Any city or county
which requires a permit to eonsnnct. alter, improve, demolish, or rcpoi, any sure 0
prior In hs issuance, also requlmxthe npplisnnr lin such pern.i, to llleasignedsm¢menl
that he is licensed pursuant o the previsions (if the Contmaor's License Ca.
(commencing with Scalon 9(MKI)of Division 3 Of the Business ane Profusion, Codc)or
that he is exempt therefrom and the bras lin the alleged exemption. Any vio lmioo of
gal-Isd AMPS
OVER I"AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METIER OR POLE INSP.
J
C SO i)\ IA
❑ NEW BLDG/ADDITION ❑ DEMOLITION
W m
F Z>'
PSC
F•
a 3 m
Stereo 9031.5 by any a,plicam Porn Peri anbjects lheupplleom mnclvll penalty nl
not more than five handrail dollam ($5W).
❑ Lo the work, the progeny,(itmyemployeeswith Bred fostheirsok compensation,
will dotMwork,Cand
e:ThemrcisnmiLicensorawercoes not apply 911 N. Business
Code: The Cntnmcmrs License Law does not apply outsell un owner of
and ,ly who
pmpeny who buBtls nr oided th thsuch i end who ansa m n tinte sdOffamd gh
his own employees, provided that such vre not intended m nffcmd far
POWER DEVICES
❑THNANT ❑FOOD SERVICE
IMPROVE)dENT
DOTTER
SWIMMING 1'001 ELEC'I'kIC
011'TLETS- I'rCBES-PI%TURES
NEW )P 'I'IAI. BLP.C'I'k SQ I'I:
SQ. IM FLOOR AREA
WSQ. FT.
sale, If. however, the building or Improvement I% sold within one year ofcompletion. the
e mens I% old w
owner -builder will have the burden af,mving that redid not build m improve for pur-
pose of sale.),
I.o awaar nl rlro pmpeny, wn cxdunivcly amtmc,ing with licensal cunveanrs m
'roTAL.
msimn Ne prapert (Sec. RHs, Raciness and Proferome, Cade) The Conbvcmr's L i-
nslawdoexnotapplymanawnerofpropedywhoM1mits, or improves thereon, and
QTY, PLUMBINGPF. MIT FEE
who contrams for such projects with acmdract v) Ilaaned pumuwt m the Contractor',
1117RMI I ISSUANCE
ti3
License law.
❑ Ium csem,t under Sec. ,R& P C for this mrson
AGER- DRAIN & VENT - WATER (EA)
Date
VALUATION
9`
t.
ncr
"f WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
underCcnullyaf Orjoycu of following dcdanniuns:
Ihand
1
fliaffino
omem. self- ,ore forabloonsiCompen
❑(1'heas and will for by efete Of the abor Code.
for Section,I..39W of the labor Calc, for the perfannance of the
snow, n providedIhis
DNAINS- PLOOIt,RWP, AREA, COND.
STORIES
TYPE CONS'I'kUCr10N
wufk for ich this pcmtai is issued.
I'I%'Il1kES-PER TRAP
nvo and will maintain nca, as required by Section
IrOuraal,
Co,c
al ,hlon
h. ali's
or
391X1 of lho Lab ur Cndc, fonho,crformrmecnf,hcwork Gn'whmol, Wis permit lx issued.
GAS -I:A. SYS, TEM -I INC, xf1U'I'LETS
OCC GROUT'
APN
My Work rs Contpentuon Incur ace runic, and Policy number are
Carticr72Policy Nt...
GAS - EA. SYSTEM -OVER x(P.A)
QiRTIFI OMPEEAI R-EvIONFROM WOHKE 5'
COMPENSATION INSURANCE
GliIiASF/INDI15'I'kL WAS'I'li INTERCEPTOR
BUILDING DIVISION PL'E,S
(This section need not he mmpleod'd,helnrmit is Intone hundreddolbtrs($11X0
or less.)
GRIEASETRAI'
I'fANCHF:CK FEE
SEWER - SAN[ FARY-STORM EA. 200 FT.
I certify that in she performance Of Oe work for which this permit in issued, Ishall
not employ any person in any manner so as to become subject o the Warkerr; Compen-
ENERGY FEE
WN117UpMIt W/VENT/1ITIE FR
ZZ
Q
y
;
Lk)
W Q
= z
U C)
Qf" r
satin.. Lrwanf Call' a. Date
Applicant
GRADING 17EE
SOILS FEEa
NOTICE TO APPLICANT: If, after making this Canificam of Exemption, no should
became subject to the Worked Conspensation provisions of the Labor Cale, you must
forthwith com,ly with such provisions or this permit shall he deemed revoked.
CONS '1'RUCTION ].ENDING AGENCY
Ihereb firm that there is a construction lending for the Performance of
hereby gasency
the work for which this permit is issued (See. 3097, Cir. C.)
Lender's Name
WADER SYSTENWREATING
WAI'1iR SERVICE
PAID
Date I ceip.
TGI'AI
NEW RESIDENT JAL PLMIi. SQ. FT.
Lender's Address
'I'(11'AI.:
INC P. r
IC FLEE
{U
F-' y
U
1 certify that I hon mad this application and slet, that the olwve iimmmorm is
ronect.I agree to comply with all city and county ordinances and state laws reining to
building commaction, andhcrehy authudze representatives of this city orram.pon the
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCEAW
LEC'1'
abnvcmeniioncd pru,city for inspersion purposes.
(We) agree m save. Indenmhy and keep harmless the City of Cupertino again
ALTER OR ADD 10 MECII.
liabilities.judgments. cosaandcapensesasbicb may in any way accrue again, said City
in asequence of the grating Of this peanit.
LUMBING FEB
AIR HANDLING UNIT ('1'0 10,000CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WI"IH AL1. NON -POINT
SOURCE RECALLA1'IONS.
CHANICAL FEE
HANDLING UNIT (OVER 111,0X1 CFM)
Ct
ONS'I'I
HOUSING MITIGATION FEE.
Slgmndre ofA,,IicmWComraanf ()ate
I IAZARD(II1S MATERIALS DISCLOSURE
EXHAUST GOOD(WMUCI')
IIBA'I'ING UNTI' ('TO I of'of, BTU)
WO the ap..heron, or lidnre building wear, m sora or Lente hu'rwduux rmdcrial
as defined by the Cupertino Municipal Code, Cougar, 9.12, and the Hcahh and Safety
Cale, See ion M5326a)'
UU,,TING UNIT (OVER 100,000 BTU)
❑ Yea ❑ No
PAID
(late Reealpt p
VIN 'I'ELATION PAN SINGLE HESIDI
I;01177 -COMP OHP OR IIX1,D01 BTU)
Pidirict?
Will ti the applicant in els a building by the B use equipment or Micas which
oazvdous air contaminants as defined by the Bay Arca Air Quality Management
E] Year El No
UT
BOILER -COMP (OVER 100,000 BTU)
AIH CONTI TION 11H
1 have rem( the hawNnux nmmrialx rayuimmemx under ChapterOS of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL. MECII. SQ, FT
fnmia Heahh & Safety Cale, Seaton, 25505, 25533 and 2553x.1 mmommnd Nat ifdm
does nt currently have a moam, that a is my mspmsihil'ay In notify the occupant
G1 —?,pbuilding
of
of the nouirements which ruin ke Oum oHer ,o mmeare� Certificate oT Oetunanev.
-
OFFICE