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26071APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO IBLUM's - KEFICTRIUAt BUILDING DIVISION APPLICATION/PERMIT PLUMB[NG.MECHANICAL BUILDING PROJEL7 IDEN'1'IFICA'I']ON PFRMrr NO, 26071 BUILDING ADDRCSS: SANITARY NO. APPLICATION SUHMITI'AL DATE IO ar UNIT# LOT# 3 -1 -Al -t OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO: NIC ❑ CONTROL# -I Lan, I L•� �r , , WG �h/ ARCHITECUENGINEER: LICNO: ADDRESS: CONTACT : 'PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDGELE PLUMB ME❑CH PERMIT ISSUANCE T �^ LICENSED CONTRACTOR'S DECLARATION 1herebyaffirm ThatI amlicensedinss Knitviriomions Coca 9(commencing with Sectione andefect.'s on3or the Business end Professions Coda and my license is in full force and effect. License Class Lic.# APPLIANCES - RESIDENTIAL JOB DESCRIPTION �j #a�� � ��a\� PAprE15 ai UP T0300 AMPS Date Combine 201 - 1000 AMPS ARCHITECTS DECLARATION ATIO 1 undersand my plans shall T used DECLARATION OVER 1000 AMPS SQ. FT. FLOOR AREA .,# It $/SQ. FT. SIGNS ELECTRICAL �� CO Licensed Pmfesaionul OWNER -BUILDER DECLARATION ON SPECIAL CIRCUIT/MISC. I hereby infirm.(Se that I an exempt from the Contractors License Lew for the TEMP. METER OR POLE INST. Code: My city or county following risen. (Seaton 7031.5. Business and Professionsdemolish, ct, ngec improve, demolish, repair any sw n permit re conp,has Pon, i its i,es slicensedp rsu requires t file POWER DEVICES that r visionnor theuchpermiue License La(Clamstatement previsionsthe be rtractorsBasin. License Lawn, CW:) 9( he islicensedSlImmthe preDivision 9(commencing with Semion ]000)of Division3o(the Buainev and Profarions Cade) SWIMMING POOL ELECTRIC VALUA� or that he ix exempt there(mm and the basis for theallegedexempow. Any Acidic. mif Section 7031.5 by any applicant for o permit subjects the applicanuoacivil penalty of ww.� //yyrrsA� OUTLETS -SWITCHES -FIXTURES not more than five hundred dollars ($500). ❑ I,asownerofthepmp;try,ormyemployeeswithwagesastheirwlecomp nsadon, NEWRESIDENTIALELEC R _SQ.FT. STORIES TYPE CONS'TRUCT'ION willdothe wool, and the srumureis not intendedoroffered fineale(See. 0044, Business and Professions Code: The Connwroes License Law does not apply b an owner of , propenywhobiildaor improvesthereoq and whodosstIch work hinneafonhrough his own employees, provided that such improvements nine not intended or efferrM fortune. If, OCC. GROUP RPS. UNRS however, the building or improvement is sold within one ywrofcompledon,theowner- builder will have the burden of pinning that he did not build or improve for raw. of QTY. PLUMBING PERMIT FEE sale.). [II,asownerofthepropcny,amexclusivelycomractingwiN]iccnu conoactonb FLOOD ZONE APN instruct the project (Sec. 7044, Business and Professions Code:) The Contmcbrs License Lawdoes not apply town ovecrofproperty whobuilds camproveethercon,and PERMIT ISSUANCE who contracts for such projects with a contractors) licensed pursuantto the Contractors License Law. ALTER (FA ) FEE SUMMARY ❑ 1 em exempt under Sec. , ❑ & P C for this reavon BACK PLO V PR([M7. DGVIeE DRAINS- 00R PAREA,CONDrm SIDE FEES Owner Date T Y YN RECEIPT# WORKMAN COMPENSATION DECLARATION ❑ IM1ercby affirm thetl M1avew¢rtificme of consemmwlGinwm, are eeniftcamof Workers' Compensation lnwmnce ora certified copy thereof (Sec. 3800,Ieb CJ which OOLTAX YN I RIiCEE"# RK Y N FIXTURES PER / oven all employee's under this permit. Policy# GAS -EA. STEM -1 L TE RE IIT# UILDING ISION FEES Company GAS - Ii . .OVER4(PA) PLAN IEC �( L V ❑ Certified copy is hereby famished. ❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRI. WASTE INTERCEPTOR GRADE CERTIFICATE. OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASETRAP SOI S SEWER - SANITARY - STORM FA. ENER FEE (This section need not Ise completed if Ne permit is foram hundred doRan,UH00) or lay.) WATER HEATER WNENT/ELECTR I cenify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner w v to become subjcet b the Workers' Compensmionl-awso(Califnmia. Date Applicant WATER SYSTEMITREATING PAID Dure ecelpt# NOTICETO APPLICANT:ILefttt making this CertiRcam of Exemption, you should NEW RESIDENTIAL PLMB. SQ. TOTAL: M1ecamesubjectb the Compensation providerofthe GMs,you must such Pr forthwith comply with such provisions or pemdt shall be deemed mvaked. amount BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC TEE 1 hereby affirm that there is a construction lending agency for the performance of TOTAL ELECTRIC WE Lf the work for which this pemtit it issued (Sm. 3097. Civ. C.) lender's Name Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE 1 wnify that I have read this epplietakn and one that the above information is l agree b comply with all city and county ordinances and state laws reading b PERMIT ISSUANCE MECHANICAL. Mr. building construction wdhereb thon=.Munafivesofthiscirymentttuponthe above -ramie prop; art jnsTttttion pts sus. ALTER OR ADD TO MECH, CONSTRUCTION TAX ( grt to nave iodic y d ke p lav the Ciry of Cupertino egeiwt iinhil' u,judgme c as�d expert w ch yin any way...ru egwm aid Ciry AIR HANDLING UNIT ('10111,000 CFM) n soqu aG ming of this 14 AIR HANDLING UNIT (OVER 10.000 CFM) Signemm a(ApplicnnVCnntranor m EXHAUST HOOD(WIDUC) PAID HEATING UNIT (TO 100j" BTU) HAZARDOUS MATERIALS DISCLOSURE Date Receipt# Will the applicant or future building occupant store or handle haurdous material sea defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health end Safety HEATING UNIT (OVER 10R" BTU) TOTAL: VEN71UTION FAN(SINGLE RFSID) Code, Section 25532(4)? ❑ Yes RrNo Will the applicant rfuture building uccupur use equipment ordevices which will BOILER - COMP (31 IF OR 100,001) BTU) ISSUANCE DATE hazardous air contaminants as dented by the Bay Area Air Quality Management Dindn? VON. VNo BOILER. COMP (OVER 100,000 BTU) P NEW RESIDENTIAL MECIL SQ, FT. 1 have rad he hoz us mi equimmems under Chapter 6.95 of the CaHeart Sefet Code, act 505, 3. l3 and 25534. 1undmand that if the builJing snot carr tly veemn thvt my renponxihililywnotify the s �� O e Ir cupum of require was m h must be m to issuance of e nifcam of D cap ey. r 1 G `� L ISSUED BY: Owner or coalbed agent Doe TOTAL,: OFFICE 1 11`0 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO IBLUM's - KEFICTRIUAt BUILDING DIVISION APPLICATION/PERMIT PLUMB[NG.MECHANICAL BUILDING PROJEL7 IDEN'1'IFICA'I']ON PFRMrr NO, 26071 BUILDING ADDRCSS: SANITARY NO. APPLICATION SUHMITI'AL DATE IO ar UNIT# LOT# 3 -1 -Al -t OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO: NIC ❑ CONTROL# -I Lan, I L•� �r , , WG �h/ ARCHITECUENGINEER: LICNO: ADDRESS: CONTACT : 'PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDGELE PLUMB ME❑CH PERMIT ISSUANCE T �^ LICENSED CONTRACTOR'S DECLARATION 1herebyaffirm ThatI amlicensedinss Knitviriomions Coca 9(commencing with Sectione andefect.'s on3or the Business end Professions Coda and my license is in full force and effect. License Class Lic.# APPLIANCES - RESIDENTIAL JOB DESCRIPTION �j #a�� � ��a\� PAprE15 ai UP T0300 AMPS Date Combine 201 - 1000 AMPS ARCHITECTS DECLARATION ATIO 1 undersand my plans shall T used DECLARATION OVER 1000 AMPS SQ. FT. FLOOR AREA .,# It $/SQ. FT. SIGNS ELECTRICAL �� CO Licensed Pmfesaionul OWNER -BUILDER DECLARATION ON SPECIAL CIRCUIT/MISC. I hereby infirm.(Se that I an exempt from the Contractors License Lew for the TEMP. METER OR POLE INST. Code: My city or county following risen. (Seaton 7031.5. Business and Professionsdemolish, ct, ngec improve, demolish, repair any sw n permit re conp,has Pon, i its i,es slicensedp rsu requires t file POWER DEVICES that r visionnor theuchpermiue License La(Clamstatement previsionsthe be rtractorsBasin. License Lawn, CW:) 9( he islicensedSlImmthe preDivision 9(commencing with Semion ]000)of Division3o(the Buainev and Profarions Cade) SWIMMING POOL ELECTRIC VALUA� or that he ix exempt there(mm and the basis for theallegedexempow. Any Acidic. mif Section 7031.5 by any applicant for o permit subjects the applicanuoacivil penalty of ww.� //yyrrsA� OUTLETS -SWITCHES -FIXTURES not more than five hundred dollars ($500). ❑ I,asownerofthepmp;try,ormyemployeeswithwagesastheirwlecomp nsadon, NEWRESIDENTIALELEC R _SQ.FT. STORIES TYPE CONS'TRUCT'ION willdothe wool, and the srumureis not intendedoroffered fineale(See. 0044, Business and Professions Code: The Connwroes License Law does not apply b an owner of , propenywhobiildaor improvesthereoq and whodosstIch work hinneafonhrough his own employees, provided that such improvements nine not intended or efferrM fortune. If, OCC. GROUP RPS. UNRS however, the building or improvement is sold within one ywrofcompledon,theowner- builder will have the burden of pinning that he did not build or improve for raw. of QTY. PLUMBING PERMIT FEE sale.). [II,asownerofthepropcny,amexclusivelycomractingwiN]iccnu conoactonb FLOOD ZONE APN instruct the project (Sec. 7044, Business and Professions Code:) The Contmcbrs License Lawdoes not apply town ovecrofproperty whobuilds camproveethercon,and PERMIT ISSUANCE who contracts for such projects with a contractors) licensed pursuantto the Contractors License Law. ALTER (FA ) FEE SUMMARY ❑ 1 em exempt under Sec. , ❑ & P C for this reavon BACK PLO V PR([M7. DGVIeE DRAINS- 00R PAREA,CONDrm SIDE FEES Owner Date T Y YN RECEIPT# WORKMAN COMPENSATION DECLARATION ❑ IM1ercby affirm thetl M1avew¢rtificme of consemmwlGinwm, are eeniftcamof Workers' Compensation lnwmnce ora certified copy thereof (Sec. 3800,Ieb CJ which OOLTAX YN I RIiCEE"# RK Y N FIXTURES PER / oven all employee's under this permit. Policy# GAS -EA. STEM -1 L TE RE IIT# UILDING ISION FEES Company GAS - Ii . .OVER4(PA) PLAN IEC �( L V ❑ Certified copy is hereby famished. ❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRI. WASTE INTERCEPTOR GRADE CERTIFICATE. OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASETRAP SOI S SEWER - SANITARY - STORM FA. ENER FEE (This section need not Ise completed if Ne permit is foram hundred doRan,UH00) or lay.) WATER HEATER WNENT/ELECTR I cenify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner w v to become subjcet b the Workers' Compensmionl-awso(Califnmia. Date Applicant WATER SYSTEMITREATING PAID Dure ecelpt# NOTICETO APPLICANT:ILefttt making this CertiRcam of Exemption, you should NEW RESIDENTIAL PLMB. SQ. TOTAL: M1ecamesubjectb the Compensation providerofthe GMs,you must such Pr forthwith comply with such provisions or pemdt shall be deemed mvaked. amount BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC TEE 1 hereby affirm that there is a construction lending agency for the performance of TOTAL ELECTRIC WE Lf the work for which this pemtit it issued (Sm. 3097. Civ. C.) lender's Name Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE 1 wnify that I have read this epplietakn and one that the above information is l agree b comply with all city and county ordinances and state laws reading b PERMIT ISSUANCE MECHANICAL. Mr. building construction wdhereb thon=.Munafivesofthiscirymentttuponthe above -ramie prop; art jnsTttttion pts sus. ALTER OR ADD TO MECH, CONSTRUCTION TAX ( grt to nave iodic y d ke p lav the Ciry of Cupertino egeiwt iinhil' u,judgme c as�d expert w ch yin any way...ru egwm aid Ciry AIR HANDLING UNIT ('10111,000 CFM) n soqu aG ming of this 14 AIR HANDLING UNIT (OVER 10.000 CFM) Signemm a(ApplicnnVCnntranor m EXHAUST HOOD(WIDUC) PAID HEATING UNIT (TO 100j" BTU) HAZARDOUS MATERIALS DISCLOSURE Date Receipt# Will the applicant or future building occupant store or handle haurdous material sea defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health end Safety HEATING UNIT (OVER 10R" BTU) TOTAL: VEN71UTION FAN(SINGLE RFSID) Code, Section 25532(4)? ❑ Yes RrNo Will the applicant rfuture building uccupur use equipment ordevices which will BOILER - COMP (31 IF OR 100,001) BTU) ISSUANCE DATE hazardous air contaminants as dented by the Bay Area Air Quality Management Dindn? VON. VNo BOILER. COMP (OVER 100,000 BTU) P NEW RESIDENTIAL MECIL SQ, FT. 1 have rad he hoz us mi equimmems under Chapter 6.95 of the CaHeart Sefet Code, act 505, 3. l3 and 25534. 1undmand that if the builJing snot carr tly veemn thvt my renponxihililywnotify the s �� O e Ir cupum of require was m h must be m to issuance of e nifcam of D cap ey. r 1 G `� L ISSUED BY: Owner or coalbed agent Doe TOTAL,: OFFICE 1 11`0