26491 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU¢DEIG L ECTRTCA. PERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAL 26491
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING AIlIlR15S: ( C1- Ml /�� /Y-/IP SANITARY NO. APPLIGTIONSUBMfITAL DATE
/ UNLTI 7 LOTI
OWNERS NAME. PHONE: CO 1 R'SNAME LIC NO:
U -(33s NIC ROLL
CUUECl'/PNGINIH'R: LIC NO: ADDRESS:
7 (i!'7Pico °� ❑
C ACT ` PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
9 g e BLDG FIECf PLUMB MECU
G PERMIT ISSUANCE ❑ ❑ ❑ ❑
I.LCLNSEDCONTRACfO visioDECLARATION APPLIANCES-
RESIDENTIAL JOB DPS{'RIPyI(7p�
yro Ih7000).roulay fimmtion3ofI arm iceBasildapravui«uafChepsarandmyIll.isin 4 4^Ar-
5-
`Ar-
i p00 Section llMp)of UivinimJof the Businrss and Rofeuiom Coss,and my lkeruc is in pwpJg
ly t[IF. full f«ce emW effam.
QGw License Clw LicY UP TO 200 AAtP5
�6 d Due C.. 201-1000 AMPS
F-� ARCHITECTS DECLARATION .FT. ARG 5/SQ.II'.
Z 01L luxmraumld my Plants Dull be anted u Wblic martinis. OVER 1000 AMPS
SIGNS FI VUTRICAL
rL �J I'ttn+d ProletimW
X�Ix6 OWNER-BUILDER DECLARATION SPECIAL.CIRCUTT/MISC.
W C)W ttV.. 1 hereby aRhm taut 1 un caanp frown Jc Carlini U.Iatw fm the
[ll 1 O y folbwing rrnaon.(Sadao 7031 S,Busm¢s vW Professional Code:Any city or comm, TEMP.h1E'IFR OR POLE P'ST.
which rttryire I permit to cwlvrvn,l ter,improve,demolish,or is{it any awnwc
Xn} prim to its iswena.also re airu the epplium fon ti aoch tench to file a ed mmemert POWEIR DEVICES
wK5<p IMI he is liccnxd Pursuant to the provisiau nclor'a oftbe ConlLicrnx Laiw(Chapter
,Cx1 9(cmmeming with Sewim'l")of Division J of the BannexW Promalwu Code) SWIMMING POOL ELECTRIC VALUATION
W=y «IhW he is exempt thercfmm and the Buis for the alleged exemption.Any violation of
zYQ Sayion7031,5 by any npplicem f«a pemat subjects llc aMA cam In a civil pamby or �S-S��m-pry) /�111wI ,�-
2 rZ not more than five hamlt dollars 18500). ` ��{••(�
aFG ❑ I,aaowiernflhcPmpmy.mmycmploymwiln w.yaulheirxlecompanedan, NEW RS Mi ELECq_SQ. STORIES IYPECONSTRUCHON
ci � will Jo lhewmk,and the alrlmallmx isnot inmmJd woRered fn xde(Sa.1044,Btuimlw
end Professions Cade:The Contractors License law docs nom apply Io N..of
pmrcmr wnanailm«6mpravaa wmm,armdwlmad�,men w«knimxlrrimhmmgnM1i.
employees,fvavloMrtutaumimpovcltrnu tie nm merlddwoHerd tha.walr, P NITS
tlowcver,the W ilJing v improvamcm is sold wirier rise yevofcmmpletion.Ilse owver-
blulder will have the b«dal of proving Nu he did ant build or im ruve fon pmptve of TQM-'
ark.).
❑ I,uowmerarlhe PnoKHY•em escluaivclYanwedaml with littmedewvinasto QTY PLUMBING ERMIT FEE FLCsTDZONE AIN
ormhout Ile M jam(Sar TOW,Bud.and Prafram.Conk:)The Comnctars
License lawdtee not aPplymanomeerfson imy who Wills or impmvelMem,ell PERMIT ISSUANCE
wWcwluacu facsuch PmJMs wiffill r«(s)Iilrud N.U.Ilia Cmtncbra ALIFR-DRAINS VF .WATER(EA)Liccnm Law. FEE SUMMARY
❑ 1 em cacmp lusda Sar B&P C f«Iasi roman BACK FLOW PROTE7if.DEVICE SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,R F,AREA,COND. fOOI TAf
YECTIPTI N
❑ Ibemby nffiem lhatlheve•crnifieam of eomwnlln xlLinaurt«aanifiam or D)(T(Ip FC pER P RECEIPr!1
Worken'Cimmpalnramhm Irl.marxx vacmifid copy lhmml(.Scc.lgfMl,lsb C.)whicn RK FFE. Y N
r.vcn all mmployre'e omler mhis p-mail. RECF:I PT M
OAS-G.ST -I INC.40UILFlrs
PulicyM BUILDING DIVISION W
C^"nprny GAS-EA.SY VER 4(LA) PLANCUFA FEE
❑ Cmifid copy is McbY rumishd.
Fri
❑ Crnifidcwyisfildwllh dtyimpccdondivism GREASE/INDUSIRL!An
A INTERCEPTOR GRADING :E
CERTIFICATE OF EXEMPTION FROM WORKERS GRGSETRAP SOILS FET:
COMPENSATION INSURANCE
(Tams Wim mad M he coloPmd ifthe psamal L Friona hundd dollan($U10E SEWER-SANITARY-STORM EA.200 EIIERGY '
rilm)
I earthly Nnt in the Pvfartluve a the wah for which Nu permit is trud,l shall WATER HEATER W/VC T/FJECTR
not employ any pmon in say rather W u to bavme wbjat an the Workemi PAID
Cvpms
namian Lat"of CalJoma, Due E
e WATER SYSTEM/TREATING Dame Racipl
Q z Appli.
z O NOTICE TO APPLICANT If,ther making mhu Cotificsee or Exempian,you aMuld NEW RESIDENTIAL PLN B. SQ.FT. TOTAL
is
a fmh-1h emorlY with aucchi Provis vmortbia pcmlilla11all be armed Camel. m. BUILDING FEE �.
0. ❑ CONSTRUCTION LENDWG AGENCY SEISMIC FEE
-Dz I hamby affirm Ilial there is a conarmlim lembits agency for the perfvmmmame of
U O the wrak fur which this permit is ieald(Sa.W,Civ.C.) TOTAL: ELECTRIC IIT:
O Irralcr's Name
t<rsler4Athi QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I crnif,ifY Inti 1 nava rt it ons application ens slam Ion the above aws rulmlan it
canrech lalmxtncomply with Jlcity mdcounry wdinerlaeaur;ai,1. melsemn the PERMIT ISSUANCE MECHANICAL FEE
F-' Z Wova-g<oarauctiomamal Me by Recorm abr,s xolalive oltlmia city mthly upoo the CONSTRUCL'ION TAX
U abmveWa)tionscApimae. for irapactim Purposes. AFTER OR ADD TO ARCH.
(We)aya to nave.idammmify seat kap hatrablemy in
it the City of emilitim yeinn
liabilimia,yadgmmu.amu malcapmm whidm rlmYin anYavaY accrue agaira aaN City AIR HANDLING UNIT(x010,000 CFM)
N onrmuaquvax of Ile granting of this pemrmut.
AIR HANDLING UNR(OVr]t 10,000 CFM)
S roof Appl/icam/C`Irisin 4 D EXHAUST HOOD OVIDUCT) PAID
IIAZARD()US MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 RTU) Dem Reed,,I
Will Ile appli.or fulmc building occupant more or haste haeeNoua mucriel ANO UNIT(OVI:R IOo,fNp RTU) TOTAL
v dcfnd by the Cturami o Municipal Cde,Chr,mr 9.12,analthe Ileallh and Safety a
Cork.SatimEl 25332(0'1
El Ya ❑No TIVENLATION PAN(SINGLE RESID)
WilllWu liconmrfutum Wildm BOILER-COMP(JIIP OR IIMI,gMI B'N)
ISSUANCE ATE
Ian gaaaln+mll veryuipmrcnt«Jevicawnichcmim
nvarJnm air comanilnmma uv defined by Ile Bay Arta Air Quality Marugemarn BOILER-COMP(OVER 105.003 BTU) R9 p e
D.wic1^ lr M
❑Y. ❑No NEW RESIDENTIAL MECIL SQ,EL
I have mesl tie hvamdous muaialx mquiremrenv under Chapter 6.93 of the JUN\( - 8 1 Q
CW rmlia Ilcalth h Safety Cade,Sailbom 23303,23533 and 15334andnmv
. 1 cld than
if the building dm ant clm antly have a mount,Bon it is my respmuibiliry to mtify the
tampmll of the vquimrnew which mmm be anal Priv to iuuana a a Cmifiac of QT Vf t.4 V
Wvey.
Gwrcrri aullerixcd agrnm Dam TOTAL ISSUEDBY:
OFFIC