26396 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOILDI .-ITECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 26396
BUILDING PROJRCr IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO. APPLICATION SUHMTITAI.DAT?
2O 3 z5 V A Y UNITIf LOTg ; . r'Z'R(�v
OWNERS NAME: PHONE: CONTRACTOR'S NAME LICNO:
('j 2"17-SS SS Q O 141
NIC C'ONTROLN
RCHIIECDESOINF, LIC NO: AD RF.S ❑
Zr
O CT: PHONE:
9y L6 AyZA_, ) QTY. ELECTRIC PERMIT FEE BUILDING PERMITPILUMH O
a ( // c t� BLIX: LECT PLUMB MECH
Lb AyZAs h,D, Ia0L5 e SPd Z 17's�-J PERMIT ISSUANCE fo
LICENSEUCOM'RnderprR'SUI3CLARATION pppl.lANCGS-RESIUCNTIAL I� JOB D_ F:SCRIPTI_ OB�—
p0.vz Iherehy affirm
that I son CENSEDCOsW uACTORvisDECL DECLARATION
(commencing with
WRIP ON-
Poo Section 7008)of Division 3 of the Business and Professions Code.and my license is in PANELS
y66fail force it
Licnse Claserre�Yy 5y6QLt UPT02MAMN �s l �^
Ia„ZW License Class Lic.M ' v1
s' Date Cmrtmmor 201.I(Nq AMPS
2OrmitG ARCHITECT'S DECLARATION OVER IfI(NIAMPS SQ.FT.FLOOR AREA $/SQ.FT.
0z0
I undcrntund my plans shell he used es public records.
F.rot SIGNS ELECTRICAL
Y� Licensed Professional
10Whim-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
00.E I hereby affirm that I im exempt from the Cono-actola License Law for the
following reason,(Section 0031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
k�0y which reyuires a permit m consumer,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such Permit o file o signed statement POWER DEVICES
�y �0 that he is licensed pursuant to the provisions of the Contractors license Law(Chapter
0.401 9(commencing with Section Wall of Division 3 of the Business and Profession Code) SWIMMING POOL ELECTRIC VAL_UAT�IO
or y —y SeNathci31.5by therefrom applicant for
the basisfiresbeasegedeaemptt to civiny l
of OUTLETS-SWITCHES-FIXTURES 1 r—
Sa
out
thiLS by madmilicanl l$50irmil subjects the applicannoacivil penalty of
S not mnrelhnn Ovfthepr� riy,ormyem).
C� ❑ husnwncmRhe properly,nrmyemployeeswilh wages esthcirsolecampensmian, NEW RUSH)ENTIAL LLIiCTR —SQ,FT. $TORI TYPfiCONSTRUCI'ION
a3 will du the work,and thestrucmreis not imendedoraffered forassa(Set.0044,Business
and professions Cade:The Comncmes License Low does not apply to an owner of
properly who buitdsarimproves lherean.and whodeea such workhim alfordtroughbis
own employees,provided Nmauch improvements urenai intendedoroffered forxle.lf, OCC.GROUP RISS.UNITS
however,the buildingor improvement is sold within oneyearofoompletion,Iheowner-
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑ Lm owncr.fthepropeny,ameaclusively contracting with llcatuWconeacmrst0 QTY. PLUMBING PERMIT FI7F FLOOD ZONE APN
construct the Project(Sec.01144,Business and Professions Code:)The Contactors
License Lowdoes not apply to anownerofpr.pony whobuildsorimpmvesthmmxr andPERMITISSUANCE
wb.comracts fursuch projects win e<onvacmr(s)licenxd pununm[.,he Creamier., gLTIiR-DRAIN&VENT-WATER(EA)License Law, FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason O .1D, 5
BACK FLOW PROTECT.DEVICESANITARY Y N
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,GOND. SCHOOLTAX YN
❑ IherehyafriMthatihaveacenificateofconsen0.self-insure,«acenlfiateof RECEI g
Workerx'Contiamostion Insurance or a certified copy thereof(See.3800,Lab C.)which FIXTURIS-PER TRAP PARK PEP, Y N
is,1. covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RE PI'N
Policy N BUILDING DI ISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Cl Candied copy is hereby furnished.
8Candied copy is Bled with the city inspection division. GREASWNDUSIRL WASTE INTERCEPTOR GRADING ME
CERTIFICA I'E OF EXEMPTION FROM WORKERSGREASE I'RAP SOILS IT H
COMPENSATION INSURANCE
(This seclionnenlism he completW Era,permit is forms hundred dollars($1110) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
«lay.)
I cenifythat in the Performance ofthe work far which this permit is issued,Isbell WATER HEATER W/VENTAILECfR
not employ aaZ person in any manner so as in become subject to the Workers' PAID
z Compensmmr Lawsof C.Idomi.. Data WATER SYSTEM/TREATING ReceiplN
Applicant
Z 0 NOTICE TO APPLICANT:If,ef¢r making Chia Cerlifcate of Eaempti.n,you should NEWRESIDENTIALPLMB. SQ,PI'. TOTAL:
(_q became ct m subjethe W«kers Compensation provision of the Labor Code,you mus,
,7
aforthwith comply with such provisions or this permit shall be demand revoked. HUI E �e
A CONSTRUCTION LENDING AGENCY SEISMICPtE
z I hereby aflimnhat then is a construction lending agency for the performance of w ELECTRIC
V the work for which this Permit is issued(See.309],Civ.CJ �•
0 Lenders Name
Lenders Addie., QTY. MECHANICAL PERMIT FEE PLUMBING .E
I certify that I have mail this application and slate that he above information is
4 correct. I agree to comply with all city and county ordinances and state laws relating in PERMIT ISSUANCE MECHANIC .FEE
uj huildingcnnstruction,ondltereby amhorizerepreccurtivesofthiscity tocmerupon the CONSTRUCTIO AX
TJ z above-memioned Property for inspection purposes. ALTER OR ADD TO MSCI I.
(We)agree 1.save,indemnify and keep hurmlua Ne City of Cupertino against
Ilubilities,juA n hie ay in any w yxcm ugunst said iry AIR HANDLING UNIT(TO ,GOO CFM)
In cans Ce the®err 11.
G AIR HANDLING UNIT VER U),WO )
Signa reof 4Commclor ate EXHAUS THOOD N 1kA PAID
r HAZARDOUS MATERIALS DISCLOSURE HEATING!/ 1 BP.Ii, Duk kcipl#
Willits applicant.,(at..building«cupant store or handle hoot do us mamdul
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety HLA yro UNIT( 100, TOTAL:
Code,Section 25532(.)?
El Yes 1:1 No VP TILA ON A (SI LLIRESID)
Will applicant orfowmbuilding«cupent useequipmenmrdeviceawhich emit
BOILER HP I U) ISSUANCE DATE
hamrdous air cantaminann®defined by the Day Ana Air Quality Management BOILER- 0 R 100. TU)
District?
13Yes ❑No NEW RF,SIDF A MECH, SQ,fT.
1 have read the hazardous materials requirements under Chapter 6,95 of the P411)
California I lea th&Safety Code,Sections 25505,25533 and 25534.I understand that zs.
- if the building does net,currently have a terlmn,that i,is my responsibility to notify the
occupant of the requirements which must be mel prior to issuance of a Certificate of n VJ
Occupancy,
Owner of uulhanced agent Data TOTAL: ISSUED BY:
OFFICE