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APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUHAJINO -KLI 'TRICAI.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
PROJECCp IDENTIFICATION
PERMIT NO.
28028
B U; LBUILDING
BUILDINQADORISS:
SANITARY NO.
APPLICATIONSUBMITTALDATL
O / UNIT# 1.0'11#_
y�
OWNS MEPHONF
a�GYMP
CONTRACT'OR'S NAME: LIC 1,0:
N/C
❑
CONIHOh#
!!l! `
��/�Y
\ C'JUIECUENGINEUR: LIC NO: I
AD MESS: D
-
CONTACT: PHONE:
N I ' ���_��
rBUILDING
QTY, ELECTRIC PERMIT FEE
PERMIT INFO
BL i ECf PI. LMB MECII
PERMIT ISSUANCE
LICHNSIiDCONT'RACfORS DECLARATION
I hereby affirm that I am licensed under pmvWarned Chapter 9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
fallen]andie fDivision Jnf the Business and ProfesIsions Code, and my license is in
Licertx Class hic.p J�/
Lice lasseffect. 6 d / vs
PANELS
UPT0211IIAMPS
Date Co..,.,=SOVER
q CHIIEC,, ON
I understand my plans shall be used as public mttxda.
20 1- 1 AMPS
V T w
OVER 10(I(IAMPS
I
SQ. PT. FLOOR ARG "SQ. FT.
11.751M w�
SIGNS ELECTRICAL
Ina
`D
Uttnaod Pra(vssinnul t
Ot I am BUILDERnt the Contractor's
hereby that 1 am exempt the Cantmcm License Low for the
SPIiC1A1.CIRCUIT/MISC.
TEMP. METER OR POLE INST.
n. (Se co3 Lmer,5. nessap Po Care: An, city in
followan,fir sort (Se It uma
which rtquisu a permit ac consumer, alto, improve, demolish, or repair any swmam
to it the.. li t,or c ear
#norm its issuance. applicamfor ptarmus file a
POWER DEVICES
pursuantacquirestdo, the Co License Law
9 (c he is licensed pursuant to the 'sia s of the Contractor's Licenu Law (Chapter
9(rommeis ixemwith thectir, nfD is on tali the Business end,Any viola Qde)
arthat heisexemptthcrefm and tbebasr for the thedeaempttma.A civil peationof
Scdionv by un idolare apemt subjects the uPPlicannnacivil lwnulty of
SWIMMING POOL ELECTRIC
/� Vg1.UA/T1�0N
• el I; 1`�•
ourLETS-SWITCHES. FI%TURHS
thin
oat ton asow mWrecily,ormycon ). n.
❑
wrk.anhepmpeny,ormyetntend ewithwed eompBusiness
NEW RESIDENTIALBLECfR_SQ. FL
STORIES
TYPECONSTRUCTION
will nthewark. andthe stmcmreisnots
the fiasthe(Ser. 4, Business
end fusions Caustic: TTe lion a Law does not apply lf on owner of
Lie a Law apply 1.
ves comrs
Jim w,ces'prost I'll tree ,and w. does such drkhimulfonbsoughhis
n mPloyees,provi dtha' i per emems notimendedorof(ered fnrxle. If,
-
OCC. GROUP
how ve6the wilding t s Idwith oneyearofcampletim,thcawner-
m
buil twill no 9th edit of build or improve for purpose of
QTY. PLUMBING PERMIT FEF:
suit.).
o
❑ I, s o"Hy,a selusi omruning with llcense4 wnunctorsfo
FLOOD ZONE
EA
coast. p alter (Sec. ](94, B ess and Professions Code:) The Contractor's
PERMIT ISSUANCE
Licenscl it snotapplyto erofpropeny who M1uilJsorimprovevhereanand
wherein.
a orm. rsuchp suiNaconhenoAs)littnud pursuvtuothe Cnmmaars
License
nl
gLTITR-UIEAIN&VENT -WA'TER(G)
FEE SUMM
ARY'.
❑ am a mr, See B & P C for this reason
BACK 11 -OW PROTECT. DEVICE
UI'S L DE S
SANITARY Y N
RECEIPT#
Owner Date
DRAINS - FLOORROOFAREACOND.
, , , .
WOR KMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Ihereby affirm th:elhave ucersifwte nfumsent to wlf-insure, oro certifcure of
Worker%Compneratior l normnce or a cenifed copy thereof (See. 3900, Lab C.) which
RECEIPT#
FIXTURES - PER TRAP
PARK FEL? Y N
covers all employee's under this permit.
policy It
GAS -1?A. SYSTEM -1 INC. 4 OUTLETS
RECEIPT
BUJVbING DIVIS NIT
S
Company
GAS - G. SYSTEM -OVER 4 (EA)
PLANCHECK IT
❑ Certified copy is hereby fumished.
GREASE(INDUSTRL WASTE INTERCEPTOR
GRADING ITE n 13
❑ Cenifed cupY is fled with the city inspection division.
CF.RTIFICA'I'1: OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
GRIASF,TRAP
SOILS FEE/
l �.�
a
SHWER- SANITARY - STORM HA. 201
ENERGY
(Thisseclion need nnl hcaompleted iFthe pvmdt isfmn onehundred Jnllwe(SIM)
or It,,.)
WATER HEATER W/VENI'/ELECTR
I cenifythat in the performance all work for which this pemlit is issued. )shall
not employ any persmn in any manner so as to become subject to the Workers'
P
Compenaatienlsweof Califomix. Dme
Applicata It
�'A7'R SYSTF. GTING
SAL
Dam Rmciptp
NOTICE TO APPLICANT': If. after making this Certificate o Enem tion,y ushouid
•NC R(?SID• PLMB. SQ'UU
TOTAL:
become subject the Workers Compensation provincial of the Labor Code, you muxt-
fonhwhh comply with suchpovintins or this Permit shall be dcemed rcvakd, I
f yp
J ( tl
BUILDING OF,
—•'
_
SEISMIC I";E
CONSTRUCTION LENDING AGENCY
I hereby affect that them is a construction lending agency fm the oer(remene of
the work far which this pc.it is issued (See. 3o97, Civ. CJ Ili'kf r
l
Ila
ELECTRICI
Le
Lender's Name
Lenderi Address
QTY. MECHANICAL PERMIT FEE
PLUME ING FE
I certify that I have real this application and state that the above information is
tact. I agree to comply with all city and county ordinances and state laws reining to
PERMIT' ISSUANCE
MF.CHANICAI. F N.
huildingeorwruaion, and hereby authorize representatives ofthis city (center upon the
ubuva-mentioned property far inspection PuTa.is.
AL I FR OR ADD TO MECI I.
CONS'1'RUC PION T �] S
V
(We) since to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way were, against said City
AIR HANDLING UNIT(TO 10,0111 CFM)
in conse,usence of the granting of this Permit.
AIR G UNIT (OVER 10.000 CFM)
ofAp3mu//
ca/Ct—a
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO IOgWO BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Re. ipt#
Will theapplicuntor future building oceupnm store or handle baurdnus material
as dcfincd by the Cupertino Municipal Caere, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IIIo,l100 BTU)
'I'AL:
VENTILATION PAN (SINGLE RESID)
Q1de, Section 25532(u)7
❑ Yes ❑ No
BOILfiR- COMP (3HP OR 100.000 BTU)
aNG�
/SSUA F.YY MM 11
Will the William or form building occupantuxequipmemerdevices which coal
BOILER Hall W BTU)
harardous ❑ Yet, �men❑ s defined by the Bay Area Air Quality Management
In t tnnT
No
MAY 1995
NEW RESIDENTIAL MECII. SQ. FT.
1 have read the huanrlou, mmenrids reynhcentrs under Chapter 6.95 of the
Cade,Sectionsan, th255??andsponsi 1undemund that
if
if the building
ing lth does not
nm curremeats y have my responsibility to ratify the
�yy�
CSIY Ut IrUYt1F'
-
reprotlofthe res
m st to m t prior
cupant of the requirements which most be met poor m issuance of o Cenific�me/of
which
'
OccuPwcYC LZ�\
ISSUED BYffi'
Owner or authorise cm m
OFFICE