28300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
U...IDN(1- ) CIRICA, FuRMITNO. /A ^ OO
CITY OF CUPERTINO PLUMBING-MECHANICAL L 3
BUILDING DIVISION APPLICATION/PERMIT Ina o.Du IDRNTI KATION
BUILUINO ADDRESS: a _ ^ SANITARY 50(1. AUPLICAI ION SUBMl'1CAL DAIP.
690P(c /l/'r/,1v UNITR 1.01'0
UWNFRS�(r►.1¢ PHONE: CO RAi DR'S NAME: UC NO"
7e f:�Z /✓ / y '-J N/C C(INTROLM
In CIIITIiCf/ENGINP.IiR: LIC NO: A URI /I ��- rel. ❑
"
CON TACT: PHONE: ,t ai,ri (�`'•.<; BUILDING PERMRINPO
JewPERMIT ISSUAN V / g�l O HLL�LDDDGrr FIX NUMB MI.CII
CF ❑ ❑
LICENSED CONTRACTOR'S DECIARATION APPLIANCES.RESIDENTIAL 1 U' 1191
Qyz Ihnehyaffnntlutt mlicensed underp,mvisiomof CTorycr9(commenting with �T/I�'t•'.�ai 'r 5s
R0WO❑ Section 7a110)of Division 3ofohe Bv,ime,xamd Pmfcs,ion, nd my license is In PANELS l k / /
UU full force?a7n%dk/d��f/ecst).C�.Ig;'�p� /.�—'L, UP TO Np AMPS
e6.zuW Lice,
/ Lie CLD /
y6a Dale Contract- V 201-IBIYIAMPS
O W ���777 SQ.IT.Il.00R ARL'A t/50 1'I.
z�sr�Z ARCNITECPS U public ind%. OVER IOHB AMPS
I nndmmnd my rinm mall he used a public rccmds.
SIGNS ELECTRICAL.
4V`1,E Liaenm�n•rnreasion.l
E iyK hm I sm BUILDER iR n tha Co AT10N SPECIAL CIRCUIT/MISC.
1N�j OyFV- I heeehy affirm Ihm 1 un eumpl frmm the G•nvadmi License Lew for the
4 full,-ingne...(Seclion 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
uJOI whichrnptiresn Permit mmmrucl,elle,Implants,demolish.or repair a ay structure
I!IN� prior to its issuance,ols^rnluire,the applicant for such permit o File a Signed statement POWERUEVICES
pp�Z a O that he is licensed purmam to the pmixion,of the C^mmclor's License Law(Chapter
O SWIMMING POOL FIX VALUATION
Gxo�' 9 has he
wile$mitm 7¢q)Ilse
basis
7nOlm Businn„and hvr,AadoorCMel
WZjH Sectio 7031. by
the pari,fmbjecilrgedeaemrylnn.Anytpamimmf N
CzQ Section 7(p L3 by my arrlicnmhas Pemduunjen,Ilse arplicmn macbil penally of OUl1.G1'S-SWITCIIIiS-PI%TURI!S
M marts than rove bundled dollen(5500).
O NEW RESIDIiNI'IALCI,ECIR _SQ.IT. Ril)RIILS TVI'EC'f INSIRG('lIG
n❑ Luxnwfk.anheprnlmemn,i nycmrlouledin ffengesoaneirsole cmnrcmmi^n,
I��++ will Jndrework.Code:Tu Contra to imLionse Law
dos art appl(Socy
74 94, waver ss
ofand Aofemionx Code:The Contractor s Littnse law Jmx let epPly m an owner of
property wMn Mrildsm imiaoveahere�n,nnJwho Mcunch wnA himxlfo,drmughhis (X:C.GROUT` RIL.UNITS
howempinyee,.pmnided Rotovenbapms sold
wit eranot earofdmnfrnnl lersale.If.
however,the ave do tor dins of ennnt Is within one yearm improve
the owner r`
o0c). will have the hurJen of proving thea be did not build mImpmve fm purpose of
SpIO')' QTY. - PL�1�,{B�NO PERMIT ' . 1�H ma%)D zoNE nrN
❑construct
thenprtett(Sec.7044,Bu des,,an Profession.hde:)" CmmCbms -
nnnruct w project(Sec.(Sec.mann,Burma and ywho bi,ms Code:)The Cnnvadoia � ,
Liccose Lnwdmxnol apply tar anownerof prsspcny who builJsmimpmvevhere^n,anJ PERMIT ISSUANCE
whocolinos forsuch projects with acmnredrnp)licensed pursuant to the Connector's
litems,Lnw. ALTER-URAL dNT-wnrr:R EA) FEESUMMARY
❑ 1 am exempt under Sec. .B J,P C AS this mann BACK Fl.OW O OFVICC °
SANITARY Y N
Owor Dem DRAINS- R.BOO , ND. RECEIff
WORKMAN COMPENSATION DF.CI.ARATION SCHOOL TA% Y N
I ❑ I hembyaffnn that l havtsacenifieam^fconsem Mm
toself- m,ura certificnmof FIKTURIS-PFR TRAP Rf:Clill'fM
Wmkrri Cumpensmitminsumntt oracenified copy thermf(Stt.7R00,Iah C.)which PARK FEF Y_N
—
RECEIPT
all empinyee'x unJerthis .it. GAS-G.SYRTEM-1 .4 • S RFIVI IT g
Policy 0 BUILDING DIVISION FEES
Company GAS-r:A.SYSTEMOVERJ( ) PLANCIIECK FEE
❑ Certified copy is hemThy fumixhed.
❑ Coifed entry I,Ned with the chy inspection divisinn GREASNINDUSTRL WASTE INTER GRADING FEE
CERI'IFICATEOFEXEMPHON FROM WORKERS' GREASETRAP SOILS FEC
COMPENSATION INSURANCE
(Thin mtion inedmol M:completed ifthe permit is forams hundred dollars($100) SEWER-SANITARY-STORM EA.20)". ENERGY FEE
in lava.)
I certify that In Ilse performance of the work for which hin pemnil in issued,),hall WAI TOO I I PAT FR W/V RNTAiLECIR
lex employ any perem In any..act tar as to hectare subject is,the Wrukni PAID
Conmenaelirm law,of Califxnia. Data WA'PER SYSI'IIMIT REA'I ING .I eveiryR
O Z Applicant l TIL:
Z A,fiem'IU API'hICANI':It,after making shin Ccttificnrc hn
of F,<mPtinn,you. ulJ NEW RFSI DENTIAL PLMTL SQ.R.
Id beconue suhjcd In he Workers Compensation provisions of Om Luber Crate,Ynu moa NUILDINC PTiIi
Ki fombwllhn...1,with old,pmviainmmthi,permio.hull hedeenmd revoknl. tv
CONS IRUCfION LFJJDING AGENCY SEISMIC FIFE
z I hereby affirm that them iso construction lending agency Willa performmce of
tV' TOTAL: f:LF:CTRIC FEEO the work(or which thin permit in issued jilm.3097,Civ.CJ
{2. sr Leader Name
[V` Lendda Adlm„ QTY. MHCHANICAL PEkMIT t PLUMBING Err;
I versify Rot I have mad this alipfcatism art state that the above information is
carrtdrt MECHANICAL TEF.
6. .I agree to comply with all city acounty ordinances and stale laws relating to PERMIT ISSUANCE
D) building consuvcoionand hmehyauthmim mpresemaoinmifohis city serum,upon the CONSTRUCTIONTA%
(,f 7 Nine mentioned property for Impassion psproas ALTER OR ADD TO MFCIL
F7 (Wel ngreem,eve,indemnify art keep the City of Cupeninoegeinxt
hall 1,e.lud nu.nets erten nsespewh may' any waysocme against said City AIR IIANDLING UNIT(TO 1o,(IOOCFM)
inceso ,it ,.n,7:nn n.
AIR HANDLING UNIT(OVER 140101 CFM)
tgnammnf APPlic4mr-cn me EXHAUST nam(WmuC) PAID
IIA, ,GODS MATERIALS DISCLOSURE HEATING UNIT(TO 10TOW BTU)
Data ReeeiryR
Will dn.ppliv.t fumm builJing uccupenl pore or M1aiullemm�rdnu,material I MATING UNIT(OVER IgI,(010 RTU) TOTAL,:
u defend by the Cupehino Municipal Cods,Charter 9.12,and the Ilealln and Safely
Code.Section 255320)1 VENTILATION FAN(SINGLE.RFSID)
❑Yes ❑No
I )f�DATE
WilDM1eapplieam m future ImIdingocavm
pant uneequipment dea vicwhich emit BOILER-COMP OIIP OR UNIONS)BTU) ^!
:ardons air contaminants as de0md by the Bey Area Air Quality Management BOILER-COMP(OVER 100.001 BTU) �� C
uimrid7
-- ❑Yo ❑No NEW RESIDIiNTIAI.MGCIi. SQ.19'. oa�
1 have mM the hamodou,material,rcrutmmcnts sunnier Chapter 6.95 of the 01 u;- 1995
California llcnhh A Safety Gale.Section.25505,25575 and 25534. 1 understand ohm LE3N
it ibe building dies not conomly have a tenant,that 111,my re,prmdbtlity m nos the
occupant of the myuircment,which must he met pilin m lo®anec of a Ceni ficvle of
Oncupmrcy.
f
1.I'll Its anthuimd.,at Data TOTAL: ISSUED BY:
'
OFFICE