28276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-LLF.CI'RIC.kL PERMIT NO,
APPLICATION PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION 'BUILDING PROJELTIDENTIFICATION 28276
BUILOING SS �� , it u• SANITARY NO. APPLICATION SU`BBBMMITTALLDA'IL
2`{Ity 1/ LOT4 V
OWNERS E: PHON CONTRA SNAME: ` LIC NO: 4
�e 1,�Plrrl cce
` Ce.LIC NIQ CONTROL❑ a
CHITE (NEP LCNO: AO VVV
` Ca 4` s
CONTACT. PHONE: •" �` `
BURDING PERMIT
/ QTY. c°'. >y.i ELECf'RIC PER TT ��<<$ ' ."�E•�' BL EL PLUMB MECH --
I,v. PERMIT ISSUANCE `IST11�
LI ENSEDCONTRACTOR'SDECLARA ON APPLIANCES-RESIDENTIAL TOB DESCRIPTION
acez Ihcrcbyaffirm thmlam littnxdunJcrprovui....f Clupumstmoernmeng wish
WOO�;; Senfarmad1of Division3of the Business and Professions Cade.and my license is in PANELS [s ��
FZty icenseC�d eR<c . Lic.p UPTO 2M AMPS L`�jL/`✓)
pic3G660�
on a Date Ceram ics 201-1000 AMPS Fj' RRR,��sgg¢EEEppp ��'
F- ARhall be LTS DECLARATION OVER 1000 AMPS ��' i' �Q'FT'
I understand my plain shall be used u public AI'lO /_fir`_
y I_J SIGNS ELECTRICAL
y�J Licensed Professional I
�C a that
Ian OWNER-BUR-DER d re,CoATION SPECIAL CIRCUIT/MISC.
OiU Ing a affirm that 1 an exempt from the C,ntmnNr License law for the
a0y following reason.Second 7031.5.Business end Professions Cade:Any city or counry TEMP.METER OR POLE INST.
.1 which rcyuircs a p it w conswct,alar,improve,demoliN,a mpwr any stmcmre
>2 prionm it,issuatme..a.rcyuima theapplicam forsuch Permit,.Bleaaignedsaamnd POWER DEVICES
.C C Cm that he is licensed pursuant o the provision of the Contractors License Law(Chapin SWIMMING POOL ELECTRIC
Keo 9(cammendng with Section Divisim3.fihe Business and Professions Code) �1 VALUATION
V_y or NM
at he isesempt therefrom and the basis the alleged exemption. y violation of OtlREfS-SWITCHES-FlXTURES /2 'Z%9w0—
F Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of [r
E'
not mom than five hundred dollar($5001. NEW RESIDENTIAL ELECIR _SQ.PI'.
�Fptt ❑ LmownerofNeproperry,armyemployenwith wagosstheinolemmpensadon. STORIES TYPE CONSTRUCTION
n:!2 will domework.andfacummwe is not inandrdmofferM fencek(Sm.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of I ^ ISM
�
property who buildsor improvnNerton,andwh,d,nsuchw,rlt hiamulfarduough his OCC.GROUP RES.0 NITS
own employers,provided thauuch improvements me nm imendml orofrerid for sale.If.
howeash,ver,the building or improvement is sold wisdoms ynrofcompletion.the owner.
builder will have the burden of pmving that he did not build or improve for purpose of
❑ I,usowner.f the propeny,omexdmively, conducting with licensed conaaaom PLUMBING PERMIT c 'FEE'- FLOODZONE APN
QT.Y,Kase._.:.r....,.a. .. , .,,- ,*z+_...:,:1.w.:+F}+,•
,mwm the project(Ser.7094,Business and Profusions Cade:)The Contractor's
License Luwdmanotvpplywanownerofpr,penywhobuilda mimprov<stherton.and PERMIT ISSUANCE
who maiden for such projects with aconuactorfa)licensed porsuanttothe Customers ALTER Li[Cnu Lvw. wCi.;,•"'FEE SUMMARY.;,
❑ I am exempt under Ser. ,B R P C fm thi
BACK FLOW PROTECT.DEVjff
_ SANITARY YN
r WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.ARFA.COND. SCHOOLTAX RECEIPTN
(hereby affirm then haveaunificew ofconumweelf-ireurt, acetificaaof FlXTUFUS-PER TRAP N
... WorkersCompensation insurance or a ondfiW copy thewof(Sec.3 .Lab C.)Which O PARK FEE N'
oven all employee's under this permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS PT N
Policy p BU NCWISION FEES
Company GAS-EA SYSTEM-OVER 4(EA) PLANCHECK
❑ Certified copy is hereby fumishd.
1101 1
❑ Caddied copy is fined withthe city inspccf division. GREASE DUSTRLWASTETNTERCEPTOR GRADING
CFRTIFlCATEOFEXE ON FROM WO GREASETRAP SOILSME
COMPENS ON INSURANCE
(This section n<ednol becomple ifdre pemtit car I2� 111
SEWER-SANITARY-STORM EA.200FT. ENLRGV FEE
m less.)
Icertify Natintheperformance fthewmk fo If t6isWATER HEATER WNENT/ELECfR
employ any person in any man er so ss w w Ne PAID
Z Compewtionlaws.f CaRlmmia, D WATER SYSTEM/IREATING Dine ;*TAL
Applicant
Z O NOTICETOAPPLICANT:IL afar mak Idea _ of Eaemptim. ushould NEWRESIDENTLILPLMB. SQ.FT.
In become subject to the Wmker'x ComN 'on pros,"' ' liber ,you usual
Xforth with comply with such provision on 's pemdt ihd Off re ked. BUILDING FEE
CONSTRUCTION L- DING AGENCY SEISMIC FEE
Z I hereby afbrn that there is a considers, IeMingagencyfm performance,of ELECTRIC FEE
J Q Ne work for which this permit is issued(Ser.J 9],Civ.C.)
`J. Lenders Nome a, ,a 7rc b('�f PLUMBING FEE
.) Lenders Address Q'YY,.�•z�:yyl? ,MECHAMCAL PERMIT.',+ ;:psy Nrtg FEE;; -:
1 certify that 1 have read this application arM m that a above information is °"'ys'" 4it'J'
amoves.Iugreewcomplywithall city end county met aMaaelawamlaingm PERMIT ISSUANCE MECHANICAL FEE 146
V) buildingmessrvcdon.moh<rcby nushonze repreunmtiv fthiscirymmucruponda CONSTRUCTION TAX
U Z above-mentioned propcny for inspection purposn. ALTERORADDTOMECH.
I We)ague 1.save,indemnify and trap harmina the City of Concert against
go
Iiabilitin,judgmenu,costs and expenses which my in eery way accuse agai tsaid City IS HANDLING UNIT(TO 10.000 CTI ale
n ronuque ce, he gmntirig,f this permit.
HANDLING ANOLING UNIT(OVER 10,000 CFM)
/Signature of AppEmatiCconactoor ID.I. EXHAUST HOOD(W/DUCT1
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 170."BTU) Dae Receipt 0
Will Ile applicant,orfuture building ommemvonm hanale 11to maanal HEATING UNIT 100,0011 BTU) TOTAL:
us defined by the Cupertino Municipal Care.Chapter 9.12.and the Health and Safety
Cake Section11Ycs 11 Na 26572(a)^
❑ VENTILATION FAN(SINGLE RFSID)
NOVSSUANCE•DATE
Will they licunmrl'murc building Deco BOILER-COMp(7HP OR 100,0011 BTN ty -a as,
pp a he Bay m.AirnmdetyManachemh 1 b 1995
artl,us air mmaminunts m delineJ by the Bay Arta Air Quality MaaB<ram BOILER-COMP(OVER 100,000 BTU)
nWRf
❑Y<s ❑No NEW RESIDENTIAL MECIi. SQ.FT.
1 have read the hazardous mmaials mouimmcros unkr Chapter 6.95 mile,
Cilie buil Health&Safety Code,Sechave
rant.that
2357]and 25574. I ity to understand the \—
ifthebuildingJceanutments currently he iIhaiIis to ousonabllirycminify the
mcupem of the myuimncnu which must be met prim m issuanm of a Cenif¢ae of
ottaWm<y.
Owner or uahoriznl agent Dae ISSIJED BY:
OFFICE