28292 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-L CIANICA PERMITNO ^ ^ ^ AN /N
BUILDING DIVISION APPLICATION/PERMIT PLumBINr,.gSEcxducAl' L 8 L �9 L
r7 - -+'BUILDING PROJECT IDENTIFICATION'. t
BUILDING AD KESS: SANITARY NO. APPLICATIONSUBMI''ITTAAALDATE
J
J /C+/ ��%10 UNITX IAT#
ERS A E: PHONE: CO RACE 'S N E: LIC NO:
F' NIC CONTROLX
L1y Ala/ ti N� As 2z6z
CHITECIENG�: LIC NO:
CO ,CT: PHONE: Gtr ' ' BUILDING PERMIT INFO '
gu•`FEE '.,f� _.
ISSUANCE BLDG ELECT PLUMB MECH
J J� PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pzZ I hereby affirm that l am licensed under provisionsofChopter9(commencing with
4400 S«tI0a7Bg0) fDivixionJol N<BusinessaM Professions Code,and my license is in PANELS I .
zwI.. full forte anJ effect t/�„J� ��#�/�,J l"\`JI
6 UZw License Clps Lic.# UP TO 200 AMPS
n<a Date Comore 201-Had AMPS
F,Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
_Z y C 1 undcntend my plans shall be mail as public records.
;rt F w SIGNS ELECTRICAL
M, Licensed Professional
4 ya'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O aU I hereby affirm m that 1 aexempt from N<Contractors Lic<vu Law fm the
"�a0 y following reaun.(Section 7031.5,Business and Podoodonc Cale:Any city or county TEMP.METER OR POLE INST.
y which mgmires a pe<mit to construct alter,improve,demolish,or repair my snuqun
.o,i rt
p000 its issuance,also requites the applicant(msuch permit o rile asigned statement POWER DEVICES
Y p but he is licensed pursuu
ano she provisions of the Contncmr's License law(Chapter, SWIMMING POOL ELECTRIC
1Q 4K 9(commencing with Section 7")of Division J ofthe Buni«ss and Pofeasiom Cads) VALUATION
W❑y or Nat he isexempttherefrom and the basis for the alleged exemption.Any violation of
E•ZY Section 7D31.5 by any applicator for m permit subjects the OUTLETS-SWRCHE9-
applicant to a civil penalty of FIXTURES
��C t mart than five hundred dollars($5001 NEW RESIDENTIAL ELECIR S .Fr.
tY n❑ Lmownerofthepropeny,ormyemployep with wagam Neirsolecompensmion, Q STORIES TYPE CONSTRUCTION
a3e�0— will do the work,amthc stmcmre isnorintrwadoraffcredfarsale(See AW4,Bmsinmr
and Professions Cade:The Contracmr s License Law does oat apply ro an owner of
ptapeny who builds or improves therron,and who dap such work himself or through his
owaemployeca,provided Natauch improvements the not intendedmoffemlfmzde.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yerrofcomplction,the owner- TOTAL:
builder will have the burden of proving Nat he did not build at improve for purpose of
We.). ' .
QTP :.:.. 'PLUMBING PERMIT ?.. -.,FEE'(-+ FLOOD ZONE "N❑ I,as ownerofthe propeny,am exclusively contracting with licensed contractors to ...,, _ ; '
"�:G •t ,
commoner the project(Sec.7044,Business and Professions Cade:)The Contractors PERMIT ISSUANCE _
License Law d«s not apply to on owner of progeny who bui Ids or improves Neuon,and
whocommets forsuch projects with aconrmods)licensed punuanttothe Canno tore ALTER-DRAIN&VENT-WATER EA t .:'.'f
License Law. ( ) :-9t_.','F", FEH SUMMARY+'
❑ 1 and exempt under Sec. .B&P C for this mason BACK FLAW PROTECT.DEVICEout I
SANITARY YN
nen Date DRAINS-FLOOR.ROOF.ARFA,COND. RECEITT0
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm that l have o cenifcme of commit m ulGinsurt,or a ttrtifcam ofRECEIPT#
Wmkets'Compensation lnsumnceoracenifiedcopy diereof(Se,.3800,Lab CJ which FlXTIINFS PER TRAP PARK FEE Y N
-' oven all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy# BUILDING DIVISION MES
Company GAS.EA.SYSTEM-OVER 4EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with Ne city insppti divii n. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
nj
CERTIFICATEOFEX IPIION
OR S `f.l GREASE TRAP SOILS FEE
COMPENSATIO S
(This section neednot be mple i it isf f',,ddallats(5100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
m
les')
I cenifY that in the pe work hfeh mtit is iasued,lshall WAT[R f1EATER WNENT/ELECrIt
not employ any perun in an a <r so as t unite subject to the Workers PAID
Compensation Lmwsof Caliromis. D e WATER SYSIEM/TREATING Date RettiptX
OO NpOTICE TO APPLICANT,(,alter akin Niz Cenifcate of Exon ton.youshomld NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
e Pi
plicant
Z (g become subject y it Workers Compensation is prmitshall ft he labor Code,
voked.you must
7 foMwiN comply with such provisions or this permit be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
nZ I hereby affirm Naubem iso construction lendirstril mY for ba, rf.ceof TOTAL: ELECTRIC FEE
-) O the work far which this pemus is issued(Sec.7097.Civ.C.)
I cader's Name 4, ._ .a - t.x=•s.s -s`n w: .�'.r -y�:.rym4n < PLUMBING FEE
s ^a.,MECHANICACPERMIIF•'';,'..7• , FEE.:.
O U
Comes Address Q?Y _ _ _
I«nifY Not I have read this application and scam that the above information is w•.°
` correct I agree tocomply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
Cuilding commuction,and hereby authorize representatives of Niscity to enter upon the y CONSTRUCTION TAX
V 2 above-mentioned progeny for inspection purposes, ALTER OR ADD TO MECH.
(We)agree:in save,indemnify and which
mayinhumorless the City of Cupertino against
Iiabilitip.judgmrnH,mss and expenses which may in any way acme ogaimt said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequcme of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM) -
Signature of ApplicanVComnctar Date EXHAUST HOOD(WMUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO 100.001)BTU) Date Receipt
Will the applicant or future building mansard nom or handle mancrous material HEATING UNIT(OVER 100.0011 BTU)
m defined by the Cupertino Municipal Cute,Chapter 9.13,and the Health and Safety
Com,Section 25532(a)'! VENTILATION FAN(SINGLE RESID)
❑Yea 01W. ISSUANCE DAT
Will theupplicant or futumbuildingmeupant uucquipmentordeviceswhichemit BOILER-COMP(3HP OR 10),0011 BTU) ?�
y
rumuz air camaminmu as Defined by the Bay Arm din Quality Management BOILER-GGAIP(OVER IDU.010 BTU) /
inriot7 AI
❑Yes VN. NEW RESIDENTIAL MECII. SQ.Fr. G R
1 have read the hanudws materials regmirem<nts under Chapter 6.95 of the U-C
Culifamia HpOh&Safety e,Sections 255115.'_5533 and 25534. 1 intentional that .q• '
ifth< n in nate enJy haveutenam.Nat it is my rtsgimihility to naify the r/res
t of 4 ms w must be et prior m isst, qt Ce ifind of
capana / z d/
Owner,suNmard agent J DateTOTAL: ISSUED BY.
OFFIC