28186 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
I CITY OFCUPERTINO IOUIL "•- C ' rr:RMlr"°
BUILDING DIVISION APPLICATION/PERMIT PLUMBIN4-MF.CIIANICAL 28186
: r•'•� .•• BUILDING O IU IFIC ON ..
BUILDING ADDRESS:len2 r/( P�}�fi��.��� SANITARY NO. APPI.ICAIION SUBMITTAL DATE.
J V • Sip �I %,"Rg LOTH
OWNERS ME: E: CONTRA AME: LIC NO
Isar
V /Ah 'V 9w NIC CONTROL*
RCBIITCTAENGINEIER: LIC NO: ADDRESS: f.11/ ❑
it
CONTACT: PHONE tw3'}t `Its k 1 1 1-'v t++ Sh (,+qct" i. tc -` Bl11LDINO PERMIT INFO
.::Any "E1.6CI'RIC...... 1' 'RpbSh v «,4I,�Ef34f,`
BLDG CLECT PLUMB MIECII
PERMIT ISSUANCE El ❑ El
LICENSED CUNT RACfOR'S DECLARATION APPLIANCES-RESIDENTIAL ' `_ I.DR DESCRB'110N
MK2, I herehyriffrmthn l nm licensed underpmA,fmsdf Clggxrr 9(couresuingwith w•/c ,\\ _
E0O Secri(in?")of Dividdn 3ld the Rmdssao Prnfessirms Cos,end my license is in PANELS
YIC full forceaoeRm.
FFVlsaaaf
a..VZ twU' License Cleo Ueg UP TO 200AMPS
yQN Data Contract. 201-Phil AMPS
tryK ARCI IIIT:CTS DIECLARAI'ION OVER 1000AMP$ SV.Ft.FLOOR AREA
2 m— I undersand my pima shall he used es Public earned,
OZ
Fmk, SIGNS ELIECIRICAI" '
YdI Lieensal Prnfic.iomnl
6 hat I am BUILDER DISC ContosUN SPECIAL CIRCUIT'/MISC.
�R4'O IV. I nit om Saso.that I em emmpl from the Coshor.rr�Ca e:Any Imo for the
W3s+�tn which requires.lSecis 1.consunum alneuand PrafesainnsCde:Any city.counU TEMP.METER OR I'OLf:INST.
which rtynircsa permit reamawer.alma improve,h Permits mrcPaig anylaacmm
}0
prior.slisuaae,also mmil the appRe.1'the Couteroim role enhance POWER DEVICES
p thathenlicenuJp Seemor thatprndishi m the CdnOaan.no,LicenseLaw
ns Clerk)
Pjozz 9(cmmncncing wi@SmimT(gpbfDivisism]ollhe Buelrun and Pmfeaimn Code) SWIMMING POOL ELECTRIC VALUATION
�y or that he ie eaemN Omrehnm anJ the M1mia for the ellcgnl esanptind AnydolatimlA OUTLETS-SWITCHES-FIXTURES
(=iSY Section 11OPermit l5 by any applicant fore Peluubject%the applicant
o a civil Mildly of
rat mo a dao five hundred dollars IS").
NCW RPSIUFN'11A1.ELECTR _SQ.ET. STORIES YI`f:CONSiNUC110N
❑ I,a..anwnemOM1epropeny.nrmyemploymwilh wageautheinoleeompenaatirm,
will dothework,andtheamounthaIntendeddofmale(Sec.loan,Busiao
end Pro&asiom Code:The Contractors a Licensee Law Jas not aPPIY m an owner off
property whnhuildsur improves thereon,and whodoessuch work himulfor through his OCC.GROUP RPS.UNIIS
wnemployees,Providedthauuchinspmvcr ntsarenminmtdMorofferedf.ule.If.
however,the building or improvement is sold within one yearof complelion,the owner- TOTAL:
builder will have the burden of proving that he did not build.Improve for purpnu of
❑ Lm ownendthe n emadusiv<I convealn `e•Y t<n IrLVMnINU pE1(MIT_ HCB FLOOD ZONE APN
Pd'IR y. Y gwithhicensedconaeaonto
,
y.' s lrt s(;`, rm�•�.bja:,""
m..met the project(Sec.7044,Bmhmn and Profeariuns Code:)The Contractor'.
Liceme Lawdoesonlapply.omowavroflrnpeny whnbuildsmimprov,,thmean,and PERMITISSUANCE
wlmcontractaf(irsnchmojccawilhocanimcmOR)Iicenudpunusntmthe Contncmr's ALTER-OWN&VENT-WATER(EAT FEE SUMMARY_
License law.
❑ l em uempl under See. .B&P C for this reason BACK NAW PROTECT.DEVICE O )
SANITARY Y N_
Owner Data RECEIFTN
WORKMAN COMPENSATION DECLARATION DRAINS-MOOR,ROOF,AREA.CONM SCHOOLTAX Y N
❑ IhercbyaffiWm0da l have ecenificateolconrm.self-inure,oracenificaten! FIXTURES-PER TRAF RECEIPTN
Wmkeri Cnmpenssinnlmunnceaaani0d copy lherm!(See lggl.l<b C.)which PARK ITE Y N_
Pn all employee a under this permit. GAS-EA.SYSTEM-I INC.4 OUTL; RECEIPT N
olicy N BUILDING DIVISION IMM
Cumpuy GAS.P.A.SYSTEM-OVER CBECK NEE
❑ Certified copy shacby famished.
❑ Certified omy ie flet with the city impa0on divinioa. GRFASFINTDUSIRLW C :RCEPIDR GRADING NEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE IR SOILS FEE
COMPENSATION INSURANCE
(Ills section need am he completed ifthe Permit is for one hundred dollars(SIM) SEWER-SA R -STORM EA. F ENERGY MR
.leu.)
I certify that in the Performance ofthe work for which this permit is issued,)shall WR'I'ER BEA'1 ERW/VENT 'T
not employ any Person in any manner an as to bccome subject to the Worker' PAID
C.npmeatinalawsof Coliforms. Data WATIRSYSTEM/TREA'IING Date Receipt
O Z AfFlicanl
z7P O NOTICP"TO APPLICANT:IL elmr makingthi.o Cenifimu,of Gumption,ym.lould NEW RESIDENTIAL 1'LMB. SQ.FT. - TOTAL:
F-' y become subject to the Wmker'a C.npcmatioo Provisions of the Lada Code.you musl
HHHforthwith emorly with such Fouskicn,or this perm,shell be dermad revoked. BUILDING Mr.
IMCONSTRUCTION LENDING AGENCY SIEISMIC ITT:
I hereby affirm that re cam
e imuctim lending ageney for the pecerfmcwrof
O the work which this permit is honed(Sec.7091.Ci,C.) TOTAL:V
ELECTRIC IEE
Iaoeri Neme n - �s "
m�. �ietiiANicAL f EdMir PLUMBING NF
Landers AJdrcsa
I certify that I have rad this city
wal on and ase that the above information
ng ho
D-1 mrsect.IaArcemmmply with all city enl eoumy ordinances ad slam lawn relating to PERMIT ISSUANCE
MECHANICAL FEG
Hbuilding construction,and hereby auth.hm reprcsenutiven of this city toenmrmom the CONSTRUCTIONTAX
shows-memimmd Impeny for inspection Interference ALTER OR ADD TO MECIL
(We)rigree m arise,indemnify and keep hermleu the City or Cuprobot egri ro
Ilobilitieajudgmena,coasand e+pcmea which may many way accrue against said Gly AIR HANDLING UNIT(TO 10.000 CPM)
ming of thin permit.
AIR HANDLING UNIT(OVER IOdgs CIM)
Sigru rc .tvacta Dale EXI IAUFT I IOID(W/DUC1)
PAID
HAZARDOUS MAI'ERIAIS DISCLOSURE UEA'1'INGUNIT('TOIIXI,003131U) Dae Reaga0
Will the applicant.future building acupant ante or handle honndxa material 'ILII' 1'
as defend by the Critical Nicmm�n MCale,Clapmr 9.12,and the llcallh end Sorely BEA I ING UNI I'(OVIER IMMO 11'II)) _
Code,Section 355321x11
❑Y's ❑He VENTILATION FAN(SIN(SINGLERESID)
ISSUANCE VF
—11
WilllheapplicamalmunhuilJingaxuPata uunsm
eyuipardevices wbichemit RUINER-COMI'(n11P OR 100010 0'N7 P w '
havNom air condominiums as deflod by the Bay Arca Air Quality Managmimi BOILER-COMP(OVER 106,000 BTU)
District?
❑Yea 0 N NEW RESIDENTIALMECIL SQ.FT. JUN15 1995
1 have and the hmaJoua m urd.k rcyvitimena under Chapter 6.95 of the ys'�
California Ileolth&Safety Coe.Sections 25505,M533 and 25534. 1 unoknand that b I
Iflite building e mquirusims lyhnveust be Ibm its ntynsance oflilymnofy the f t,UPEHTTI
aavpant df the es not ru which mus a mat PctIs m reep ce of ri Certificate he
Oscillatory.
Owner or authmied.gent Dam TOTAL: ISSUPDI/Y:
OFFICE