28289 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
.) .- .., IA. PERMIT NO. ��� ��
CITY OF CUPERTINO APPLICATION/PERMIT PI1011,5ING-REPTIr ICAI
BUILDING IJIVISION BUILDING PROJECI'IDEYTItICATiON .
BUILDING ADDRESS: SANITARY NO. APP�RACATION///SUUUUBMIITAL DATE
_o UNITN LOT 4, ,V,��
OWNCRS NAME: I'IIONE: CONTRACT K'S NAME: LIC NO: lJ
O C 6 t6 NIC CONTROL.
RCIiDECf/FIJGINEER: LIC NO: ADDRESSO Si4,v QSY� ❑
CONTACT: RHONE QTY.
TM ELECTRIC PERMIT J EEE BUILDING PERMIT INFO
BLOC ELECT PLUMB IdECH
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ^ y�v((()))✓gn
KZ I hereby alum that l and licensed unJerpmvidon,of Cheplc9(ammencing with PANES t2lrt
S tESCRIPILON
00C Satie]0)0)ofDiviaionJofthe Bu,irmus uW Pmfesslom Code,seal mYlwrnx minMa.UE rw rma ani Brea aLt7C5 tn7 klrc)5 a7N�aIial . LicN ` UPT02WAMPSU, % 201-1000AMPS
zc v— ARCIITIECTS DECLIRA ON OVER 1000 AMPS
Oz—❑ I unaerstwld my plans OWI Sc,used as Public records.
F y F W�J SIGNS ELECTRICAL
Sy�J Lieee,cd Pmtevional
�< OWNER-BUILATI
DER DECLARATION SPECIAL CIRCUIT/MISC.
5xec�0 W I hereby affiml Nal 1 am exempt from the Contracntra Licca:few Gtr mbe
W3ay followingreaun.ISection101 L5,Bmina"and Pmions femCode:Any ciry a county TEMP.ME. ' ORPOLEINST.
FI'—'Og which rtquircs.pelmiltoen,tnrt.Wlm.iunow,dmieli,h.w m,ai,ami ,am
S' N� pea to iia isauatee.alar m,uima the awlicanl fee itch Permit to file.sigrul statement POWER DEVICES
<O that he iV peened pu mrnt to m,,pmvisirms of the Commoner's Lice,c l,w(CTwptm
eXi. 9Borrou ing with Saban It )of Diviaie J of the BuOoea,eae Proreviom Code) SWIMMING POOL ELECTIUC VALUATION
til—rn aJw he is enet therefrom atW the bated,for tealleged eaemptian.Anynol.lienof
C < seron7031,56yanyappl' it,ubjmx the appbcant macivil penalty of -SWITCHPS�FUCIlJR1S / �O 3,.
LL ax mare than five hu dollua($5W—) lJi !J
K O ❑ Lia floor
fie
NEW RFSI ENTIALELECfR _SQ.FT.
mmycmpbyaawiJm I TYPE CONSTRUCT
y3� will,lothew okina a1nKYYle isnot inendManffcreJ fasile(Sec.](Nd,Brune.. / .
mud Perfcvion,CNe.TM1e Cumtecwr',Littnac I,w dons int apply In a Dane of
)eopcnywhabuihlaor ove.thacvn,WwMdoe„uch wahhimclfm lLCvugM1 his CROUP TIS
am cmlNoya,,pmvN Nu,ucM1 impmvrmcw artnmotln4mdM MoffaWfasde.If.
however,malatiwingi Impmvemmt in scold within me, plaimm.theownm L _
bullet will lure de Jenorprovingthnthedidtw iW m' efm purpose of
ak.i
❑ I,mwnmoflhc i�t
mavaymntrrcl g ,cd am PLUMBING PERMIT FEE FlDZONE APN
vnstmn tle pmjat 1' '. r Coo: The CentLiceuel,weanmte Iy wM bud -= d P ISSUANCEw110[nanYLLrm sash )< MM(a)li tollle Or�llaClAL a -DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 vn e5enlpl u r SonfB C for rhu renwn BA FI—OW PROTECT.DEVICEQMSIQF,PEES
SANITARY Y N
Owner i Date / UKAINS-E.MN.ROOF,AREA.COND. RECP.IPPN
WO KMAN COMPENSATION DECLARAI ION / SCHOOLTAX YN
❑ Ihertby.ffrm Ihave a cenifieue of arugni;to self-iruure,as R,.,.of KECERTI,
WartviC Imm.nsa.cttlifwla yllcrtof(5°c.JSOQ.Gb C.)alich FlXTURFS-PER TRAP PARK FEE Y N
era all employee's nal this permit. GAS-IA.SYSTBM-I INC.40UTLEfS RGCEII'1'tl
Policy N BUILDING DIVISION FEES
Elco Cert GAS-EA.SYSTEM-OVER4 G
❑ CaifiN copy i hereby fwnishcl. (' ) PLANCHI;CK FFl
[01 Cmifiedaapyi. mledwiththecityi s,,ine imyt rvuxn. GREASEANDUSTRLWASTE]NTERCEPTOR GRADING FEE
C4 TIFlu,L_L_r✓—.^_'slMOONN FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thmi eeimrcd mabecamplece ifthepcmlit i,fm ole hundCd fallen(5100) SEWER-SANITARY-STORM EA.2TOIT. ENERGY FEE
or leu)
Ianifylhuin de perfomwna of the wvxt f watch Iron Permit is iawW,l shall WATER HEATHS W/VFNT/ELECIR
unit employ any penin in any m .-mbjcct to the Workers PAID
Compcn,ey (ra�myDate — WATER SYSTEMfMEATING Due Raut4
li z A
pplicant Ir [�v�t`•p /'
z NOTICF.IOpyANT:H,efer makmnet uCcnmfi etc of N,xrmpOun,You,M1ta1W NEWRESIDENTIALPLMB. SQ.FT. TOIAL:
a—I y become subject to tle Worker's Car mata,ion Provisions of the Labor Cale,you must
F" forthwith cmoply with such Pmrement«IM1u permit shell be heancl kM. BUILDING FEE MIS 1�
1egaey(] CONST'RUCT'ION LIiNDINO AGENCY SEISMIC IEEI Smithy off that them u m ke
a eantrretieling fm do perfmnuacor
U O the wak for whcb this permit is issteA(See.1 .Civ.C.) ELECTRIC FE
I,enders Name
D" F Lento's AdJeva QTY. MECHANICAL PERMIT FEE PLUMBING PEE
U U 1 certify Ilial I have read this application ant,tut that Ile above infawtie is
ecm%,.I Agree to comply with all ciry seal R iy oNimnees end ate law,relining lin PERMIT ISSUANCE MECHANICAL FEE
h"' h building cumamctiuv,vrxl hembyautbmda rtprc cnwtivo ofthis city toem,,upunlbe A
CONSTRUCf10N TAX
V Z above-mentiaed pe nerty fa in pectin purywca. ALTER OR ADD TO MECH.
(We)apse to vin,rdenify anal kap humlus the City of Cu,,,mma xinn
liabilitier.jrdgmele,emu uW en eme,wh,eh may io any way ettme against said City AIR II ANGLING UNIT(710 10,PM CIN)
in conseunnee of Ole grunting of finis Perot". AIR IIANDLING UNR(OVER 10,000 CFM)
si'maNe of xIim,ffArummmkaDan, EXHAUSTHOOD(W/DUCI) PAID
HAZr for. MATERIALSquo,or DISCLOSURE
HEATING UNIT(TO IM."BTU) Due Reccig0
p Will the me liturit Ca,remnuutureicipi Conecupmnaaca humallabolte hHeaNuusmatcetytif HEATING UND'(OVER IWTOK)BTU) TOTAL:
u Jafilwl by IhC Cupertino Meicipal Code.Ch.ga 9.12,aCW the HWth eM Safety
Code.Savitm 25512(.)1 VENTILATION FAN(SINGLE RLSID)
❑YNn
Will the appuant arrwrebtdein„
BOILER-COMP(JHP OR 100.000 BN) ISSUANCE DATE
�huudrus air confrontation an dcfree by the Bay Area Air Quality Managemel BOII,ER-COMP(OVER IO t'"BTU) � N '
Nitro?
11 yen �Nn NEW RESIDENTIAL MECH. SQ,FT.
I have Head the t ,Coot,motion, requireranLL uatenter CTugcr 6.95 of Ile us 01 10
0.1afnorio�Ykth arinea atcryamly oar. n255o5,255JB uW255J4. Ity.runif ltat Cpy Uf Lf .,
fthe buildingeraintcumenllyich raIcweB.an itumyreaponalof. enotify the l
(Vp011 Of Ih<uyuiremu whirr must he mel Ivies to msuame of•Cmificue of
O.mawOadxed ager Due O' ISSUED BY: ,�/ITU
OFFICE