28007 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO t lt,"NG PERMITTING.
APPLICATION/PERMIT PLUMBING-MECHANICALAT28007
BUILDING DIVISION BUILDING PROIECTIDENTIFICION
BUILDINGADDRIiSS: SANITARY NO. APPLICATION SUBMITTAL DATE
I1 1 UNIT IT LOT#
OwNkdtSONAME: { .2
PRONE —�s—fo CONTRALTO)Z�NAME: O ^ LIC NO: NIC CONTROL#
1111..JJcc lO: V VT J70
AHCfI1TEC1'/ENGINF.ER: LIC NO: ADDRESS ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby ffrmthat l am licensed under p ( gwida �p�� lOB ESCRIPTION
WOO ya pr it PoofnsimasCmeg ct mmencin ' W -,r Iwk ITT
WOO S«-ion]B00)ol Divisionlof the Business and RoPossionx Code,and my license is in PANELS (� J
as, full force and effep,..g Lie.# s9U UP-0200 AMPS r�OCIiNL
P.,LY] Li«nx Clay (�Ot
wjh Date Conlmenr 201-10011 AMPS
'l.O T`ooz ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FI'.
O Z—O I undemmrd my plans shall be used as Public records.
F`�al W SIGNS ELECTRICAL
Q x j Licensed Professional
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
X O y V I hffimsu
ereby o ,Thal 1 n m
expt from the Container's License Law for the
W 3 a y following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F LL'ON� which squires a Permit to conswet,tiller,improve,demolish,or repair any awemm
,T2 pnor o its issuance,also requires The applicant for such permit o file a signed statement POWER DEVICES
,K<O Nat he is licensed Furamm m Ne provisions cr the Ceirmacmra License law(Chapter
o•o.o� m
9(cumencing with SemW
Section Division 3afthe Business and Profeio
ssns SWIMMING POOL ELECTRIC
Code) VALUATIOa'U
or Nal he is exempt therefrom arta Nmus isfor Thealleged exemption.Any violation of ,c ��C/ 1
,T O
FZY Section]031.5 by any applicant fora permit objects The applicsrl to a civil penalty of OUTLETS-SWITCHES-FIXTURES rL
S a0 not mm Nan Five hundred dollars(SNA). 1 J V
wtw ❑ Luowncrofthc n NEW RESIDENTIALELECTR _SQ.Ff.
props y.urmyemploy«s with wagesastheirsole compensation, STORIE'S 'TYPE CONS'1'HUCI'ION
a'3— will Ju the wnrk,anJ the atruc-ure is not imm�dttloroffered lorxle(Sec.]Du,Busiwss I
and Professions Code:The Convectors License Law does not apply to an owner of
property who builds orimproves thereon,and whodoes such work hirmselforthrough his
wnemployecs.providW Thmsuch improvemenuareno-imm�dW oroffcred fmsale.If. O�C`C.GR�G/JUP NIiS.UNITS
however,the building or ithbumprovement is sold within one yearofcampletion,the owner- TOTAL: `� �V�
builder,will have e rden d proving Nal he did..build or improve for purposef
o
C).
❑ Las owneronhe property,amexdusivdy convecting with limed wnwctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
reasoner he project(Sce.70,bl.Business and Professions Cnde:)The Convaelor's
Licerse Law Jas not apply Ton ownerofproperty who buildsor impmvesdureed,and PERMIT ISSUANCE
who cmtmcN for such projects with a conwemds)licensed pursunt to the Contractors
Liccose Law. ALTER-DRAIN&VFNT-WATER(EA) FEE SUMMARY
j ❑ 1 sun exempt under Sec. .B&P C for this moon BACK FLOW PROTECT.DEVICEGU'ISIDE FEES
SANITARY YN
Owner Dare RECEIPT'#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.AREA,C D. SCHOOL TAX YN
•❑ Thereby eff Natl heves«nificamafconxnno ulf-ivurt.ora«nificve of FIXTURES-PER TRAP RECEIPT'#
Workers Compensation lmumnee oracenificJ enpythereof(Sen.3g00.Leb C.)which PARK FEE Y N_
covers all employcp�dgt� pe7O GAS-EA.SYSTEM-I INC.4 ETS RECEIPT'#
C"Epy BUILDING DIVISION FEES
Company �#O/retie— n i
GAS-EA.SYSTF,M-OVER (EA)
❑ CrnifiW copy ix hereby furnished. ur PLANCIIF,CK FEE
❑ Certified copy is filed with The city inspection division. GREASEBNDUSTRL STEINTERCEPT RADING FEE
CERTIFICATEOFEXEMPTION PROM WORKERS' GREASE TRAP 501 ERGYFFEF.
COMPENSATION INSURANCE
(This section need not berompleted ifthe permit is for ane hundred dollars($100) SEWE ANITARY-STOR ,A. ENEE
or leas.)
I Terrify that in the performance of the work for which This permit is issued.I shall W ER HEATER W/VENT/ELE
not employ any person in any manner az to become subject n The Workers' PAID
z Cnmpcnxtion lawsof California. Date u W TER SYSTEMIFI SATIN
Applicant t Date Receipt IT
z NOTICE TO APPLICANT:If,after making this CeniOcate of Exemption,you should NE RESIDENTIA
p-•s � became subject mpe
lhe Workers Comnmu
tion provisions ofthe Labor Code,you most TOTAL:
�t-' fon Ovid,comply with such Mvisions or This persom shall bearned revoked.d
� BUILDING FF.F:
D, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE ('
'a z Ihereby affirm that them is a conswcann finding agency for The performance of
CJ O the work for which this permit is iuued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Leri Name
ULenders Address QTY. MECH ICAL PERMIT FEE PLUMBING FEE
I certify Nat T have read this application and sure That the above information is
correct. I agree To comply will,all city and county ordinnees and state laws relating to PERMIT ISSUANCE MECHANICAL WE
_ buildingconswetion,and herebyauthodze reprexnmtivuof Nis egn,emerupnn Be
U z aMrve-mentioned property for inspection puryoses. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(Wc)agate manse,indemnify and kap haran eas the City of Cupertino against
himilLles.judgmonrc,costs ntl expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I B"CFM)
n cs,sequence uf�he g,who,of This it.
' nIJJ//� iJ `2s IJ AIR HANDLING ON]'T(OVER I(L00I CFM)
Signature Applicaarmuenntt(mcmr 7 Dam EXHAUST HOOD(W/DUCT7
PAID Date ee
HAZARDOUS MAgoccupg DISCLOSURE HEATING UNIT(TO 1(0,(X#BTU) Dam N¢CC'"Ip
Will Inc applicant or(more building occupant more or handle ath Healthhazardous Sa
u pey
defined by-he Curtino Municipal Code,Chapter 9.12, d the Health and
Safely HEATING UNIT(OVER 100,000 BTU) TOTAL: 9
Code,Section 25532(a)R
El Yes 11 No VENTILATION FAN(SING LERISID) u a x-
Willthea lientorfature buildingacupnTux BOILER-COMP LHP OR 100,(100 BTU) ISSUANCE DATE
hasMws air oomearmnts as defined by the Bay A.Air Quality Management
District? ❑Ycs E)No BOILER-COMP(OVER 100.0(k)BTU) MAY 23 1995
NEW RESIDENTIAL MECII. SQ.FT.
I have real The havrdous notedals requirement,under❑wpmr 6.95 of The
Claihamin llealth&Safely Code,Sections 25505,25533 and 25534. 1 undcrstnd Out V "�-•
if the building does not currentlyhave a termer,Nat it is my resporaibiliry mortify the O
occupant of the requirements
-s whi h must be metpri n issuance of a Certificate of
Occupancy, /J�>/�
ownerornthonmdage 1' rr P r oa��T
TOTAL: ISSUF.0 BY:�+`�I' /gA/T'•YWCCn
OFFIC