28376 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU11.11ING-F,LECTMAE, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECPRIEST IFICA I PON 28376
BUILDING ADDRESS: 1%VSANITARY NO. AP�PI-ECCAAT[ON SUBMITTAL.DATE
7 UNIT# 1.01#
OWNERSNAME: �-S 1H(ljJlt_ —± 3 CON Af�TOR'S NA : � � 6 Ir{ R 7A NIC COY(/ROLp
ARC]IITF.CI'/ENGINHER: 011L.IC NO. 5 A A7P JL
� C STNcrr'�S7— S El
CONACr: PHONE:
QTY. ELECTRIC PERMIT Ffili BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ El
LICENSED CONTRACI OR'S DFCLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
I herchyuffirm hot l an,licensed undcr,rovisimrsafCbapter 9(e.mmenci,with
�d0 full
'/IXp) I Division Jof the Businusund Profession.+Code,and my license is in PANELS
q W full force and<ff ct.
Fy Daten.ve Cl... _ C.m.rt UP T021011AM1'S
y jvi Dam Commctor 201-FIBER Ah1PS
SQ.R.FLOOR AREA $/SQ.ITL'.
cz-ciARCHITECTS DECLA Amd,. OVIeR IIX0IAMI'g
O Z„ 1 understand my plans shall be used as public rtcords.
�.'on LiSIGNS I:1.ECIRICAL
,.. Licensed Prnl'cssionol
W <a OWNER-B111I.D1iRDECLARATION SPCCIAI.CIRCUIT/MISC.
�J 3 1 herehy so(Se that I con exemit ,x a the Cnatmcmrx Code:Any Law for the
ollowwhich ingmne a parrction VOJ1.5 alteve and ve,demolish,orFycity inanrmmty TI?MP.METER OR PQLI3INS'1'.
which it,requires a p,d it to me micwn, duan reprove,demolish,or mpafr any xrtuaurc
�$ patheis ermaed Entivarm him tpo.,Wicamfla,0 onom a filLicense
La smtement POWER DEVICES
ap 9(comisncing with Section
epnmisysion the Ca mu'm's License Luw(Chode) SWIMMING POOL ELECTRIC VALUATION
ayo�e 9(enmmencing with Section]1100)heDiv'sio,Jof eBusiness end Profmsinns CrMe)
,�,� or tbu he is exempt therefrom and
he
M1m onhcu aged memptinn.Any violation or
> ScOiot 7031.5h ant for OUTLE'T'S
-SWITCHES-PIXTURCS
�zQ yany app is pan' s b' he applicnnnoacivil pemhy of
n......han five hundred dollen(f5 W).
C m ❑ I,a.,mocrofthu openy, ry 1 e with agesnetheirsn tion, NEW RESIDF.N'1'IAI.HLECTR _SQ,I'r. STORIES' TYPE CONSTRUCTION
y will dothe work,and t tr to is t Mproffered foreale saaess
ane Rnfessiom cal e - vac 's License I d std ,ply m yawner of
pr.peny who builds,,, es thercun, .whoa x�ilOwwn himselfonhmughhis
oesnemployma,provid th tan'tJ meyylts Iendedmoffcrsaforxala.If. OCC.GROUP RES.UNITS
hawev,,,he building. m .vement vs -,, ithil nneyearofcompletion,theowner-
builder will hove the bre f n tha he did not build or ire TOTAL:
o pravi prove far purpose of
ale).
❑ ],as owneroftheproperty,.am exclusively contracting with licensed contractors to Q9 Y. PLUMBING PERMIT PF:E FLOOD ZONE AI'N
motmct the project(Sec.7044.Tonal.end Professions Code:)The Cisnom rs PERMIT ISSUANCE
License lawdasaot apply m m ownmofpm,ny whobuild imiroprovesthemon.ual
whoconvaets formch projecia with a contmcmr(s)licensed pursuant to the Contractor's
Licame taw. ALTER BI
A) FEE SUMMARY
❑ I am exempt undo Sec. B&P C for This remon BACK FLOW PROTECT,DEVICE OUTSIDE R119-
SANITARY Y N_
Owner Date RECEIPT p
• ARIA,,
WORKMAN COMPI?NSA'I'[ON DECLARATION DRAINS.FLOOR, COND. SCHOOLTA% YN
❑ Ihereby affirm that l have a cenifcata ofcousenno self-insure,or a cenificale of Fl RECEIPT#
FIXTURES TRAP
Wakern'Compensati.n lnsumnce orecenified copy thereof(See.3gW,Lab CJwhich PARK FEE YN
eta all empp ee'Autdg ' t GAS-EA.SYSTBM-I INCAOUII. T RECEIPIit
Policy#_ ` thEIBUILDING DIVISION F..IIS
Company C b .►M 1 GAS-FA.SYS'I HIA-OVER 4(EA) PLANCHEOK FEE
AL Cenilied copyi,hereby furm,60.
❑ CmifieJ copy is HlM with the city inSPC[linn divizion. GRFASE/INDUSTRL WASTE FsPTRCFP`I`OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASETRAP SOILS IEE
COMPENSATION INSURANCE
(Thissectionnatd notbeeompleed ifthapennit is foronalundreddollan(SIIX)) S17WER-SANITARY-STORM EA.21N)FT. ENERGY FEE
or less.)
Icertify that in the performance of the work for which this permit is issued,I shall WATER I I HATER WATNT/GLECTR
net employ any pcnam in any manner to as to become auhject to the Wmlon' PAID
Campe onion Fawsof California. Dula WATER SYSTHM/IREATING Date Receipt#
O Z Appllcam
Z � NOTICETOAPPLICANT:ILaRentcold.,.his Cenlfrcateof Hxem,tion,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
� bee.mc mbi.,1.the Winkelx Compenatio
sn p.shmna.f1he Labor Code,you must
> forthwith comply with such provision,no thlspemdt shall be deemW revokwi. BUILDING FEE!
Pw Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby all!.that there is a construction lendingugency for thepe,fn.lc.r TOTAL: ELECTRIC PP.I:
U O the work forwhiehthi+permit ix homed(Soc.3)KO,Civ.CJ
Leader's Name 0
U PLUMBING FEE U I.eoders Address QTY. MECHANICALPERMIT FEE
I cenify that I have read this application and state that the above infonnmlon is MECHANICAL FEE
tout. Iagrca¢r comply with all city cord anunty ordinunees and stem lows relating to' Gr
PERMIT ISSUANCE
LI) building concoction,and hereby authorize representatives ofthiscity menterupun the
U 7 move romi.nelp Feet,for inspection purpous. ALTERORADDTOMECII. CONSTFURTRON TAX
F7 (We)agree to save,indemnify and kap harmless the City of Cupcnin.against
Iiubilitiu,judgntems,costs and expenses which may in my wayacemeagainst said City AIR HANDLING UNIT(TO 10,"CFM)
in to I"mare of the gnoting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Slgnamre of A,PlicznUCamrwmr Data EXHAUS'Y HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(10100,00O BTU) Data Receipl#
Will the applicant tino future Municipal Code,
ng Code, lumtsroreor handle hazmdous material HEATING UNIT(OVER IIXI,00p BTU) TOT
m defincJ by the Cupertino Municipal CWe,Chvpmr 9.12,and the Health and Safey
Cade,Section25532(x)'! VENT'IIA'IION PAN(SINGLE RESIDE
Eli I-Ir
❑Yes
BORAIR-COMP(3UP OR 100,0011 BE ISSUANCE DATE
Will the acontranmmix areas defir d by the ay Area Dem Quality
Management
it L� q D
hmrte,? air contaminants h def ed by the Day Arca Air Quality hfanagement BOILER.COMP(OVER 1(10.0X0 BTU) ff� F'C
D6tdct4s
❑Yer �Nn NEW RESIDENTIAL MECH. SQ.FT. OCT O
1 have read the haomions materials requirements under Chapter 6.95.f the 1995
California Health&Safety Cale,Sections 25505.25533 and 25534.I understand that Cll�, Vr
if the building dons not currenily have atenant,that it is my msponsibility to nmifythc II f,�O
occupant or the requirements w h maxi be ma prior fn issuance of a mificate of ��V�r�/� 1/�E/ll.,y��.0
Q ncY. V e \
agcn m 'TOTAL: ISSUED BY:
OFFICE