28060APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEGI RICAL
BUILDING DIVISION APPLICA770WPERMIT PLUMBING. -MECHANICAL
BUILDING PROJECT IDENTINCATION
PERMIT NO. 2 O O V O
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BUILDING ADDRESS:
SANITARY NO.
APPLICA'HON SUBMITTAL DA'Ili
/1
Ue UNIT# LOT#
OWNE1t NAME: PHONE:
CONT ACTOR'S CAME: LIC NO:
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WC
♦♦♦ CONTROL
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ICIIITEJ� '/FNGINIiIiR: LIC NO.
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ADDRESS:
s C A.A r i S4 Jafi C�
C0N'I'AC7p: PHONE:
QTY. ELECTRIC PIiRMIT FCC
BUILDING PERMIT INFO
ELECI' PLUMB M:CH
(�
DOL\ �i1G (�(,! I a / 6 S(�-7�-
PERMIT ISSUANCE.
LICENSED CO ACTOR'S DECLARAI IONAPPLIANC135
I hereby affirm thatI am licensed underprovisions o(Chader9(commencingwith
- RESIDENTIAL
JOB DESCRBUION
Section ]00)0) of Division 3 of the Business and Professions Cade, and my license is in
full fore and dfect. S 8
Lll force � hic.p O
PANELS
UP T02W AMPS
` P
, 1 Y Y
201 - 10031 AMPS
Dam Corrncmr
ARCHITECTS DECLARATI N
I understand my plans shall be used az public records.
SQ. Ill FLOOR AREA 8/SQ. FT.
V/
OVER 1000 AMPS
SIGNS ELECTRICAL
Llcemed ProfessionalIL
OWNER -BUILDER DECLARATION
1 hereby affirm thr I am exempt from the Conhactors License Ire for the
CIRCUIR/
followingrcason,(Section](1315,Ominess'nnJ Professions Cade: Any city or coumy
wl alrcs a petmll or construct, alter e, de uhsh, m repair any soacmrc
M atoitsiVitan , pplicanlforsuchpe a nfileasigticdstaumenl
TEMP.SPECIAL
Lfn
TEMP. METER OR POLE INST.
T
POWER DEVICES
I I he is licensed pursuant to the Provisions of the Corr hors License Ire (Chapter
9 commnncingwitb Seciinn7 )of Di dme 3orthcR sincssaad Professi.m Cada)
o lhatheiscxcmpuherclem dl h'. dmidlege e.comion. Any violalianuit
lion ]OJ .Shy an ppli for noir the ppli<annoacivil penally al
n mom th r fi M1u d 500).
Lazo roof, rty,ormycmployceswithw stheirsolecompensation.
SWIMMING POOL ELECTRIC
�� VALUATION
S'1'Ok1E5
TYPECONSTRUCTION
UTLEI'S.SWITCHES-FIXTURES ��OF
NEW RCSIDENTIAI. ELECTR SQ. FT.
ono
illdo Ihaarucwre isnot intends,orsle(Set. 70,14, Business
N PPoms u s Code: The Canlracmr's m Lawnot apply In an owner of
1 penyw t uildsorimpmvesth . and whodoessuchwork Wmselfordwugh his
employ e.providalih c mprovemenlsart not mucrdedororfered forsele. If,
1 tweveetbe buildin mprovemem is tela within one year of camplmion, the owner-
OCC. GROUP
RFS. UNITS
ilder will h m burden of proving that he did not build or improve for purpose of
W�It✓
QTY. PLUMBING PERMIT FEE
s le.
L asnwnernfthe pmpeny, ten exclusively contracting with licensed contractors to
FLOOD ZONE
ANN
consume, the project (Sea. 9044, Business and Professions Cade:)'llm Contractor's
licetue law does not apply to not owner of properly who builds or improveslhemon,and
PERMIT ISSUANCE
whocontmets farsuch projects with a containers) licensed pursuanuo the Cmaraemrs
Licca¢ Law.
ALTER. DRAIN & VENT - WATER TEA)
FEE SUMMARY
❑ I am eumpl under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTS FEIS
SANITARY Y N
RECEIPT#
Owner Dale
' WORKMAN COMPENSATION DECLARATION
ILcrcM1y alfum thmlhaveaccnllcele nfcanscmmsdf-inmre, aru cenifir
Orkem Cnmpensationlnsunmcenracenif,Mcopylhercof(Sec.38W,lab which
coversallcondo ty{I t it.
Poky # V T
DRAINS - FLOOR,ROOP, ARFA.COND.
SCHOOLTAX YN
RECEIPT#
FIXTURES - PER '1'RAP
PARK FBI:. Y N
GAS. EA. SYSTEM -1 INC.4 OUTLETS
BUILD114 D INION FENS
Co pany
GN- 17A. SYSTEM-OVER4(EA)
PLANCHECKP
Certified copy is hereby Buddhist.
G Tl�SEANDUSTRI, WASTE INTERCEPIOR
GRADING
❑ Certified copy is filed with the city inspection divist
CER9'IIICATE OF EXEMPI'10 OM WORKERS'
GREA'ITRAP
SOILS �a
COMPENSATI SURANCE
r SEWER- ANITARY - STORM EA. 2001-7.
ENFRGt
(Thisoctionnesl nm becom if Ne permitisfaronehun a .($
or less.)
"lik IIFATER W/VENTI1LIiCTR
PAID
Dote Receipt
Icenily Wminlhc perrnrm nccof Newark for which lhis pen- iomcd.l sir
not employ, any peen in an mvincr as to beco us the Workc
Compcnsatinnlawsof Califnd D.
ATERSYSTEM?BEATING
Applicant
NO'1'ICIi'I'OAPPLICJN'I.1 rmakingtbis Cc' empinn old
uafthe
NEWRESIDENTIALPLMB. SQ.IT.
'1 OPAL:
become subjanothe Worker'sG Pcnmti rp v o LalborC no must
Forthwith comply with such Most oto ort ''shall be cdlfevoked.
BUILDING IEE —
SEISMIC FF.F.
nd`tai
CONSTRU PION LIN 1 GAGENA
1 hereby affirm that is a onswction ding agency for Ne pert since of
the wad. for which this permit is is. teed (Sec. 3097. Civ. C.)
O
GLIiCTRIC FEE
Ql'Y. MECHANICAL PERMIT FEF:
PLUMBING FBE
MECHANICAL PEE /
Icndcrs Namc
Censer. nddres
I ecnify that I have read This a Iicalia. and sum that the ve infonnelion is
carter. lagrte to comply with all cit and coumy ordinances dstate lawsrclating to
PERMIT ISSUANCE
buildingamnruction, unJ hereby umh 'eemprcsemative. this citymemer upon the
above mcntioned prnpeny for inspcctto pu"Meas.
ALTER OR ADDTO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10.000 CFM)
(We) agrte m move, indemnify and p h ens the City of Cupertino against
liabiliries,judgmems.cons and expcnuswbc eay mmnywayareadengamasvd Cily
AIR HANDLING UNIT (OVER 10,000 CFM)
in ace ofthegrnnlingot this tc nit.
EXHAUST HOOD(W/DUCO
PAID
Signature of Applicam/C Hera' Date
HEATING UNIT (1'0 100." BTU)
'0 % RDOUS M iIALS DISCLOSURE
Dare Receipt #
HEATING UNIT (OVER 100,000 BTU)A
T'Oi'AI.:
Hit ap"m or (teem buil ocaupanl store or handle ha'uudous mamnal
as defined by the Cupcnino Mound ode. Chapter 9.12, and the Heath and Safely
Calc. gcaian 25532(x77/
❑Yes J4Nu
VEM'ILATION FAN (SINGLE RESID)
VA rtrt
U
ISS DA'Z'E
Will the acontarmfmumb defined by the Bay Area Aen Quality
Isa'dnue air contaminants as Acgned by the Bay Area Air Quality Management
( Dlsvia7
E) Yet, XNa
I have read the hazardous materials requirements under Chapter 6.95 of the
BOILER-COMPQHPOR Hip BTU)
BOILER -COMP (OVER 100,000 BTU)
!!IN!CE
JU` 24 ^�r�
1J V#n
C ����hhWWYY
"//�V�'
LUrtl l(lNV
NEW RESIDENTIAL MECII. SQ. FT.
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
i( rhe building dces not cunently hwc a mnanh that it is my responsibility to notify the
occupant of the rcquircmems whic s be met m isuance of a CerliOate of
acupamy. —s
`F�
ISSUED BY. W )
Owner or ambodmdagant If Date
T
OFFICE