28315J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO HUILIIING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MF.CIIANICAL
BUILDING PROJECT I DRN'I'I F'ICATION
PERMIT NO.
28315_
BUILDING ADDRESS; 1/
(./3GJ l.1 / hAYYN I UNIT# LOT#
SANITARYNO.
APPLICATION SUBMITTAL DATE
/n�lo��
llV//ll ll
OWN . NAME: PHONE::
' A%A 13 —
CONTRACTOR'S NAME: LIC NO:
NBC
❑
CONTROL#
ARClll'1T.CDENGINEER: LIC NO:
ADDRESS:
CO CT: PHONE:
I��/(/� ,Y 9-n/ txf i�
Ar Y �V� • •,3—",)
QTY. ELECTRIC PERMIT PETE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l sat licensed underprovisiensof Chapter9(communing with
Sextion7")of Division 3 of the Business and Professions Cade, and my license is in
full force and -Tract.
APPLIANCES - RESIDENTIAL
PANEL
BDESC 1
1
License Class Lic.#
UP 70200 AMPS
J ��
Date Contractor
201 - I" AMPS
SQ. PI'. FLOOR AREA A $/SQ. Irl'.
ARCHITECTS DECLARATION
I undersand my plans shall be used az public recoMs.
OVER 1000 AMPS
SIGNS ELECTRICAL
OR
V' —
Licensed 1'mfcssional
OWNER -BUILDER DECLARATION
BUILD
SPECIAL CIRCUIT/MISC.
I am from
I hereby .. (Se that I um exempt from the Commix Cs License Lew for the
cityo
L5.Businessmprve,
TEMI'.METF,R OR POLE INST.
whicwingnveon.(Seeirn](11
canny
truemy
which requires a permit r ronswe, alcor, improve. demolish m repair any muctum
demolish.
to also nt theapplicantof ch stao,ment
filLicense
pat
POWER DEVICES
heor lissuance.
to the Copemduo
Nat m is licensed pursuant to Ne provisions of the Contractor's License Law (Chapter
the La
9(commencing with Section ]II(IB)of Division Jnf the Business and Professions Code)
SWIMMING POOL ELF, fRIC
V
or that he is exempt herefrom and the basis for the at leged exemption. Any violation of
Section'/031.5 by any applicant for apenurit subjects the applicant to a civil 'unity of
OU'f1.ETS. SWITCI IES -FIXTURES
not mom than five hundred dollars ($500).
❑ I.mownerofth MKny.ormyemploymwithwagesmtheirsolecampensotion,
NEWRFSIDENTIALELECTR _SQ.FT.
STORIES
'IYPECONSTRUCTION
will do the work.and she structure is not intendedoroffenl frosele(Sec.70#4, Business
and Professions Code: The Connectors License Law does not apply to an owner of
progeny who build.,mimprnvn theomm, and whodoessuch workbimselforthrugh his
awn employers, provided that such lmprovemcnts arenot intended or offued for mle. If,
OCG GROUP
NES. UNITS
TOTAL:
however, the building orimpmvemem is sold within one year of cempledoa, the owner-
builder will have the burden affirming that he did not build or improve for pur swn of
QTY. PLUMBING PERMIT FEE.
ul I.
y,amexiness ely ing
proSec.
A L
A=
FLOODZONE
AIN
7 ions C de:) Th Conneoratu
and Professions
ns�wct Ne project (Sec. ]t144, Business and Professions Cade:) The Connector's
the project
License Luw doex not apply ar un nwnerofpmperty who builJsor imprves thereon,and
PIENMI'I'ISSUANCE
who contructs for such projects with econtrac or(s) licensed pursuant to the Connector's
Licence Law.
ALTER - DRAIN & VFN'T - WATER (IEA)
FEF. SUMMANY
❑ 1 am exempt under Sm. , B & P C for this reason
BACK FLOW PR(YIEGT. DEVICE
SID :Eli
SANITARY Y N
RECEIPT
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF. AREA, COND.
SCHOOLTAX Y - N
❑ thereby efBmuthatlhuveecenifieate of mnsennn self -insure, nrettdificete of
Workers Compensation Insurance or a cenifiedl copy thereof(See. 3800. Lab C.) which
FI%TURES-PER TRAP
RECEIPT#
PARKFEE Y N
coven at] employ«s under this pemrit.
RECEIPT #
.. •GAS -'EA. SY$lEM-1 INCA-gENLETS
BUILDING DIVISION FEES
Policy #
'4
Company -'^ "'-
❑ Certified copy is hereby famished.
GAS - EA. SYSTrjOVI3R4( )
PLANCHECK FEE
KSQg$A 1. WASTE IMERCEPTOR
❑ Certified copy is filed with the city ins tion Jivisi
gC
�,',
CF.RTIFlCATI?OFF.%EM ON FROM K
COMPENSATIONINSURANC. •• st
Cnis section rad not he completed if Na permit is for.crittf dpll'Ixrs�510(1)-
GB
SO1DINGFEE
S FEE
4 --ISE IER-SA AICl ` .5 RM Fj4. 201
ENERGY FEE
or less.) v `
N
I rflry that in the performance ofthe wor0for which this permit is issued, l she'/ELE
not employ any person in any manner so as 1. become subjqb p-�Ite. Wor
PAID
t.
WATER SYSTFAITRFATING
Cmitensationlawsof Califomia. Dole i UU/N
Dam Receipt
Applicant F,I.
NOTICE TOAPPLICANT: If, after making this rtificataof Exemption, you should
become subject to the Wnd<r's Compensotion pro s of h CiWeT9En INtiS�'s
forthwith comply with such provisions or his perrot.s a c cenardFrevoked
rig �f.WS RE61DEM7iS1. PCMB. SQ. FT.
TOTAL:
BUILDINGFEL>
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm Nm there is a conswaion tending agency (.the pesformemee of
Ne work far which this permit is issued (Sec. 3097• Civ, C.)
TOTAL:
ELECTRIC FEE
Leaders Name
tender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 cenity that I have read this applicarino and auto, that the eNo,c infomration is
correct lagreemcmd ly with all city socksumymirmances and state lows elating to
PERMITISSUANCE
MECHANICAL FEE
building construction, and herebyauthorize re,rouma ivesofthiscity to enter upon the
above-memioned property far inspection purposes.
ALTER OR ADD TO MIiCH,
CONSTRUCTION TAX
(W<) ugre save, indemnify and'cep huuml" the City of Winn against
Iiahilif gmems, tsund expenmswhichmay irony weyaccr cogs st,ariJ City
AIR IIANI3LING UNIT (TO 10,000 CFM)
se cc ofthe ending 01 this permit.
.r 8iQ
AIRIIANDLINGUNIT(OVER IR"CFM)
Aplicaut/Contmct« Date
FXI IAUST HOOD(W/DUCG
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
r&fined
Date Receipt #
e upplicamt or future building occupant state or handle hmurdous material
the Cupen,.a Municipal CWq Chapter 9.12, onJ the Health end Safetyn
IIF:A'fING UNIT (OVER 100,000 BTU)
OT
8532(a)]
❑ Yes 11 No
VENTILATION FAN (SINGLE RESIDE
DOILIER- COME(3HP OR 10, 000 BTU)
SISSUANCE D
Rq sq IATE
Y� R1
Will theapplicamorfuturcbuilding«cupam useequipmentnrJevices which emit
BOILER - COMP (OVER 100,000 BTU)
hoznNmm contaminants,,
air A. defined by the Bury AAir Quality Management
wsamty
❑ Yes ❑ No
1 hew read the hazardous materials reyuimments under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
ifthe building does not currently have a tenon, that it ismymepomeibihty to marry the
user,, at at the mr,m menu which must be met prior to issuance of a Cenificam of
AUG 10 1995
yVY
I Ul• "Ur-j:Hj (,
NEW RESIDENTIAL MECH. SQ, IT.
Occupancy.
ISSUED BY:
Owner or amhadzed agent Date
TOTAL:
OFFICE