28201 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICAIPERMIT NO, 0
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION � BUILDING PROJECT IDENTIFICATION .`:.•"
BUILDING
Ct IIADDRESS: k-�yk SANITARY NO. AIX'IACATION SIIB���M11+++"fAI,UAIE
—ai 11'` UNIT# Loop
O ERS NA s:e p110 C NTRACI'OR:S,Nµ1CJLIC NO: `•�
CClIN1NI )R� Ilpp\\�lJJ G./y) LIC N/C COME R(lLM
tCllll'ECI'/F.NGINEIiR: ,IC NO:
DRESS
1 ❑
carvrncr: m1oeE: 1,Y"'I ECIRIC PERMIT �''`D't " 9 BUILDING PERMIT INFO
1, I.a s1� QTY C+.
Wyk P \ `oI )� , 1r1i 04 y I BLDG I .1:T PLUMB MECH
"V -) r 1 lV ✓ f PERMIT ISSUANCE
LICENSED COINTRACTOR'S DECLARATION APPLIANCFS-RESIDF.NTIAI. IUB DESCRIPTION
F100IM1em1(drby d Pnmatl 3 ofli Bmiased under prd Pmfesi...Cod r9(cnmmrnense with
IAOp Scctiun 7011(drd Diviainn Jnf the Bmineu and Prokaviom Gde.end my license ie in PANF.IS
y tcd full form nnJ cffca [8
'dZW License Ica -Z Lic.0Z�(o UP'rU 21M)AMI'S
r~i)=,a Dam Convae 17M G• 201 IUW AMPS
,p'z ARCIIITECT`S DECLARATION OVER 111110 AMPS SQ,R.FLOOR AREA 35Q.FT.
j Z_ I uMersmM my plans shall bet uad as public meorda.
:yCw.4 SIGNS ELECTRICAL
;jf j Utra ed Pmfesinnel
'y'adQ OWNER-BUILDER DECIA ION SPECIAL CIRCUIT/MISC.
101E I bench eWon that I.m eacmpt from I onus lar'.,License Law for me
3LL"wQ following rteson.(Section 7011.5,Huaines ,Profession Cade:.Any city to county TEMP.METER OR POLE INS'L
mJ which require,a .Ill.cormumG. .improve.d.) b.m repsir any,loam,
�W�X prim to its issuance,alvemcuims spprc.m fm such pemt no File a signed statement POWER DEVICES
]C_p0 but he is liscread Emoomnt pravidnntaflns Cminon, 'a Llcenaclaw(:mNar
-xdp� 9(commencultwith ton T%10)of Divismnlofthe Buai 1s.MProfessions Cade) SWIMMING PWLELECTRIC VALUAfIOp'
W—rat mmm he is mcrefmmandmchasisformeallegedc Iption.Anyvioletimof /`s�V
C>Y
Section 70.31 S by any applicant for a pemlit.subjaU the ap ticanl In a civil Penalty of OUILIIS-SWITCHES-FIXTURES n /jC!)0
f -`p nm more that FirchmdmddaHar1(S51XH.dyt+lws''a' y
❑ Laanwl nal11,epmpcnY.ormyempla en pcnm NEW RE'SIDENTIALFLECTR —SQ. T.
y- wldl lhcirsnlccom Iron, g'IGNIIiS "I'YI'T:CGNS'IHlIC11UN
will do me wn ,enA meatmwurt iannll nIe(Scc.7044,11tom ,
end An&«ia t Caste:Ilse Con -M'�liei n t ly to an owner of
pntpenywhn ildami G B.Cia[h imalLntbnughhia
lmwcmpinyn ,pmvl rrtn end AmoRcreJ for wle.If, OCC.GROUT' RES.UNITS
sveema timet -OGlmin eyearnr nplefion,lhenw11ef- Tmal.:
bdlderwillh amp Ilial he oat build or improve for purpnscof
i•••.. TY. ,' PLUMBWO PEhhf1T ?' `' I
❑ Las owe "Aft ,iin<selusr as0n Cona:)Th Contrmnm Q t FEEz•'(� fiWUZONE APN
ycon gwi n9.ac. ++!`-re's
amatmn the earim(Sec.mans,Bu' w ape ywhabuild Code:)The Cmu.nar'a
whacalawa<tnnuppject, cr afpropeny wlenVApen impmvee Costae,end PERMIT ISSUANCE
w1, use,L.ss mmch pmjecb 1M1 econoaclm(a)liccn.Mpursuenuolhe Canlreclnr'a
Liana Lew. AL1TR-DRAINAV .WATER(EAI jl'Jt•f_H, ' PEE SUMMARY
❑ I am encm u ,or. P @ P C for this reason BACK Ell U OTECT.DIiVICE OUI SIDE FEES
SANITARY Y N
Owner Dale U S.FLWR.RWP,AREA.GOND. RECEIPT#
WORKMAN COMPENte ofmo DECLARATION SCIIWL,TAX Y N
Iherchyafprmmallhaveacenif ate of mnammall-inxure,mamnificate of .%TURPS-PF,R TRAP RECHIYTN
Warkeni Compenedion Insurance or a ceni0ed copy thereof(See18110.Lab C.)which PARK FEF, \' N
vers all erprJgya��ngdenhi;q{ryk,I�.� GAS.EA.SYSYEM LETS RECEIPTN
policyp ''11Rtt7711 `c�9 ✓✓WWVV BUILDING DIVISION FEES
CompanyGAS.EASYS
, ' -M- 4(En) PLANCIIF.CK T.H.
Ceniredcapy'ishcrebymmimed.
C7 Cenified copy is filed with me city inspection division, G iWAS R :PT GRADING FF.F.
CERTIFICATE Op EXEMPTION FROM WORKERS' TRA . SOILS FEE
COMPENSATION INSURANCE
(This section need not bemnplcted itlhe permit is fanne hundred dollars(SIM) SEW SANITARY-STORM EA.20NT ENERGY Mr.
less.)
I renify 11,111.the perfonnoncenf the work for whiehlhis Kama isiasuedlshnll AMRIIEATERWNEN'TBiLF.0
nal emN m become any pe,,.in any manner In beme subject m th "
.oe Works
Cona,matimrlawf C.lifmnia, No PAID
T[R SYSITM/IEFATIN
D 'z Applicant Dale Receipt
, 0 NOTICETOAPPLICANr:ILafmrnlakingmia CeniOnaorEampt,, you,htwld NE ESIDENTIAL p. SQ.FT. TOTAL:
-• � me n
becosubjecn the Worker,Compensation provisions of the I Gdc you nwst
fnnbwilh cunply with such pmnitinm m this permit shall he deemed nevnked. BUILDING ME
L. Q CONS MUCr10N LENDING AGENCY SEISMIC ITE
Z) Z Ihereby affm111mthem is a cnnsurolum lending agency fon he perforllowaof
) O the work fm wnichthi,permit is issued(Sec.ID9l,Civ.C.) TOTAL ELECTRIC Mr.
L Lendee,Name 1, -
Lenders Address QTY. •t MECHANICAL PERMIT., I'g PLUMBING ME
I cavity that I have reed this application and stale that me above information i. liT.ysirt,
yC correct.l agree m comply with all city and county ordinances end stem laws miming to PERMir ISSUANCE MECHANICAL FEB
uj building construction,and hereby omhoriae represcnutivetntmi.s city menterupatthe
7 above-mounded pmpeny for inspection purpme q ALTER OR ADDTO MECIL CONS'MUCf10NTA%
C7 (We)agme to save,indemnify and kup harmless the City of Cupertino against
liabililia.judgmm�u,cmnand expense which may inch way scans,against avid City AIR IIANDLINO UNIT(TO 10.0co CFM)
camsequemen rc coming of mit pe.11.
6 / AIR HANDLING UNIT(OVER IO,np CF M)
alert MAppliranV on nanr S�`I Dam EXHAUSTBOOD(W/DIICI)
PAID
IIAZARUOUS MATERIALS DISCLOSURE!, HEA[ING UNII'(TO IM.NX)11 It)) Dam ReccipM
Will the applicant or future building occuparor
n se or handle bvardous material
as deMcd by the CUPenhm Municipal Code.Chapter 9.12,and me Health sed Safely HEATING UNIT IOEE.cod R I U) TOTAL:
Cade.Section 255121.)?
❑Ye, 0 N VRNTILAI'[ON PAN(SINGLE BESIDE
Willtheq contaminants
as building by the Bay Ams Aent Quality
Management
BOILER-COMP(311P OR I IXI,000 B'I'U) SI IA CE DATE
nnbaa sir ammminama es defined by me Bey Area Air Quality Managcmenl BOILER.COMP(OVER[(MINX,III'UI !l
.istria?
❑ad ❑No NEW RESIDENTIAL MECIL. SQ.ET, JUN 21 1995
I d-Flhave read me hvaNnm maledala 5505.2mcma and
34. tun understand
of me V kt4 k�
Ghe hail Imdur s of Safety Cwle,havStece
a t a 25505at itis y r 23514. 1 andvuand mal C' r
ifinehnildingdrc,nncaurnm currentlylhich must ha mmilknry rcapmeiof.Cefir"m the U� LUh'kfilll
occupant of the regniremem,worm moat be met prior m Issuance err.Cenificem of
(kcupnncy.
Own Imamho .ga .gem Dam
TOTAL.: ISSUED BY:
OFFICE