28013 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIm;HINfTF,ITCTRTCn. PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL. n 3
e 0 vI- BUILDING PROJEC'1'WEST IFICA'I'ION Lo 1J
BUILDING ADDRESS. - SANITARY NO. APPLICATIONSUBMI'ITALDATH
s0 UNITN LOTH
OWW 'NAME: Je
y��PHH�ONE: CONTRA R'S NAME: LIC NO: J
1 k'a• 62— M � NIC CONT OL#
• ARCHIT'IiCT/fi MUM: LIC NO: ADDRIiSS: ❑
CONTACT: PHONE: 'a x } y BUILDING PERMIT IN
QdTf� „t{_ k�PLHCTRIC,PBRMIT PEH
? BLDV ELECT PLUMB ME❑CH
PERMIT ISSUANCE
LICEb?SED CONTRACTOR'S DECI.ARA1 ION APPLIANCES-RESIDENTIAL TOB DE CRIPTION
0yz, Ihereby offirm that l ren licensed under provision of Chapter 9(mnunendng with l��I 1
5100 Senior,7”) D�ivaision3 of the Business and Professions Code,and my license is in PANELS !`C6kI Id
�WE full barceandeffa C\n� v%��y
QUty Lice. C ss O Lic.4 UPT02MAMM
y=ti Date Connactor_3�, ry fl�J 201-1000 AMPS
F-o,z RCHITECTS DECLARATION SQ.FI'.FLOOR AREA $/SQ.FT.
z 0 ve— OVER 1000 AMPS
CZ-0 I undersand my plans shall ba used as public records.
CQted SIGNS ELECTRICAL
,y,Xd Licensed professional
Wei OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
m lallowI hereby affirm that 1 am exempt from the Comment'.Liunse Low for the
p� ingreasun(Section 7031.5,13usiness and Professions Code:Any city urmarty TE)s[P.METER OR POLE INST.
F J which requires a pemtit to construct,alter,improve,demolish,or repair any structure
2 Y� prior,,it,constants,uloor,aires th.mplicant for such,monam fileasigned satement POWER DEVICES
O
0 that he is licensed personal the provisions ofthe Commends License Low(Chapter
1" C g n SWIMMMG POOL ELECTRIC
404. Commencing with 7000)nf0ivisionJof the Business end Professions Cade) ,g VALUATION
ly2y or that heir 1.5 by hcrefromand the basis fonhetsalleged exemantto civiny l Penalty
of OUTLETS-SWITCHES-FIXTURES Y�f,p-Nle ��
$4 Section 7N LS by any applicant fora permit subjects the applicanuoacivil Pendry of 'P 000
�$ not more than rive bundredd.ham(5500). NEWRESIDENTIALELECTRC —SQ.fT.fo ❑ I.mown,,(thepropeny,ormyemployeeswiNwagesasiheirsolecompmation, STORIaS TYPE CONSTRUC9'ION
y3� will do the work,and the structure is notimended comfort forsnle(Sec.7044,Business I
and Professions Cale:The Contractors Liurtse law does not apply to an owner of
property whobuildsorimpmves Nereo,andwhodoes Rich work himulforthrough his
own employees,Provided Wan such improvemenisareml intended metered forsde.If, OCC G1ROOUP RES,UNITS
however,the building orimprovement is sold within one yearofcompletion,the owner- TOTAL: S F12
builder will have the burden othin a f proving he did not build improve for purpose of
rete]. : . .
❑ I,asowner offs property,am exclusively contracting with licensedcontmemrs to QTY, ' PLUMBING PERM IT FEE [TODD ZONE APN
construct the project(Sec.9094,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law does nm apply tom owner o f property who bui Ids or im proves thereom and
who contracts for such projects with a conlractor(s)licensed pursuant to the Contrecmr's
License Law. pLTIN-DNAIN&VENT-WATER(EA)) FEE SUMMARY
❑ I um exemPn under See. ,B&P C for phis revxon BACK FLOW PROTECT'.DEVICE O SID: F
SANITARY Y N
Owner Dane RECEIPTM
• c DRAINS-Iq,00R,ROOP,ARPA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
❑ Ihereby
pensm thatInsave a urance
or ifcmeofconumereof(to insure,or Lab C.)hite of RECIi1Pfp
FIXTURES-PER TRAP
Workerx'Compensminn lnsurmce oracenifietl copy there.f(Sec.38IXt.l.uh CJ which PARK PEC Y_N
employ s rs pef�n�U3J —I? GAS-EA.SYSTEM-1 INC.40VILEI'S
RECEIPT p
1'alicy M BUILDING DIVISION FEES
Compact irgai On AIC F'^"a�— GAS.EA SYSTEM:OVER 4 GA) PLANCHECK FEE
❑ Certified copy is erebYb fumishN.
❑ Certified copy is filed with the cityihspatiori divlsioh.r GREASE/INDUSTRL WASTE INTERCEPTOR GRADING]AM
CER'T'IFICATE OF EXEMPTION MOM EN$I �— r !"°- GRILSE RAP '� SOUS RAE
COMPENSATION INSURANCE �(]e P
This section needaot becompfeted ifthe permit is furore n d olars($)I0i SEWER-,SANITARY-STORM FA.20017. ENERGY FEE
orlex,f
I certify that in the performmce ofthe work for whichthis s�si sked,IshWnilf - ER ATER WNINT/ELECfR
nm employ my person in my manner so as m'hecom bject t Workers' PAID
Coona,mantion Lawsof California. Dasa ER SY.STE EA'T'ING Dara Rueiptp
O z
Z 0 NOTICE TO APPLICANT.If,after making this Canif¢meTnTftECmp .yWR oo ahoultl NEW RESIDENTIAL PLMB. SQ.FT. OTA
q) become subject to the Workers Cnmpgnsatbn previsions ofthe labor Code,you must -
"-' fanhwith comply with such provisions onhis pemhit shall be deemed rcwked. A,'...' BUILDING IgiE
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z Iherebyaffirn Nasrherc isaconstreation lending agency far the perfonnanu f
o
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: RLECIRIC PEE
Lenders Nom PLUMBING FEE
0 U Lenders Address QTY. ',MECHANICAL.PERMIT FEE
U 1 cemfy that 1 have rad this application and stat.that me above Informationrs .4 ' 1�' & 1
meet.l agree to comply with all city and county ordinance and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingeondruction,and hereby imbonze representatives ofthic city to enter upon the
U above mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTIONTAX
(We)agree m rove,indemnify and keep harmless the City of Cupertino agui ns[
Iiabilidex.judgments.costs and expenses wbich may in my wayoum i,utiart avid City AIR II ANGLING UNIT TO 10.000 CFM)
in consequence of the granting of this permit.
L AIR I IANDLING UNIT(OVER 10,000 CFM)
Slgmnurcof Applicant/Contmamr r Date EXHAUSTHOOD(W/DUCIT PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data R'CdPI g
Will the applicant or for=building occupant store or handle hovrdous matmd IfFATING UNIT(OVER 100,000 BI U) TOTAL:
us defined by the Catania,Municipal Code,Chapter 9.12,and the Health and Safety
Curie.Section 25512(e)P
13 Yes CI No VENTILATION PAN USING LE RESID) 6 a p
Will theapplicant orfumrebuildingoemptint use equipmentordevices whichemit BOILER-COMP QHP OR 100,01(g)BTU) ISSUANCE DATE
ha'undous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) AUG o V ,Q95
Uistdnl v
❑Yes ❑Na NEW RESIDENTIAL MECH. SQ,VU (� �s
I have read the hazardous materials requirements under Chapter 6.95 of the CI' I Ut Wirt['. V
Caliromia Health&Safety Code,Sermons 25505,25533 and 25534. 1 undersumd that
if the building does nm curemly have a tcnanL that it is my msponsibiliry to notify the
cupant of the rcyuiremenw which mu.xn M men prior m issuance nfn Certificmc of
fxcanmay.
Owmcr ser mthaneal agent Date TOTAL: ISSUED BY:
OFFICE