28128 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN
ONLY
—
BuumNc-RLecAI. PERM]]'NO.OF CUPER'rINO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA
E( P FC ^ ^
BUILDING PROJWENT IATION
BUILDING ADDRESS: �y ✓1 SANITARY NO. APPLICATIOONN SUBMITTAL DATE
O Li UVO UbWt# LOT# /Y�ygq
OWNI�S'NA,E: PHONE.: CON'TRACTOR'S NAME: LIC NO: N/C CONTROL#Mp1 -
HCI1155'IEYYYY�TrI1GIN1iliR: L.ICNO: ADDRESS: ❑
a ou6ST�Z G
CONTACT: PHONE:
Kim IA�gt,TZ 408-g95-3ygl QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
tlwLDO ELECT' PLUMB MBCA
PERMIT ISSUANCE. I9
LICENSED CONTRACTOR'S DECLARATION APPLIANCE;$-I,IiSI1l1iNTIA1. fes_
CIZZ Ihereby affirm that l um licensed underprovisions of Chapter!)(commencing with �a� ' fUD DHSS`¢C\RRIIf '(ON
HOC❑ Section 900an0).!Division Sof the Business and Professions Code,and my license is in PANELS
Fa k�U full force d effect. UP T02f0 AMPS L `♦V\m1
l.'
FZW License Class Lie.#
`A<y Dae Contractor 201-1000 AMPS
F-,zARCHITECTS DECLARATION SQ,FT.FLOOR AREA E/SQ.FT.
ZOy— understand m OVER I"AMPS
ld
OZ�O my shal l be used as public records.
�y W SIGNS ELECTRICAL
�i Licensed Professional
a
OWNER-BUILDER I, OEhe ARAI[ONUmbracla, SPECIAL CIRCUIT'/MISC.
OF Ingreas nOLm tion um exempt from tM1 r Commdnh e:Any Law for the
m following reasnn(Sedian]IULS.Business and Pndcssione Code:Any city or county TEMP.METIER OR POLI?INST.
�; which requires a permit to construct,alter,improve,demolish,or repair any structure POWER DEVICES
}� prior to its issuance,also requires the applicant forsuch permit to file u signed statement
,W<0 that he is licensed pummnt as the provisions of the Contractors License Law(Chapter
,Ex:Q 9(cortmencing with Section 7")of Division 3 of the Business and Professions Cede) SWIMMING POOL ELECTRIC VALUATION
WZZ_m or that he is exempt herefrom and the basis for the alleged exemption,Any violation of OUTLETS-SWITCIIIS-FIXTURES
� G
Section ion 9031.5 by any applicant for a permit subjects the applicant a civil penalty of
Gn[mothan five hundreddollms($5W). .❑ re[,as owneroftheprolrrly,oroyemployees with wagesaitheirsolecontpenNEW RESIDENTIAL IiLNATR H Irl'.sition. Q STORIES TYPECONSTRUCI'ION
G willJo theworv.rdthe straeureis notmtmd,duoffcrul rorsule(Sea 9004,Nusiurx,
and Professions Cale:The Cnnlracmr's License Law dors not apply m an owner of
property vdm Ndldxmimpmvcathereou,andw1mdoc,such work himsehfonhrou,h his
own 1 as.provided that such int t t intended oroffered Tarsale.If,
OCO GROUP RIS.UNITS
amp dy Prov lel within
no in en
however,the have
the
bur improvement is hath within one year ofcomo a for the owner- TOTAL:
builder will have the hmOcn of proving that he did not build or improve for puryou of
ale.L QTY. L GPERMIT FEE FLOOOZONE APN
n
❑ 1,as rofthe property,am exclusively contracting with licensedc.rhmoars to
construct the project(Sec.7044,Business and Professions Code:)The C.nmmmr's
License Lawdoes not apply It,on ownerofproperty who builds or mproves themon,and N
who contracts for such projects with aeommetogs)licensed pursuant to the Cnmmnor's
License Law. vENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this rcmt FL W PROTECT.DEVICE SANITARY OLU YI FEES
60 NN, N
Owner Dote RrrrtI'T#
RAINS-FLOOR.ROOP,AREA,GOND.
WORKMAN COMPENSATION ofoo DECLARATION SCHOOL TAX Y_._N
❑ thereby Compenrmion Insuranceve a
ora certeofco,ythemend of(Sself-insum,or Lab C,)c hi of FIXTUR[S-PC:R TRAP RIiCIiIPT#
Wnrken'Compensation lnsumnce orscenifiedcopytherenf(Sac.3e00,Lab C,)which PARK FEE YN
coversall empl°yee'sundenhia t. RECEIP #
fern'' GAS-[?A.SYSTfiM-I INCA OUTLETS
I'ol cy# BUILDING DIVISION PEES
Company GAS-EA.SYS'I EM-OVER 4 CA) PIANCI IF CK FEE
❑ CxmfiodcapyiaheriAyfumi,bcd.
❑ Certified copy is filed with the city irepcnion division. GREASUIN .R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIISFEE
COMPENSATION INSURANCE gn
(This section need not M completed ifthe permit is forone hundred dollars($100) SEWER-S 5 an peck co OF
or or er ace mplebs
Icenify[y in the pin no,
so ark farbecamehi object 1.the WIshall WATERH F o
not cnmloy any penton in tiny n sonar as to become subject m the Warken' w
Z CnmpmeuOm Lows of Cullfornin.t Date so WATERS { or co r a n a Dale Receipt#
Am
0 Z NOTICE TO APPLICAN'1':If,nOcr making this Cenificntc of Exemption,you should NEW ftCS son TOTAL:
4 become subject o the Workers Compensation provisions of the Labor Code,you most
a , forthwith comply with such provisions."his permit shall be decmed revoked. /e a BUILDING FEE
0. [] CONSTRUCTION LENDING AGENCYrwa • yg SEISMIC IEE
Vz I hereby affirm that there is a x.rcum dime heading agency Airline perfovmnce of
O the work for which this Permit is issued(Site3097,Civ.CJ "UAI ELECTRIC FEE
p.r Lender's Name PIAMBINO PBB
lender's Add... QTY. - M I 1A
U I cenify that I have read this application and smte line the above information is
Fa coned.l agree m comply with all city and county ordinances and state laws relating to PERMIT ANICAI.FEE
U) building construction.and hereby authorize represenmtives ofthiscity'center upon the X
U z above-memionM property for inspection purposes. ALT�E-jt OR ADD TO MSCI I.
(We)agreem save,indemnify and keep heirmleas the City of Cupmeino.,West
liabilities.judgmerne,costs md expenses which may in any way carve against said City AIR HA U a IO,000 CF
equenceo the;
mmi ;, e AIR HANDLING UNIT(OVER 10,010 CFM)
Signutu ofApplmam/Cooloct- e:: AGe7_7
Date EXHAUST I IOOD W/DUCT) PAID
HAY.ARDOUS MATERIALS DISCLOSURE
HEATING UNI'f('IO JOB,"BTU) Date Receipt#
Will the theC unto.m or Municipal Code,
atnrcor huddle hHealth and Safely HEATING UNIT(OVER 100.000 BTU) 'TOTAL:
m defined by the Cupertino Municipal Cade,Chapter 9.12,Wad the tlmhh end Safety
Cade,Section 25512(a)?
❑Yee, ❑No VENTILATION FAN(SINGLE RESID) Iie
BOILER-COME UUP OR 100,"BTU) ISS A DATE
Will ap,Sdxnmrfntore defining by henipmemnrhevices whichemit
hmanl0us air conWminanN us defined by the Be,Bay Arta
D11,110? Air Quality Management BOILER-COMP(OVER 100,000 BTU) MAY 25 1995
❑Yes ❑No NF.W RFSIDEN'I'IALMECII. SQ.1r T.
CI1 r yr curtINC)
1 have read the Safely
Coe,materiels requirements under Chapter erst of the H C IN
if,Cidhe uil Health&Safety CMe,have.
to cen,de it
andx,rand I ry tohuff that
if the building does not nnerscurrently hove n tenant,that it is my nuance of a e notify the
O
rampantan of @e mtuirements which must be me pdm to issuance of a Certificate of
Occupancy. ,
Owner ormthorized agent Date TO'T'AL: ISSUED BY:
OFFICE