28092 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BwCT
LDi G-ELERICAL PERMITNOL. 28092
.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAIIUILDI GEC'1'1LIKN'I'IFIGA'I'ION
BUILDING ADDRESS: �/ SANITARYNO. APPLICATION SUBMI ITaALLDDATE
UNIT# IAT#
OW tj:: PHONE: C !�(Tp`— NO:
JJVV11 C/_ NIC LM
COMI�tO
•ARCf1ITECT/ENGINELR: LIC NO: 0360: ❑ 16
I �(� f
CONTACT: PHONE: QTY. EL:CTRIC PERMIT FEE BUILDING PGR 41T INFO
ELECTPLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL BDIiSCRIPI'ION
GCZ Iherehyaffrm that lam licen.acdunderpmvisionx^f Chapter9(commencingwith
la1OL) Section 70N)ol'Divisi^n 3 ofthe Busirediud Professions Code,and my license is in PANELS
Ufull force INAeffect. T1
Qty Z I.icenu Cl.s - Lic.p 12, UPTO200AMPS J
y 6y Dau Carol.or 101-HIM AMPS
SQ.Fr.FLOOR AREA S/SQ.Ff.
ZOv�ARCHITECTS OECLA ATION OVER 1000 AMPS
OZ�W lundemand my plans shall be used es public records. 110 — �
SIGNS ELECTRICAL.
KQ+�Y LicenuAl'rolcssinnnl
y'd' OWNER-BUILDER DEC Al ON
SPECIAL CIRCUIT/MISC.
KOy U I hereby affirm mat 1 ren escmp fru a Cmnmmola License 1.w far the
F�wFi following reason.(Scction lUJl S,f{arid end Professions Cedc:Any city secretary TEMP.METER OR POLE INST.
which requires o permit to commute er,improve,demolish,or repair an structure prionoitsissuance.�lsorequi wpplicamforsachpnniuofilesaigned moment POWERDBVICES
p mat he is licensed pars o the pnrvixions of the Cnmrumnr's License Lnw Chapter
m p�ppi 9(cotmandeingwl( cation 9IX10)nf DivisionJof lbe lluslness and Profemin aCode) SWIMMING POOL ELECTRIC VALIIA'fION
orthatheisese wherefrom and the basis forthe alleged exemption.Any vio lionof
OUTLETS TCHES-FIXTUNIS
SWI
�ZQ Sibrbed7031.. YwY applicant foropermit subj¢ts the applicant loecivil pe olty of 1
AZO not marc the five hundred dollars($SW). NEW RESIDENTIAL 1:T.ECfR _SQ.FT. l•
Ce ❑ Lasu xnfthepropeny,ormy<mployaswimwugessstheirsolecompen ruled, STORIES IYPECO STRUCUON
willdothe rk,mathesmucmreisnot intendedorafferedmrsale(SaJ044,B mass
-
and Prefer otn Code:The Commerce x License Law
not ap m ua aw of
prnpcny cab tbullAsodmpmvn@arc^n,omlwhodcrcs w kh rex far ouhhis
I Jdmas him Ira Le tuff .If, OCC.GROUP ERESNITS
amp cry es,provi a proveboweventbe naldvellucgorimpmc cat' 1 cam oProacc nJh rpbuilderwill vetheburdenof m� ane wild or improvef rya of
ale.).❑ Lasow erofmepro y,t v elusivelyconcoctingwi nsearomramnrsm QfY. PLUMBING PERMIT PEEILOODZONEN
construct the najcet(Sec.4U4 ,B si and yr fwri Code:)The Comruclor's
Lierm,c Law, u, nmrpPly tau , unIpropcnyw ul Ids a,improser maroon,and PERMIT ISSUANCE
whacommec orauchpmjeds oronamba, tcemedpersuxotao the Convocana
License Low. ALTER-DRAIN&VENT-WATER IEA) FEE SUMMARY
❑ 1 am exe pt underSev. ,B&P C for this mason BACK FLOW PROTECT.DEVICE O 'SID •E
SANITARY Y N_
Owner Dae R[CP.II'T#
• co DIiA1N5-FLOOR,ROOF,AREA,COND.
WO NCOMPF.NSATION ECLARATION SCHOOL TAX Y_N
(�[�Ihere�y afimmotlhoveocxdi0emc of sun to eclf-Insuro,ora cam mcof It NCEIPT#
Alexa Comperernon hem..derm.artii copy mercof(Sea.38001,Lab C.) ich FIXTURES-PERTRAP
PARK FEE Y N
rsollcm I ¢c nde,dio IL GAS-EA.SYSTEM-1 INC.4 OUTLETS RFCCIPP#
POlicyp BUILDING DIV NPEP,S
Company CAS-FA.SYSTEM OVER 4(FA) PLANCHECK LEE If
❑ Certified x,Py to hereby fu is J.
❑ Certified copy is filed with th city iaspectidniivlsion GREASE/INDUSTRL WASTE INTERC1iPfOR GRADING FEE
CI?RTH CAT 1:EXEMPTION FRO KERS' EASE TRAP SOILS FEE
C PFNSATION INSU C.
or less�tssectiateeed bec^mpletedifinepetm is onehandred do m )I SI: :R-SANITARY-STORM EA.100FI. ENERGY ITE
Icertify that in cpe, yancen wok rwhichthis pe tsi�ed,l shall W ,R HEATER W/VII/ELECTR
not employ any P o any monde etas n racoma subje t t th'Workers' pglp
,z Compensudon Laws tf Califomlo. Date ATE
SYSTEM/TREATING Date Reccipt#
Applic t
� 0 NOTICE TOAI'PLIC 'I:If,nfmr nmkingthi enificme Fe tion,you should NEW RESIDENTIAL PLMB. SQ.PI'. TOTAL:
F ^ become sobjecno the W ars Compensedon iu^m of m r Code,You must
forthwith comply with sac ro ions.... his probit pe(mit shall be deemed revoked. BUILDING FEE� ,
W
E CONST vtCfION 1,ENDING AGENCY / SEISMIC FEE #
I hereby affirm that there is construction lending agency for the perfonnmc f
UO theworkferwbichthispermit Isis uul(Scw3099,Civ.C.) 7 'TOTAL: ELECTRIC FEE
ty Ieadefs Name
t' / PLUMBING FEE
lender's Address QTY. MECHANICAL PERMIT SEP.
U 1 certify that 1 have read this ity i tion and state that thea tate a info atien ed
romcd.l tocom 1 th all cit J n ordinances end stat law Irvin m PERMIT ISSUANCL MECHANICAL FEE
a agree comply yen iu ry g
U Novengc timnedtioe,and hereby umhnrize toP� ntxtives armor city to to upon the CONS'IRUCTIONTAX
U 7 above-memioneJ properly for inspection putpo'ses. ALTER OR ADO TO MIiCI I.
F7 (We)ugr m s ,Indenmlfy and keep harmlEsa'tbe City of Cupertino against
liabililies,ju rent. cuts andeapcnsea which try many wryaccrueagaint said City AIR HANDLING UNIT(TO 10,"CFM)
in con No ce a ti this permit.
n� �'/ AIR HANDLING UNIT(OVER 10.000 CFM))
igndmrc DattEXHAUST HOOD PAID
HAZARDOUS MATERIALS DISCLOSURE I1HA-I INC,UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle haxardons material
its defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 255JZ(e)?
❑255Yea ❑No VENTILATION FAN(SINGLE RRSID)
I{OILER.COMP(31 IV OR 100,0010 BTU)) ISSUANCE DATE
Will the applicanumasu,building by the ay Areequ.Aent ..Ijt,abiich geomit pp
. Distrdous air conmmitmnts as delined hY the Bay Aren Air Quality Managemen0 BOILER-COMP(OVER IW,O0013TU) PAID
Distrix? [!
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. MAY 6
I have read the hoz rdos m
umermh requirements under Chapter 6.95 mf the 1995
California Heahh&Safety Code,Sections 15505,25533 and 25534. 1 understand that �s y
if the building docs not currently have a tenant,that it is my responsibility at notify the C/�l ur oar ;
occupant of the railm meals which M or m must met prior issuance ofa Certilicute of tk/
Occupancy.
Owner or authorised agent Date TO'T'AL: ISSUED BY:
OFFICE IsdE