28135 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES•USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL
CITY OF CUPERTINO APPLICATIONIPERMIT PLUMBING-MECHANICALPERMIT O. 28135
BUILDINC DIVISIONF"RRRWTjwpAkNg row
BUILDING ADDRESS: SANITARY NO. APPLICAIP SUOMPTAL DATE
QVIC UNIT# LOT
WN FIIONE: CONfRACfOR'9 NAME.•, . 1 NO•
L) Gir7eS CO O #
]f"ECTIIENGIN LIC NO: ADDRESS:, Oc./ei/ �D ❑
OA k I 4A 11
COMPACT: PHONE: =RESIDE"AL
BLDO ELECT N.11M8 M0 ❑ 0 27LICENSED CONTRACTOR'S DEMM11ON,_, Ihertbye111rm IMl l un licensed under provWaln of Chpter9(eanmmctng with /� JOB DESCRIPTION
�.00Section 10001 of Divh Businw am RokwonsC ,elW my license hies #Sic POL4144w, LmllIfull Taw W eRa✓INil P/Sp"�'�)
Calurwla HIT.1000 AMPS ------- mr- tm�
C1.S ARCHITECTS DECLARATION OVER IMAMPS SQ.Pr,FLOOR AREA S/SQ.FT.
r�! 1 understand my pew Asti be used u public mcada.
!all
' SIGNS ELECTRICAL
Y Licensed d Wasslol
K OWNER-BUILDER DECLARATION SPECIAL CIRCUlTfMISC.
O fff... I hacby.Ilhm flan I am eaempl from th Ccoosemra Lim.Lew fa the
3 LLy fdlowing rtuw.(Section 70313,Business eM Professions Code:Any city a county TEMP.MEIRR OR POLE INST.
SIN 5 which Ipubw a permit to occuruc6 Am.Imprvve,dvmll h.a apir any monma
�1T prim m led luuutw.aim"Ulm.themplkull fa such Permit w Rb aJba4 eutement POWER DEVICES
�g Op dad M b licensed possum to dos povi.l.of lbe Comwta'e Liana Law(CMper SWIMMING POOL EI.P.CfRIC
9(catm In$with Salton70W)of Division S of the Business ad Profeselon.Cab) VALUATION
fn a that h buanp thaofron and the bade fa du llegdmemptbn.Any vlolatlmof
Section 7071.3 by ser applicant foe prnNlmbjal lie rpplicsm m s civil penny of OUMITT5.9WIlYTIB9-Fl%TURES
O om mons than Ove hdeed doll. NEWRESIDENTIALELECTR _SQ.Pf. TO
❑ I,uowarofthepa(erty,amyetnploraswlth wgnnthbwbwnpetwtlm,
RIES TYPHEMMUC
will dothe.al,W thuroctme I.notinultleduraOadraule(9ec.7011.BuJneu
Ad Profeadons Cade:Th Con summa's License Law does not apply m an owner of
po{erry who bui lds orlrryuoves thraem,sd dlo duessuch work hlnmif or tbmuSh Ida GROUP RES.UNITS
ownanpbyces,Pcvldd0ul wchlmporars m"inutdedaoRemdra Ws.If. OCC'
ho eves,Use building or Improvement b sold within ane your Wcompletion,five owner- TOTAL:
build"will have the burden of proving dol N did rot build or Improve for purpose of
Ilk.).
PN
❑ I,ummorihpmpmy,ameacl%Wr lymnba"ingwllhlkmwdcmuwwnm '
censboa the project(Sa.7011.Bualau a A Prufmions Cade:)Th Cmnwlar.
Licew LswdmwlspdywuownerofpnperrywimbJldsalmpmvadl ,and PHRMITISSUANCE
whoc imuIhmue faawbpojabwithacanmwmds)IkmWpumanlmdosCmtwctors
Le.. ALTER-DR)UNAV WATER(Efff
❑ I urn eaemp nada Sec. ,17 At P C fa rob rwrl / OUTSIDE FEES
BACK FlAW BVI SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS OOF,AR . ND. SCHOOL TAX Y JURCRIPT# N
I haeby.m.that l have scmin.ma ofeonsent wwlLlnual scadOcue of RECEIFT#
Worken'Comensubn Ins.a a aniBad cop,duese Jf(Sm.7900,Lab C.)which - PARK FPR Y N_
ea all mrWwla.oda rola permll.�C� _/of1Q�a -EA.SY ..G1f1181'9 RECE1�
Policy BUILDING DIVISION FEES
CaPgnI a y OAS A.SYSTEM-0VER e(M) PLSNCRECK FEB
I� Cenifud cap?b haebr hmisAM.
❑ CenlRnd copy is 0ld with du city Inspection division. GREA9ERNDUSTRL WASTE INIERCEPIOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASBIRAP SOILS FEB
COMPENSATION INSURANCE
rlbbactionnwd wt be convicted lfuupamh is In,mehia"dolW Him) SEWER.SANITARY-STORM BA.]00Pr. ENERGY FEB
or bed.)
I molly lhl In the performance of de ooh for which this permit Is lsswd,Isbull WATER HEATER W/VENVELECIR
was employ my pasum In any mouses an u in became subject to the Waken' PAID
z Canpemsionlawsof CJifanis. Data WAITRSYSMWMEA11NO Dam Receipt
Applkant
� 0 NOTICE MAPPLICANT.If•sRamding this CWfkmofBaempm,ywshould! NEW RESIDENTIAL PLMB. SQ.fly. TOTAL:
fA
(hmcohalds comply wilns,ohh pe vCloJmmpselawtlm porblanaf welnba Cale,Yw muse
this penNtdull be deemed makd. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
vz I hrtby dMn than Then N.conaHadon lending afewy for the petformucs of TOTAL: EIXICIRIC FEB
0, dewM fa which Ms peemll Is lowed(9a.R197,Cir.C.)
Cadets Name
0 RUMBING f•EB
u LmvAes Addrtss
I cedfydos I ha rad""sppelwdon and 'a
than"'above wfamaHm b O MECHANICAL FEE
council lyra wwmply with all city and comedy ad..and sate l.w.rtImig to
UmbelPERMITISSUANCE �Q
pry hlMingmuvw0on,Umbesuthmem
or miumeala0vesofthlsclly mer upon sea
7 Jove-mmdowd papmy fa Inspection purpw. ALTP.R OR ADDTO MEOI. CONSTRUCTION TAX
G7 Hite)ogm to ova•Idamlfy,um kap harmless dos City of Npmlw against
HARIIln•Jdgmengcau adeapenas which may lousy way mcmespinst"Oly AIR HANDLING UNIT ITO I0.(Im CFM)
In counts
wrocce of As gun ryof rob w f� p_y AIR HANDLING MIT(OVER 10.000 CFM)
9imt1Tlot Applkan o-sna b/ Uses EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE - HEATING UNIT(TO Im,000 BTU) Data Receipt
Will th sppkant a fumes building oesvWi neon a handle haurdous material HEATING UNIT(OVER 100. �,O7d s Q V TOTAL: �
u de0ad by the Cmar lm Mwlcipd Code.Chapeau 9.17,ad the Ileslth ad Safety
Cab,Section25532(.)? VENTILATION PAN(SINGLE RESID)
❑Yes No
' ISSUANCE DATE
WIII thc.ppllwnta loins WIMlryaavpanl uwequipmentaderiw whlcbemit
BOILER-COMP(711P OR Im,000 BTU)
v .1 old conumtnanIt dennd by the Bay Arta Air Quality Mwgement
EOII.PA-COMP(GVHR IOD,000 BTU)
Di.m"' P•A 1 D
❑Yu No NEW RBSIDHNTIAL MH�I{, SQ.PT. ,
1 ha rtd the huadolla msurid.re"Imorm s oda asps 6.95 of the
CJI(o da I Iwlth dl Sday Code,Section.]5505,75577 sd 21571.I mdmmd that I
MAY 0 1995
If rh hildlN flay nor currwlr hos a octant.dol II b mr rcapaulNliry w wary tle
occupm of the ulamenis which Most bellows Pia
to Iunsnw of s CS+tlOwns of ry
Occupancy. /I //� 5)jJa is V uurtNl My
Owar orsmhon yens •1M..F� ��� am TOTAL :1.00 ISS �L