28122APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
TRICAL.
CITY OF CUPERTINOtl ICH NG - ELECL.
BUILDING DIVISION APPLICATION/PERMIT PLUADDNG- MECHANICA
BUILDING PROJECT IVENTIF'ICAI ]ON
PERMITIN /� L L
L /N � /N /�
VX
BUILDING ADDRISS:
SANITARY NO.
APPLICATION SUBMDTAL DATE
I c , l
SULSOtV I JR• UNIT# 1_0 J,
$_�� ceS
OWNHRS N�AM`I-3/. A I'll<)N
\17rL11
CONTRACI'OR:S NAME L_ LIC NO:
-.ate• so3ft8B
NIC
CONTROL#
ARCIIITI:CT((iNGI +ER: LIC NO:
5L'..wa�
S2/ rs M,
�k.•// ,U
CONTACT: � 1 PHONE:
'W
PAUL- p6LTI_QS 3 71�//O OO
I
�•
QfY. ELECI'RIC PERMI'I' FEE
BUILDING PERMIT I NT°O
BLDG ELECT PLUMB MCC11
BLDG
PERMI'PISSUANCE 3--2,QOIli
of la IG
'S DECLARAION
LICENSED CONTRACTORT
I hereby affirm that l and licensed underpmvisionsof Chapters)(commeneingwith
Sedien 7000)of Division Sof the Business and Professions Code. it my license is in
APPLIANCES - RESIDENTIAL
PANELS
JOB DESCRIPTTIIOIIN
D�'6 vl CI'xv G`
full fume and effect '
License Class •J Lic# 3�8
UP TO 200 AMPS
_
Date CommalD $dt�E.S
ARCHITECTS DECLARATION
„�4nJentnnd my plans shall he too]as public reviews.
201 AMPS
SQ, 1-1. FLOOR AREA
3/SQ. In'.
10
OVER IOm AMPS
OVER
SIGNS ELECTRICAL
i�
nxcA
OWNER -BUILDER C
SPECIAL CIRCUIT/MISE.
fee. Contractor's
I hereby affirm thm I on cxempt from the GOadmen o License Ltw for the
TEMP. MLTGR OR POLE INST.
following motion, (Section 7031.5, Businesxmit Coot: Any cirymrnnety
permit provefdormli smucture
which rcyuires demolish, nr repair n
which crnamn, alter, im
prior Ins issuance re foro d
tpruisions nftheCotricio In a s La ffihapter
POWER DEVICES
-
lcensd potter to to th Licele
9 (commencing he is cnw th Sewn Ir Inc provisions of the Commcto xs License Law (Chapter
7000) of Busom.pnd Professions Crile)
SWIMMING POOL ELECTRIC
VALUATION
mflisxemit
basisianJofthe
Snout he is exempt lhcrefmm and the basis(onheellcged exemption Any 'mounted
red nom loan umodrodicoll hatupermilwbjecnthe applicnm loacivillwnahy of
nm mmcdunrofthe Jre y,ormyem).
oithwed f...le Svo.04,t.Bsmvex
❑ Lasowne.ituddpmpeny,ors am intended to
will do the work, node:
OQ
COe�o
OUTLETS - SWITCHES - FIXTURES �Q
/r
NEWRfSIDENTIALELECTI _SQ. IT.
STORIES
TYRE CONSTRUCTION
no Contrac or'sLi ease Low does not apply to an owner of
progeny whobuilds nr improJes thereon, and who dtw...chwnrkhooselforthroul, his
own umploycee, provided B utsuch improvements are not Intended arofferrd forsale. IL
OCC.GROUY
RES. UNITS
however, the building or improvement is sold within one yei iofcompletion, the owner -TOTAL:
builder will have the burden of pmuing that he did not build or improve for,dopa. of
QTY. PLU NG YERMF1
'sale')'
EII, rs owner of t he progeny, am exclusively contracting wish licensed contract ors to
FLOOD ZONE
APN
tmslma the profit,(Sec. 9044, Business and Professions Cmde:) The Coulowtods
License Law does not apply to an owner of progeny who builds or impervesdhereon,and
PERMI"I:1 SUANCB 3 1O0
who ommcts fnrsuch projects with a commetrgs) Itcemedpumoulamthe Crumnames se Law.
License
ALTER-ORAL VENT- KIi'
FEE SUMMARY
❑l am exempt under Sec. R& P C for this or
BACK FLOW PRO[ E DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT#
Owner Date
DRAINS- FLOOR, ROOF, ARACOND. J
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Ihcreny affimnhatlhavee certificate nfnnsemmselGinsurc, �racmificate of
Wn kits'Comprrmdon Immancenrn reorlificui hereof(See. 3g, Lab C.)wbich
covers all employees under this permit
Policy X
RECEIPT4
�-y a•$� S
FIXTUR13S-PER T/S RAP �C
PARK HE Y N
RECEIPT p
GAS - EA. SYSTEM.I INC. 4 OUTLETS
BUILDING DIVISION FF: fS
GAS - EA. SYSTEM -OVER 4GA)
PIANCHECK FEE
�_
mMified to, is hereby frout,hund.
GREASI%INDUS IRI. WASTE IN'IIRCEFDOR
GRADING HE
❑ Ccnifted copy iv filed with the city inspection division. '
CIBU IFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM HA. 210FT.
ENERGY HE
(Thiesenlooneed not be completed iftbe permit is forone hundred dollars ($100)
doIt,,.)
WATER HEATER W/VENT/ELECTR
Icenify that in the performance of the work for which thin permit is issueA, Ishan
not employ any person in any manner so as to become subjcot to the Workers'
PAID
WATER SYSTEMO REAPING
Compensmionlawsof Califomia. Date
Dam Receipt#
Applicant
NO'T'ICE TO APPLICANT: IL after making this Cerlifcale of Exemption, you should
NEW RIISIDENTIAI-PLMB. SQ. I'T.
TO'1'AI,:
become subject to the Wmio,es Compenmtino provisions of the Labor Code, you must
r this on sha116e descried revoked
comply with such provision ope
forthwith/
BUILDING HE b Q
SHISMIC FEF
CONSTRUCTION LENDING AGENCY
1 herebyaffirm Thal there's,, construction lendingagency for the giffornnar eof
the work for which this,¢ p is issued (Sec. 3097, Civ. C.)
TOTAL:
fiLliCfRIC ME
Lender's Name �O
QTY. MECHANICAL PI7RMIT FEE
PLUMBING PER
Lenders Address
1 citify that I have read this application and stated t tha above information is
correct. lagrec tat cnntply wiN nil city and county nrJinunces trod state lawn relntingm
PERMIT ISSUANCE
MECHANICAL FEE
builmogconstmetion. and hereby amhoriu representatives mihis city to enter monodic
above mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agmen save, indemnify and keep harmless the City of Cupenino against
tencv, cauls anA cxpemeswhich may many way accrue ngmnxt sold City
AIRIIANDLING UNIT(TO 0,00ICPM)
00
amsequencer - ollnm n,Z,pemml
AIR HANDLING UNIT (OVER 10,000 CFM)
�A l
EXHAUSTIIOOD (Wfl)UCT)
J'' pp�� 7
PAID 7`3-'/S j�L
ice•-
Signature of Applicant) ntrzn J )utc
BEAT ING UMr('I'O I00,0100 B' I' U)
HAZARDOUS MATERIALS DISCLOSURE -
Dale Recelpl#
Will the applicant or future building occupant store or handle haraidom material
as defined by the Cupertino Mi nicipul Code, Ch0pter 9.12, and the Health and Safety
Co da• Stowe 25532(0),/
❑ Ycs �ky
HEATING UNIT (OVER 100,11(10 BITI)
TOTAL: 3i•LX3
VENTILATION PAN (SINGER RUSID)
9 Q
ISSUANCE DATE
Willlhe opplicam or fmure M1vilJingoccupanluuequipmcmnrdeviaswhichemit
humrdous air cmumpinana as defined by the Bay Area Air Quality Management
Disiio? ///���
ElYcs ' ]p Nn
I have read the hamrdous materials myaimeri under Chapter 6.95 of the
BOILER-COMP(3HPOR Im.01JOB'TU)
MAY 2 31995
Cl I Y Ur curt
BOILER - COMP (OVER Im,mO BTU)
NEW RESIDENTIAL. MECH. SQ, 11I'.
y Code, Sections 25505, 25533 and 25534.' l understand that
California Hodih & Safelof
-
he
m s bi the
, laponl
turbine ... currently havealenanl, tint it is my mmince
4re"i
e'Cmlfitify
. r N<mquire ich must be mm r of. "tifiefy
37 ciparty
ISSUED BY,Toe /-���•�/�V�•
Owner ora m<d agent- ��� Dam
TOTAL:
OFFICE