28106APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRI A
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO. 28106
BUI DING ADDRESS:
SANITARY NO.
APPLICATTONSUBMITTALDATE
M
19 333 OWKWAF UNIT# LOT#
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1i
O ERS NAME: PHONE: ONTRACTORIs NAME: LIC NO:
APJ,PeMCSM 5 o 152175 0
N/C
❑
CONTROL#
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RCHITECT/ENGINEER: LIC NO: ESS: 940 vD.
S. MILFIZA$
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEB
BUILDING PERMIT INFO
BLDG ECT PLUM B MECH
El
JOHN SiIcE PERMIT ISSUANCE
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LICENSED CONTRACT'OR'S DECLARATION APPLIANCES -RESIDENTIAL
Thereby of Division 3 of the Business Professions Code, and mmenense with
Section add efrset. on3of the Business and Professions Code, and my license is in PANELS
bitter.
Liocnse Clasv LIc.N UP T0200 AMPS
Date Contractor 201 - UX 0 AMPS
- j�o�
7
'ICL` 00"
V21
DECLARATION OVER 1000 AMPS
I understand myplans shall be used as public records.
ELECTRICAL
SQ. FT. FLOOR AREA
$/SQ.FT.
Licensed ProfessionalSIGNS
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L ix�
O IY F
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OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 ant exempt from the Contractors License Law for the
followiii, mama. (Section ]031.5, Businesl and Professions Code: Any city or Tema y TEMP. METER OR POLE INST.
Jwhich
MC
W QP'
reyvires a permit to construct, alter, improve, demob r rep 'r any structure
pninwasissuance, nlmregmma the applicant for such mtto file a so nedstatement POWER DEVICES
that he is licensed pumuanno the Provisions of the nuactor's Licen Law (Chapter
9(commencing with Section ]0007 o[Divlslo the Business and Pro amens Cade) SWIMMING POOL ELECTRIC
VALUATION
,y
F Q
or that he is exempt therefrom and the has r the alleged exemption. A yviolationof OUTLETS - SWITCHES - FIXTURES
Section 7031.5 by any applicant for omit subjects theapplicanuo. vil penalty of
not more than five hundred do $500).
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❑ I,asowneronhe rty, ormyemployeeswith wngesaethcirsole ompensatiao, NEW RESIDENTIAL ELECTR SQ. FT.
wmlldethewo the structure is not intendedoroffered for sale ((Site 4,11miness
STORIES
TYPHCONSTRUCPION
and Profits tons Code: The Contractors License Law does not apply t an ..or of
propertyw builds mimprovestherson, and whodoessuch work Almsel onhroughbis
ownumplay s,pmvldedtha[suchmmpro'ranto sarenoti mdedmiffe dforsale.Lf,
OCC.GROUP
RES. UNITS
howovegthe wilding or improvement is sold ithinoa ear f npleti n 11mowner-
builder will It ve the burden of ving that h of ild or improve or purpose of TOTAL:
sale.).
❑ I.asown ren propel y,am I met c[ingwiffi been ontrnctors to QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
construct the roJcc[ ec. ]m
a Profxisims C . Th Can,raoe'e
License Lawd snot lyt ofprepenywhobuilds improve thereon, and PERMIT ISSUANCE
whocontrae[s m me a aeontmem,E)Ikensed uan[tothe Contrnemr'e ALTER (EA)
License law.
FEE SUMMARY
❑ T em axe gladden, c. , B & P C for this reason BACK FLOW PROTECT. DEVICE
DH EES
SANITARY Y N
RECTI#
Owner WORKMAN COMP A N DECLA BION DRAINS - FLOOR, ROOF, AREA, CON I.
❑ Ihereh affirm thatI aveaceni cat femsentroself-in re,oracertificateof FIXTURES -PER TRAP
Worke"C period.nI sooner, ifim copy mereof(Sec. W,Lab CJwhich
SCHOOL TAX N
RECF,1 #
PARK FEE N
ovaosalle loyee'sunderthis GAS-EA.SYSTEM-TINCAOUTLETS
Policy#
IsF#
BUILD DI SIGN FEES
Company GAS -EA. SYSTEM -OVER 4 (EA)
EI Ccrdfi dcopyisher ished.
'❑ Comfif dcopYisf d uhthecmtynx, i or GRRASEINDUSTRL WASTE INTERCEPTOR
PLANCHECK PE O
GRADING IEE
CE CATE OF EX M FRO W i . GREASE TRAP
CO ENS INSUR '
SOILS HE
ENERGY
(Thisse, area d ..the c p di the pet�tiLs for nehundrod Iars($100) SEWER-SANITARY-STORM M. 200FT.
orless.) � ``
Icenify at inthe perfo an fthe wmk Wwhich this peon' tsisseed.lshall WATER HEATER W/VENT/ELECPR
co
not employ a y person in my m es m become suhje to the Workers'
PAID
Oz
.
Comp minnion awsof Califomia. to WATER SYSTEM(OEATING
AIN
to Receipt#
NOTICE AP (CANT: IL after making ificate Exem toZH p i n, you should NEW RESIDENTIAL PLMB. $Q. FT.
TOTAL,:ii
becomesubJem tot orkernCompensonso he LaborCode,yon mos[forthwith comply with s incisions oshe deemed revoked.
BUILDING FEECONSTR
U
U
U
IONGENCY
1herebyaffirmthatthereisam rng ageney far the performance of
the work for which this permit is issuediv. C.) TOTAL:
Lender,
SEISMIC FEE
ELECTRIC F E
Name
Lenders Address QTY. MECHANICAL PERMIT FEE
pLUMBfN FEE
1 certify that 1 have read this application and state that the above information is
'eamet Ingree to comply with all city and county ordinances and state lawarele[ing to PERMIT ISSUANCE
buildmngemstruaion, andhereby autll representatives ofthis city to enter upon the
above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
MECHAsH AL FEE
CONSTRItTIONTAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against _
ImInlid",judgmeausaposts andexpenrswhich may in any way accrecagamst said City AIR HANDLING UNIT HO 10,000 CFM)
in canseon v f this pemtit.
�ntin
O
�� 10 Q� AIR HANDLING UNIT (OVER T0,000 CPM)
Sign a p1riEcnt/Contmctor Date EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BTU)
Date Receipt #
T
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT (OVER Mit" BTU)
as defined by the Cupenmo Municipal Cade. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)]
11 Yes ❑ No VENTILATION PAN (SINGLE RESID)
ISSUA DATE
Will thea licem orfuwre buildin 'taste ui mrdevices which emit BOILER - COMP (3HP OR IW,00) BTU)
pp g q Amen
k"+ qA
'L
by then
hazadaua air contaminants as defined by the pay Area Air Quality Management
District' BOILER- COST(OVER RXIM BTU)
❑Yes 11 No NEW RESIDENTIAL MECH. SQ. FT.
NAY so 199S
I have read he hazardous materials requirements under Chapter 6.95 of the
oily 4N1Y�
Califomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
eche building
if the of due res not meatscurrently hich m tenant, that it r my responsibility ernotify the
e
of Ne requirements which most anme[ tilos m issuance of a Certificate hof
tJ/
Vf✓(,`
Demount,
ISSUED BY:
O sear m inammeed agent Date TOTAL:
OFFICE