28348APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILIIING.MECIIRICA ANICA.
BUILDING DIVISION APPLICATION/PERMIT 1'LUMIIINC-MF,CIIANICAI.28348
IIUII.IIING i'EOJECf IIIFIN,rIFICATION
PERMIT NO.
BUILDING ADDRESS:
SANITARYNO.
APPLICATION SUBMITTAL DATE
L 11 f�
1639-7 )vYr, VIIS/ rolF 'plWA1 UNIT# LOT#
$"-2S—Qc—
OW FRS NAME: ('� )yt1— PIIONE:
YCHIS�d i1L.k kv _ 733-99/9
CO RACTOR'S NAMP' LIC NO:
Ikd �i'L�-L (o21-F9u5
N/C
❑
CONTROL
ARCIIITE ('/ENGINEER: IAC NO:
AfiD
/ Sr hy` a/t 1-�ll
CONTACT: PHONE:
QTY. ELECTRIC P13RMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERIOD ISSUANCE
❑ ❑ W ❑
LICENSED CONTRACTOR'S DECLARATION
hfftr
embyam chat I am licensed under provisionsofClupter9 (commencing with
APPLIANCES - RESIDENTIAL
LOB DESCRIPTION1
.PANELS
UP T0200 AMPg
j Section 7000)of Division 3 ofthe Bminessand Professions Code, today, license is in
j full Location effect
l Liccnx Class Liap
I Dam Commcmr
201 - I000AMPS
ARCHITECTS DECLARA9'ION
1 understand my plums shall be used as Public emids.
OVER IBRO AMPS
SQ. IT. FLOOR AREA
S/SQ. FI'.
SIGNS ELECTRICAL
LicensedPro@ssional
SPECIAL. CIRCUIT/MISE.
OWNER -exempt RDIth Concru ON
I hereby ino(Se that 1 am emit from the Co License law for the
TEMP. METER OR POLE (NST.
followwhich ingmasoa
r. 7031.5, Bu slows and cions Code: Any city orcounty
ermit to
which requires n permit m construct, alma improve, h penlish, or repair my atmcmm
ve, de oli h,oar
file.Liclugnd smhaptermenom
prior res
theaisiom,
('OWER DIiVICCS
of Lie Counmiuo
licensed amsomt to the LicanveLaw sionsCpmr
that j 9(comisncing with Section7h)ofDivision the the Business
9 (utmmeis exem it m30)he Division 3 ofthe Business and ism Cade)
SWIMMING POOL ELCCGFUC
VALUATION
tS retro . An,
exemption. Amyvimaion of
j Sethi h7031.5 by mya (remand the basis subjects
Section
collars apennit subjects the applicant toncivil penalty of
y/ � U G
OUTLET'S - SWITCfIFS- PIXTORFS
not than five hundred
j not more than five hundmJ dollen LS500).
prnpetgortn bed
❑ I, aeownmof the t Y P Y b pensotinn,
( 00O
NEW RESIDENTIAL Ii1.P,CTR — SQ. Ff.
STORIES
TYPO GON$TRDCf1GN
willdo the work, the ti or for andei(Sec. 7atn
offeredforsole(pec. 7044. Business
Crabs ho C.n,isnotinrendde
Professions Ctde: Cannmcmr'c License Lew does not apply m an owner of
pri mpr
owns ywho
yees,pdndedthavesthemmovand who does such wmk hirnffmcdfthrough his
fore
employe bs,pmvideimprovent such impmvememsexne evrof
042C. GROUP
RES. UNITS
TOTAL:
omplfared
,tar.
however, the ave the
gurden ofpmmntissoldwithinonsyear ofcompv for
builder oil have the burden of proving that he tliJ not build or improve for purpou of
purpose of
QTY. PLUMBING PERMIT PF.E
ale.).
❑ I, us owner of the property, on exdusivelycnmracting with liccnsedcomructon to
FLOOD ZONE
APN
consumer the project (Sea. 7044, Businas and Professions Code:) The Comment's
License Law does not apply mamownerafpmpert whobuildsor improves therema, and
PERMIT ISSUANCE 2-p u'
who contracts forsuch Projects with awntrautor(s)licensed pu arm to the Conaactors
License Law,
pI TPR-DRAINA VIiNT-WATER PA
L )
FEESUMMARY
❑ 1 um caampt Linder Sec. , H at P C for this msson
BACK FLOW PROTECT. DEVICE
OUTSIDE HIM
Owner Dae
DRAINS - FLOORBOOP, AREA, COND.
. .
SANITARY Y N
RF.0 PI'p
WORKMAN COMPENSATION DECLARATION
❑ (hereby affiLm that have mcenificme of conxm mxlFinxure, oracenificae of
Workery Compensation lnsumnce or a certified copy thereof(Sec. 3800, Lab C.) which
SCHOOLTAX Y N
RF h1PT#
Fl%TURES-PER TRAP
PARK FEE N
GAS - EA. SYSTEM-) INC. 4 OUTLETS
coven all employee's under this permit
Policy#
ECEIPf #
BUILDpit. DIVISION FEES
Company
GAS- EA. SYSTEM-OVFR 0 HLA)
PLANCHFCK FEE
❑ Cenifial copy is hereby famished.
❑ Cenifal copy is filed with We city impaction division.
GREAS[VINDUSTRL WASTE INTERCEPTOR
GRADING IEE
CERTIFICATE 017 EXEMPTION FROM WORKERS'GRGASE
COMPENSATION INSURANCE.
TRAP
SOILS 21i
SEWER -SANITARY -STORM CA 200FT,
ENERGY THE I
(This semitioneedrom becomplem! if Nepenn it isforomhundrMdollan(5100)
m las.)
WATER HEATER WNENT/F.LECIt
I amity that in the performance ofthe work for which this permit is issued, l shall
not employ any person in any manner an es as become subject a the Workers'
Compensation Lmoof Califomia. Date
Applicant
WATER SYSTEMMRGTING
PAID
Dem Rett t#
NOTICHTO APPLICANT: Latermaking@Is Cenflimmof"empniom, you should
become subject to the Workers Compensation provisions of the Labor Code. you must
NEW RESIDENTIAL PLMB. SQ. Pf.
TOT
forthwith comply with such provisions or this permit shall he deemed revoked
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 hereby affirm that here is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL: 07 0,i
ELECTRIC FEE
Undo's Name
Under's Address
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
I certify that I have red this application and state that the above information Lc
correct )agree eromply willid)cityundcnumy.inirmou, and state laws eluting 1.
PERMIT ISSUANCE'
MECHANICAL FFG
buildingcmumattion, and hereby authmire reprexmstives o(this city tomer upm de
obove mentioned Property for impirciam purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(WB) agree in cave, indemnify and keep harmless the City of Cupertino against
habiliries,judgments,cosm and expenses which may in any way Lemueagainst said City
AIR HANDLING UNIT (TO 10,(X111 CFM)
in conseyuence prom granting of this permit.
ALR HANDLING UNIT (OVER 10,000 CFM)
Slimume of Applicint/Contow., Data
MIAUST FLOOD(W/DUC,
� s�����
PAIDML7 (�
HEATING UNIT ('ITL ION") BTU)
HAZARDOUS MATERIALS DISCLOSURE
lT Doom cceipt#
Will the applicant or future building occupant store or handle harardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Code, Section 25532(e)1
El Yes ❑ No
VENTILATION FAN (SINGLE RISID)
as
caut building
Will t6, nBay equipment
BOILER - COMP CHP OR 100,030 BTU)
ISSUANCE DATE
coinum a t, as by the
mrardoDI'mo us yr cmttaminmts nn defined by the Bay Arm Air Quality Management
unlit Management
UiaricIT
❑Yes ❑ No
r.0 rs O
BOILER - COMP(OVER 100,(KK1 BTU)
NEW RIiSID1iNTIA1, MLC11. SQ. IT.
I have Lewd the hazardous materials maptiremenm under Chapter 6.95 of the
California Health & Safety Cade, Sections 25505, 25533 and 25534. 1 mrommul Nat
G 25
if the building does not currently have u tenant, that it is my responsibility to notify the
1995
occupant of the a uiremenm which must be met Friar to issuance of a Cenificam of
Gtmpanay.
r:1 �1r•e�LLIHEHHsI INOO
ISSUED BY: �/ V•s` ISN/s%R"�'C''
Owner Lir emhorittA agent Date
TOTAL:
OFFICE