28200 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-LIR- RICAI. PERMIT NO. /� O n O O
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION RUILDISG PROJECT IDENTIFICATION L o G
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
/ UNIT# IAT#
OWNW NA :, p110NE ON17!5TMR'S NAME% L O:
[J^ 7 WL CONT LY
RC11 lliCl'/FNGI I: LIC NO: D ❑
CONTACT: PHONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BL ELECT PLUMB MECH
PERMITISSUANCE S
UCINS ED CONTRACTOR'SDI;CIA RATION APPLIANCES-RFSIIIFNTIAL
M C 7 1 hereby.ITnn that l am licenced uaderptvvlsiom MCltelasr9(comnenirtt with JOB DESCRIPTION
t WE full ho eoldCflOvisimrJMlhc flu.lrcss.ad Pofmainm Cdc.mJ my llcemeia in I'ANF.IS �����
FK� f Iiom7"cRccl.
FZw License Clms Lie.# UP TO 200 AMPS
o,<- Date Coaittum« 201-this)AMPS
ZOOLyO IuMmtand myon sshWlibe usdgu publARi cordsN OVER I000AMPS
SQ.IT.FLOOR ARFi1 $/SQ.Ff.
a to t l SIGNS ELECTRICAL
rL 7� LiccnsN Pmfevi.I
'es6 OWNER-BUILDM DECLARATION SPECIAL CIRCUIT/MISC.
°JOaF I hereby affirm that I CIN eeempt fr«n the Corr tats U.U.for the
LLOs� following re.wn.(Smcion 1031 S.Business and Profesbm Code:Any city m county TEMP.METER OR POLE INST.
rn I which requires a permit m cmvlmcl,aper,improve,Jetrtaluh,or m,air any structure5�}2 (prior to its l•„-oc•,aleo aryuires da,applicam for such permit to file a signed statement POWER DEVICES
t S:,Zo0 that M md is licepurmml to the provisions oftle Conlnctor's License Law(LTnNer
d X.E' 9(mmmencing w Se,tion7”)of Division 3 Mtltc Bmnu.said Profession Cade) SWIMMING POOL ELECTRIC VALUATION
ty_•o, cetees he is cxcmpt therefrom and the Weis for the alleged exemption.Any violation of OCILGfS-SWITCIIES-FIXIVRPS
LKQ Smion 7031.5 by any applicant f«a ,,rail subj"me applicant w u civil vmortyM
oaI more itw fere hundred dalbu.lS500). If
NEW RESIDENTIAL Ea.ECIR _SQ.FT.
� � ❑ Lmown ,"me conalty,«mycmpinyiedoro wed for sale
744.Busineon,ss STORIES Pfi CONSTRUCTION
a3— will Jolhew«k,Coulee he,coure Is not Cantuesn's LMde Lawmlfmoapply to an.Business
arta Profusions Code:The,Cothe., aid vOm Ioew ouch oat apply to w oarcr of
pmpeny wM1n builrl or impmvcx thereon,ud wMndm steh wort hitmclf«tlwugM1 hie
ownemploYea.pnvidd that sucM1impsmilwtaionve iverdd«offereifwowneIf.r- C.GROUP RFS,UNITS
MlclibwillhavlheImimpmvemcotiscathwithinocycC ofIm"vei«,the aw of
W il4r will have the bunlcn of Ipruvint Nm he Jid not build«Improve for purpmc.of �—
k.l.
❑ I,mo a po jet(Sac. Business
h c )Th Court dot's QTY PLUMBING PERMIT' FEE R(xeD E APN
equWcl IW pmject(Sec.]034.Bwinaa and Pmfusiom Cotle:l The Conmetor'.
Licenulaw Mcsrmhfirojmtwowrcorma,mcnYonto Wilds«improves thereon,and PERMIT ISSUANCE
Lkramcew.f«oatenpmkctsoraeacuiwctm(s)hcrnsdwnuwtmOC Cunlraclar'. ALTER-DRAIN&VFM-WATER(EA) FEE SUMMARY
❑ 1 em exempt tmM Sec ,B&P C far miss rerun BACK FLOW PROTECT.DEVICE
OUTS.115E MS�_
SANITARY T N
syvrmu Dire RI;CR:IP1'R
WORKMAN COMPIdvSAlION DECLARATION DRAINS-Fl,OOR.RODI.ARW,COND.
❑ f
SC100LTA% Y ,
N
W«lm'Conmpmlion ttpyWrrof(Stt.3800.lmC.)which FlXTURFS-PRTRAP, RECFIPTN
PARK IaiE Y N
n ell employee's uaouer this premit. GAS„EA.SYSTEM-1 INC.4 OUTLETS RFLEIPI'N
PMkyM - r. BUILDING DIVISION
Company `c GAS-EA.SYS V� OVER 4IRA) RANCIIF.CK FFR
❑ Coifd copy is hereby furadrlted. ors.
❑ Cmifideo isfldwiththechyinspectbndivisicm. ,.,d'a'l GRIiASMNDUSTRL WASTE.,INTERCEPTOR GRADING FFt
Cl'RTJRCATE Oil EXFI.1PTION FROM WORKMS''' ,+ GRP�SIiTRAP\�� '
COMPI?NSAl1(IN INSURANCL I Tia SOILS ETF,
«lus(Tua secti�nn trd he camplctd if the pvntitlsfmorrhuNrcd dollCa I I ('SBWER-S -STORM EA.20() FNFRGY FEE
1.
m empbyemlY ytpvsortn Hy cef ukio deofine�wK41^ oW T EATFR'WNFM/EL[CTR PAID
Cmnprmsun lows of.lams. Dote `�l �91R SYSILM/IRfATWG Ihm RseiptN
Oz pFlq K-ya '•' A _
Z
NOTICE TO APPLICANT:If.after meting tbia CcmficaoafIxe ,youshoold vv- NEW RESIDENTIAL I"B, SQ.FT. TOTAL'
fn becomesubjcvt to the Wm1l,,'.Contlten.fion povinara the labor Code'' m11J1'
fonhwith comply with such provision or thio pemot shall be de,med mvakadV BUILDING FEL
Ow. O CONSTRUCTIONLENDINGAGPNCYSUSMIC FU= z Ihereby affmm tWttheae is.conttmeti.lending agalcy for theperfommeenf'
U Q the wok fur which thla permit i. (Sc,.i.u'ud309].Civ.C.)s� �r•I r., TOTAL ELECIRICFEE �
I<Wcr's Name r�
F I< Nmmo
s AQTY. MECHANICAL PERMIT FEE PLUMBING Fla;
0 CJ wI¢rtify Etat I have tend Nl..'licr uien mW awe tont the above ulformatim is
mntcl.lagmc to comply wile all dY had cvuvy«dm.rcuand sore law relating to PERMITISSUANCE MECHANICAL FEE
building canelmcti«,ard hereby wtM1orirs rt,m,acn stivm of this city to enter upon the
U z above meitiostd propeny Baru tion purpose, ALTFRORADDTOMECTi. CONSTRUCDONTAX
(we) m save,i fy ad Ime,harmless me,City of Cu,Mira against
liabititi 'ren". penms whiehnmy In my way same agdrol vid City AIR HANDLING UNTT CFO IO.OW CFM)
maoflhe an, ftimparrem.
AIK I IANDLING UNIT(OVER 10,000 CFAD
num ofpylic m Nat EXIIAUSfHOODOYMUC[j
PAID
IIAZSRDOUS MATI:RIAIS DISCLOSURE IiGTING UNIT IT 100,000 BTU) Date Receipt X
Will[he aWlicml or future building«cupam store m Handle bvnrdoci unvocid
as BEATING UNIT(OVER 100,00)BTU) TOTAL_
defined by Oe Culanioo Mwicipsole
l C ,Chapter 9.D.had tie Hullh and Safety
Code,Secdo 23512(e)?
❑Yes 11 No VEM'ILATION FAN(SINGLE RFSID)
Will henppticwt«fulurtboildingoccupant u.ceyuipmertvrdevicecwhichnrdt BOIhI]i-COMP(JHP ON IW,Igs) SUV�pCE DATE BTU) 1J'
e M1 us sir ctairwls es defined mded hY the /Bey nu QaaBManaManagementM .gcmt
useric mBOILER-COMP(OVER im,orsh BTU)
❑Yes ❑No NEW RESIDENTAL MECH. SQ,FT. JUN w 0 1995
1 Wve read the Wcriol a materials rtyuimncnl under Chapter 6.95 of IM1c
Coliform.Health&Wetly Cal,Sections 25505,25533 and 25574. 1 uMemmud Oct CITY U� UWIEH ONO
if Nc bullring does nor cvmmly love a Rrant,tees it is my revpmaibRily to esti"Oe
u«upenl of the rtyuirnrcnty which mtw W mel prim m iaaunara of s Cenifue of
Owner or•°O'°^'1°tent Dme TOTAL:j ISSUED BY: Vlr—yYsyR�TI
OFFICE
Liu Ow 'z.VG
l�ErkD 5�`
.7 6v
STEL
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0
l..��r�tb Sd�s� �/ t(�bv6ElLs PG�y� - OSSG.
L(o 3a ,G B1p
As FL9
No P1,01
5'r� -f/zrMn E
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2X6 DDuBC�n �/�N �/�fe5
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• p \NSPEC�C PER�p���
p\A '
800-644-7410
Signature Roofing, Inc. 408 524-8640
"Your Home Roofing Specialist" Fax 408 245-87O`
•
1190 Mira Loma Way Suite V Sunnyvale CA, .94086 Lic. C601463