28059 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R A PERMIT N°.
APPLICATION/PERMIT PING PROD CT IDENTICAL 28059
BUILDING DIVISION BUILUINf.PROJECT IDENTIFICATION
BUILDING ADDRESS C AVE SANITARY NO, APPIUCATIONSUBMrITALDATE
1 x UNLF* LOTH
OWNERS NAME,: PHONE. NTRACTOft'SN P: LICNO:
0� 1 N/C CO
•ARCFIITECT/FNGINEER: LIC NO: ARESS: C T ❑
D M a e
COM'ACT: PHONE_ QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
O —/V DG 11��11 FF�� PLUMB MfiCll
160
PERMIT ISSUANCE ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
WOO Ih71)(0) Uirmthml mtufthe BusinJvpnviuBbazions Coda,ananrtieting with
FOO Session by of Division J.ftk BaUrcn Profeof(:Codc..rldmylE¢ Swan PANELS
W
full force aIJ eff cl 12
<ZE Liccttu Lic.M UP TO 300 AMPS
3 3Z
va<y Doc
Con'
301-1000 AMPS
Gpvoni6 ARCIIITF,CI'S DECIARATI OVER IPp AMPS SQ,17.FLOOR AREA SISQ.FT.
C
Z_p I tnderxtand mY fdans.dull be lase!as public rm ols.
F W SIGNS ELECTRICAL
F n_
5 Liunscd Profasi.vl
OWNER-BUILDER DL ra,Coo ION SPECIAL CIRCl11T/MISC.
xdx0yIFV-. 1 ng Mo o.icurn(Se as I ran eaemp r an Etc conlnnor.Cods,Any Isw ren Ile
W3[iy follnwiecut.. (Sccrinn]0315,Busnxrot rews,asimvoAnycity mcnnnty TIiMP.MIiIER(M POLEINST.
fin' JM which rtquitesap,also town s t e alkr.improve,h mbitM1,IXrepurany
oamee
fe�<O le he iuisxcarxe.e =ituimthe.isii for nNt Lio, sorted Low(Clmmt POWER DF.VICYS
y�jK�p Elul he ie licensed Wnualt to the phovixrom of the Contractor's Litxtau law(Cllopla
adxo 9(commctuing wlUlSmion](p0)ofDviuon3afthc Buutl¢s end Pmfeuions Cade)
SWIMMING POOL ELECTRIC VALUATION
W^m or that be u exempt theneftom and the bast for E,alleged exemption.Any violation of
t Zea Q Sinto 7031.5 EY tiny nppliunt for. —it subjwu ul.pplicannoa civil petulty of OUTLETS-SWITCHES-Il%TURRS
Mtrot nrort dun ur
five hdead"I. NEW RESIDFNDAL FIF.CIR _SQ.FT.
❑ I.aowtcr Mtfepapmy,mmyemPloycewilh waguathcirsolccompwadm, STORIES TYPE NSTRUCI]ON
will Jn the wnrk.lhrd tw structure iv nut inlenJW,orfetcdmrsale(Sm.)014.Basircs,
and!Profession.code:The Cmtactor'.License law dao rot apply t.an owner N
popery ww Wilds mimpova thcrmn,atdwwd.a sorb work M1imselfmthmugM1 his ROUP RES.UNIIS
own employ,nor'xlW Jul such impmvetrsnuartmt imemle!moffaed(oracle.If,
M1owevm,the wildingm wporvaa u.dd within.ru yea of romplaian,hhe owner- TOTAL
wiener wJ1 nave tIz burden or paving lnm h<aia Trot wila m Improxe rtr pmpa ar
-).
❑ I.as.wnaofNepr.piney,amexciu.vdyemtractinywithlia cmtractmto TY, PLUMBING PERMIT FEE DZONE APN
construct the pmjM(Sm.J(xLt,Bioonma and Rofeodorn Cafe:)This,CantrxtNa
License Law drcs M apply to an mw r,ropinyww wilds.improve,therein,aM PERMIT ISSUANCE
whocnoti for such"jams with a rono-acbAs)IiceauM pennon,to tha CamesT
Licaue law. ALTER-DRAIN A VENT-WATER(EA) FEE SUMMARY
❑ I nm exemptunder Sec. ,B A P C for thu ration BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Ownm DateDRAWS-FLOOR.R 17, OND. RECEITTM
M
WORKAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IM1cxcby vffirtn thalNvicernLBcate o(can.aubaelf-itewc,maaniflase of ITXTURES-PER P RECEIPTN
WorlmwCwnprnaliun lostonce m s cmil c"'thcnnf(Sa.3800,Loh C)which PARK FEE Y N
uhvctx all cmdoYa's under this pcmit. G - Y -I INCA RECEIPTN
Polity♦ BUILDING DIVISION hFFS
Company SYSTI:�>jIR PLANCHECK FEE
❑ Cbnificd copy is hereby fumisM1ul.
❑ Cmifiedcopyisfilcd Oi ecityhupmiandivium GR NDUML WASTE INIT:RCEPTOR GRADING FEF:
CERTIFICATE,OF EXEMPTION FROM WORKERS' GREASE MAP SOILS FEE
COMPENSATION INSURANCE
(This taction need not w annplUcal ifthc permit is for one hundred dolluns($11N)) SEWER-SANITARY-STORM EA.30NT. ENERGY It
ce lea.)
I earlfy Jut to the perfamunccof doe walk fm which thispttmit i.i.rvM,I aM1>tl WATER HFATER W/VENGDEI.ECTR
runt employ Troy perrvm in any.,,at sen bttx as b ron subject to IIx Nm
Wee ' PAID
Caaoperlaodoulaa.of California Data WATER SYSTFl.1/fRFATING Dae Realp0
Oz AWlical,
O NOTICE TO APPLICANT:If.after Toting this CrdGaue of fuemptimn,you should NEW RESIDENTIAL PLMB. SQ.M. 'TOTAL:
beerne.ublect to the Worker's Cont'rowml ftwoorawf We Lobos Code.You mm,
forthwith mmlgY with etch poviaioru m thio pe.mlt shall be,Aarcd rcokcd BUILDING FEE
a D CONSTRUCTION LENDING AGENCY SEISMIC FTE
Uz IhertloY.M.the there it.ao.im Xmding.grncy forth,pafammnc of 'TOTAL: ELECTRIC IEE
O the work for which this pc mit i, oua1(See IPJ].Civ.CJ
I.cocer'.Name
0 F Lmcm.Addrea QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I eenify lha I have tend this applicvlion and ay.Far the all iahwrrwion is
cored l agrtc b canply with dairy anal a..y ortinaxre aM ave laws telco,to PERMIT ISSUANCE MECHANICAL FEE
F" ,, wilding arlarvnim,and hot nthoriae repreearlsoN..fthia city,.bomstpm the CONSIEUCfION'TA%
U Z .bovcmcnti tied p.gcny for rl',m ion purposcc ALTER OR ADD TO MECE I.
(We)agrte b vvc iMnahify avl k M1amJess the City of Cupmn.againv
liabilida,jldgmenu,cmu ad ex whi yin any wayaccmca waaid Citad R HANDLING UNIT(TO 10,000 CFM)
ore of tFl granling�ag permit.
t wn AIR HANDLING UNIT(OVFA I0,t100 CFM)
Signature of Ap aaVCmtractr me MIAUSIIIO0D(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,010 BTU) Dae RmaFa
Will the the,Cupertino
tiro ture Munwilding hhccuper,Asa or handle hDeal a rhwmial
a de,Sm r Z'Ctrpeniro Mwicyaal CMe,Chapter 9.13,ud tk Ileahh ud Safety HEATING UNIT(OVER 100,000 BTU) OT 1
Code,Section 3.55J2(a)]
❑Yes El No VENTILATION FAN(SINGLE RCSID)
Will The alglicult a.futurtbuilding rccupantuse mrdevicewhichemit BOILER-COMP(3HPOR IOO,OW BTU)
azallou.airISSUANCE DA
ryern
" Tf
M1cmitu
tamnts a oL:fincd hY the Boy Arto Ab Quality Mahsagenxm BOILER-COMP LOVER 100,000 BTU) ^ � ' D
Y 1�
11Ya ❑No NEW RESIDENTIAL MSCI L. SQ'FT.
I have Head the ha.adou.maaials requiremrnu coca Oha ap6.95 of tk MAY 1819
Cdihnnin Health A Safety Cade,Seminnx 35505,25533 Troc 25534. 1 utdcvanl lh.t r
if the building ba n el cureraly love a W.,clout it is my te.,,nr,d lWy b mGfy the .
occvpalt of that rryuirttratnuhi
wch mint be,inn prior b iatutta of.Cmir to.f c^/�
-
Ovcapancy.
Ow.cr or aulhoriaN agent Dae TOTAL: ISSUED BY:
OFFICE