28271 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CTPYOFCUPERTINO BU ILIING-hLN,C"I'RICA I. VURMI'I'NO.
APPLICATION/PERMIT PLUM ISINI:.MECHANICAL, !�O /�
BUILDING DIVISION BUILDING PROJF.C'F IDF.N'TIF'ICA'1'JOS G o G
71
BUILDING ADDRESS: SANITARY NO. APPLICATION SUUBBMMITLAALL DAAR
0VES7*7 A/ TtillyaG `S •
UN("[If LON
OWNERS NAME: RHONE: CONT CTOR'SN 1E: Q U4NO NI
NIC CONTROL LL lvrt� 1,zo
RCIII'rECT/ENGINEER: LIC NO: ADQRESS
)D A), / J� At ���� O
CONTACT: PHONE. QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB M[CI1
PERMIT ISSUANCE ❑ El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
gyp I bcrcbyafimvhat l am liccmeJunderprovisionsofCM1up¢r 9 Rmentencing with HOB DESCRIPTION
WOO Section 7")of Division 3 of the Business and Profession Cole,and my license is in PANELS Z/ — "
~�— full force and efer. s� }y�
Fy� License s I,ic.M �Z—v UP'10200 AMPS
y6d Date ommnor 201-I"AMPS
E— Z ARCIII ECT RATIO SQ.F1'.FLOOR A E/SQ.F1'.
ZO y [and s and m plans,hat be ase as public recur OVER 1000 AMPS
Oz—Q
F y F; SIGNS ELECTRICAL
�Qyy5, la,noxi one[
G ty 6'Q NER-BUILDIHR DECLARATION SPECIAL CIRCULDMISC.
�xx'OaUhere y affirm that 1 am exempt from the Contractors License Law for the
{r)34rEii follow awm(Sttlion 903 L5,Busmesa and Professions Code:Any city or county TEMP.METER OR POLE INST.
C< which requires a permit to construct,alter,improve,demolish,or repair any structure�7 pdono its issuance.also requires the applicant forruchpernot to file a signed statement POWER DIHV ICES
W
D]CQ0 that he is licensed pursuant o the provisions of the Contractor's License law(Clupty SWIMMING POOL IiLECBIC
9(commencing with Section 7000)of Division 3 of the Business and Professions Code) VALUATION
or thin be is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCIIP_S-FI%TURES
F Z 4 Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of
5 a not morcthan livchunJreA Jnllars(b5(X))' NEW RESIDIHNTIALELECIR _SO.FF. STORIES TYPE CONSTRUCTION
ce:!= ❑ I,mowncrofthe prsperty,ormyenrployceswuh wages as theirsolecnmpcnsanmt.
a3o0 willdothework.and the struaum is not intended proffered for sale(Sce.9040.Business
and Professions Code:The Contractor's License Law does not apply to an owner of
progeny who builds or improves thereon,and who does such work himself re through his
employxa,pmvidNthat such impmvemrnrsarenot imm�dcdmof(ered for sale.IL OCC.GROUP RLS.UNITS
however,the building or improvement is sold within one year ofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
t'ale'). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as owner of the pnopeny.are exclusively contracting with licensed comractom to
construct the project(Sec.7014,Business and professions Gmle:)Th ort tar's
License,lawdtesnmapplym aaownerofpropeny who builds= esthereon, PERMIT ISSUANCE
whoatmremsfor such projects with:tcnmmcmrtx)licensed pursuant the ConOacmra
License Law. ALTER-DRAIN&VENT-WATER(THA) FEE SUMMARY
❑ I amexempt under Sec. B P C for this anwn BACK ROW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner a¢ AINS-FLOOR.ROOF,AREA,COND. RECHIPrk
WORKMAN COME USATI?DERATION SCHOOLTAX Y N
40 ❑ Thereby offinn thmlhave acmificme of lf-inwrc,ora cenifi ate of FIX'I RF_S�PF.R TRAPRFCEIPTMWorkeriCompensation firemenceora certifiedf(Sec.3gW,Lab Cich PARK FEE Y N
coven all em In els under this permit. RECEIPT
P Y G -EA SYS .M1 INC. BUILDING DIVISION ItiES
Policy N
Company 5- .S 'TEM1)VER4(G) PLANCIIECK ITE
❑ Ccnified copy is hereby fumisncd.
❑ Ccnified copy is fled with the city inspec. division. ARGSFJI USTRL WASTE INTERCEPTOR GRADING FEE
CERTIMCATEOF EXEMPTION MWOR GREASE RAP SOILS FEE
COMPENSATION INSURA C'
(ITis sectinnnaJ nm be armplemA if the pernir ism
arm n bellurs I(1 SEWE -SANITARY-STORMEA.200FT. ENERGY FEIN
or less.)
I certify that in the performance of the work for which th'pemnitissued.lshall WAHEATER W/VENT/F,LECER
not employ any Person in any manner so as to become s 'cel to the Workers t PAID
Cmmpcasationlawsnf California. Dara WAfER SYSTEN11REAT'ING Date Receipt#
0 z. Applicant
NOTICE TO APPLICAN'I':If.after making this Ccnitiwrt of P,xcm ion.you should NT RESIDENTIALPLMII. SQ.FI'. TOTAL:
EZr-' .�. bee s
comubject ratio,Workers Compemsatloa perwommsof the labrr odes you must
� > mnhwithrnmplywHlhsuchprnvisimnsortlikKmitshallbe deemcdreit. BUILDING FLU
[2] Q SEISMIC FEF.
0.. CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a mmabumien lending agency fonhe perform of
U O TOTAL: ELECTRIC FEE
the work for which this permit is issued(Seo.3099,Civ.C.)
Lender's Name PLUMBING FEB
u"' F Lender's Address QTY. MECHANICAL PERMIT FEE
0 V I eerily that 1 have read this application and stare that the above Infomnation is MECHANICAL,FEE
>" CLd correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
E' 45n� building construction,and hereby:mthorin representatives ofthis city to enter upon the CONSTRUCTION TAX
U z aMve-mentioned Rn ainspection u toes. yy
ALTIiR ORAW'1'O MF,CII.
(we)agree rep harm s the City of Cupertino ag'nst
liabilili ,jadgn navcloon expenses which may i anywayrecarm ainsion 'Pty AIR HANDLING UNIT(TO 10,00(1 CFM)
Hm sen. a cc dthegra n6 d'Nis permit.
AIR HANDLING UNIT(OVER 10,001)CFM)
qDate'ignao .1A :nNContrnctor are
t E%HAUSTHOODOMMUCT) PAID
I HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU)
Receipt p
ill the applicant or future building occupant store or handle harnrdous material HEATING UNIT(OVER IIq.W01i'1'U) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale.SccfiAZ5532m)? VENI'RAT']ON FAN(SINGLE RESID)
PqQx El No
BOILER-COMP(314P OR 100,000 BTU) 4L�SA I UA' I'E
mpp
Will thlicunt nr(mumbuildingeccupam uueyaipmem or devices which emit r
hamrdon,air contaminants us refined by the Itay Arca Air Qmloy Management BOILER-COME(OVER 101,000 B-TU)
District? ,!k-/�
❑Yes rp No NEW RESIDEM'JAL MECII. SQ.FT. JUL 28 1995
1 have read the hawdous materials requirements under Chapter 6.95 of the
califrma caIt,Staf a 533aad255w. I understand that CITY Uh UUrChIIN) a,
dtheb 'IJP the
.cup o thetequne utbsto Ceof
Occa cy. W
-
ro egcm ate TOTAL: ISSUED
r9N]a�v(.CC.
(
OFFICE