28152 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BI111.B SD;NO MECHANICAL
BUILDING
PERMIT NO. ^ ^ ^
APPLICATION/PERMIT PING PROJECT IDENTIFICATION
L C8 FVC L
RUII,DING DI VISI(3N BUILDING 1'RO]F:GI'IIIKNTIE'ICATI(1N
BUILDING ADDRESS: +/� SANI'T'ARY NO. APPLICA'l/]ON SUBMTTI'At.DA'Go
R�� kV A UND 4 LOT#
OSV'ERS NAME; mai PHONE: _ CO n SS NAME: /fO I. NO: N, CONTROL 0
R 1111' CI'/EN INFER: LICNaOV:/ AD{al{�GS. wC'U 4
kwe
CONTACT: PI19y BUILDING PERMITINFO
2lrk)r�(J QTY. ELECTRIC PERMIT FEE B FLE PLUMB MECH
3/8^ PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nyvffum
g I mochynn that l hmmsedN
uerprovisloM nsChapler9(commencingwilM1 JOB DISCRIPI'ION
WOO Stuies7000)of Division 3uf the Business and Professions Code.end my license is in PANELS
WW full force and effect.
U FE.. UP TO 2IXI AMPS
Fyl LiacnacCas T.icp 3Pffg
vlQa Doc Comranor 201-1000 AMPS
RCfI1TECT5 .I.ARA N SQ.FT.FL RARIiA b/SQ.I'I'.
rte% OVER IOfI(IAMPS
Z
oo,t0 1 undenwnd y am shall M see• J n Is.
P W s o SIGNS ELECTRICAL
Q Y od,..I Licensed Pndcueionul
0.C' aQ OWNER-BUILDER DECLARA
.that
SPECIAL CIRCIII'1/MISC,
XCOaU 1 hereby affirm I am exemptCionan
from the ComracmrS License law for the
W�+p•vF-i following reason.(See hat 7031.5.Business and Pmfneims Cade:Any city or county TEMP.M[IER OR POLE INST.
F-Ii�g which requires a purrom mcnn.arud,aher.improve.dnnolisbo,rcpan any tormame
adsYS prior to itsissuance.also requires the applicant forsuch permit to file a signedslammot POWER DFVICES
w
W C GO that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
SWIMMING POOL ELECTRIC VALUATION
wo� 9(commencing with Scmion]IXNB of DIS the tool P AnysoaaCNc)
l_e,� Section
any applicant
the perisfonheasegedpplica ion.AnYviwoodnuf OUTLETS-SWITCHES-FIXTURES
~�Q Section than five hundred
dont for a rs($50rmit subjects the applicant toecivil pewlty of
fSp not m1.cownrofhe ore ny,lar5(yemp. NEW RESIDENT IAL,ELECTR _SQ.FT. STOR ' I TYPE CONSTRUCTION
�Fao ❑ 1.thewrk,andepropuctum isnot
withwagaasthei(Sec.compensation.
a3— will dolhewnrk.ander The Curcrano.'nmicense Lots,
doesed not
apply to an owner
vnJ Professions Code:The Rommaan.License law docs not apply to am owner of
is
townInnotSaY l.,m,wholuldsori,d deo mthcteon,andwM1 staxonuc tendo hi offmalthrough his
employees.Provided that sucM1 improvemenbarennl imm�dedorafferedforsule.If, OCC.CROUP RIS.UNITS
however.the building or improvement is Sold within one yearofcomplelion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of tot
sale.). QTY. PLUMBING PERMIT FEE w ft. APN
❑ I,as ownerofthe property,am exclusively contracting with licensed ador
mtme to
consumer the projmt(Sm.70,1G,Business and Pmllessions CNet)The Contractor's
License Law does not apply lounowner ofpropeny who builds m improvesdareon.and P17RMIT ISSUANCE
wfam,marJcuforsuch projects with a conruarms)licensed pursoanl to the Contractors
License Law. ALTER-DRAIN VENT A'1'IiR(FA) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PRO .DF.VI OUTSIDE FEES
SANITARY Y N
Owner Dam DRAINS-fl. .CON RECEIPI'p
WORKMAN COMPENSATION DECLARATIONftt, SCHOOLTAX Y
❑ Fhembyaflitmthailhavcacrniricamnfconsenttowlf-insum,orvccrtificalcof FIXTURES-PERT REC[IPTM
Waders'Compensation lmuranaaraccnifiedcopy thereof(Sec.3800,WhCJ whiche PARK IEE Y N
covers all employeds under this permit. GAS EA.SYSTEM-1 INC. 'LE 5 DEI-.
Policy# B DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK far+ I
❑ Ccrifiodeepylshcrebyfumishad.
❑ Crnifedcopyisfilcdwilhtheciryin5,ctiondivision. GRF.ASEANDUS'I RL WAS'I IN'IRRCFFI OR GRADING
CERTIFICATE OFEAEMPTION FROM WORKERS' GREASE TRAP SOIL, IT—
COMPENSATION INSURANCE
(This Section need not be completed Brim permit is flame hundred dollars(5100) SEWER-SANITARY-STORM I:A.200FI. bHJR O
or less.)
I certify that in the perforanomeof the work for which this permit i5 issued ishan WATER IIHA'TER W/VENT/F.LECTR oFai
not employ any person in any mmmer so as to become Subject to the Workers PAID
Compenotaonlawsof Califomla. Dam WATER SYSTEM/IREATING Dae R
0 z, Applicant .
z NOficam APPLICANT:If,after making this Cenificam of Exemption.you should NEW RESIDENTIAL PLMB.—SQ FT. TOTAL:
t-"0-' become subject to the Worker's Compensation provisions of the Labor Codeyou must
7 forthwith comply with Such provisions or this permit shall h deemed revoked. BUILDING.ITS
trial 01%
Lt•7 (� CONSTRUCTION LENDING AGENCY SEISMIC FTiE
Z h th
I hereby affirm that them is a construction lending agency for the Performance of
the work for whicis permit is issued(Sec.3097,Civ.C.) 1,: ELECTRIC PEE tri
U G.0r Mcr
Lu 'S Nato PLOMBING FEE
t-' Lenders Address QTY. MECHANICAL PERMIT FEE
0 V I certify that I have rend this application and state that the above infomretion rs
>^ Ck7 correct. l agree to comply with all city and county ordinances and stem luwsrelutingto 1112RMIT ISSUANCE
MECHANICAL hIiIi
F" building mmatruction,and herehyamhorice rtpmseandivesof this citymenter upomhe CONSTRUCfIONTAX
U D) abnvcmentioned props n imposition purposes. LTER OR ADD TO MECH.
(We)agree ar a e Adcounify and kc her au the City of Cugnino.gaunt
liebililia,judgmenl as undsinpcn¢ ch y' anyway in tsaiJ 'ty A IR HANDLING UNIT('1'G.Monist CEM)
in corse a antingot it y^tee ^ '
/iy/� AIR HANDLING UNIT(OVER 10.1X10 CFM)
Si ..,am of ApphruesssUm ractor Date EXHAUST HOOD(W/DUCT)
PAID
I TALARDOUS MATERIALS DISCLOSURE HEATING ON]'1'(10100,000 BTU) Dare Receiplp
Will the applicant or future building occupant shore or handle mordants material 00(1 BTU)
as defined by the Coperino Municipal Code,Chaim,9.12,and theHEATING UNIT(OVER 100,
Health and Safety TOTAL.
Code,Section 2553200? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISRtNCEIDATE
Will theapplicanlorfmurebaildineocculand useaquipment ordevice5 which emit BOILER-COMP(31IPOR 100.00BTU)
andous air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000BTU)
iJUN 15
.nricft 1995
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the barardon5 materials regaircrnnns under Comm,6.95 oLme Vr "t-th I IND
California Health&Safety Code.Sections 35505,25533 and 25534. I understand that - -
if the building items not currently have a moan.that it is my responsibility to notify the
occupant of the requirements which nmst he met prior to issuance of v Comilicale of
Occupancy.
Owner maulhnrisad agent Dam I 1 ISSUED BY:
OFFICE