28223APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECHUCAL
APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING DIVISION BUILDING PROMO IDENTIFICATION
PERMITNO. 28223
BUILDING ADDRESS: �j(�/� //
91S/V / �(/ UNIT# LOT#
SANITARY NO.
APPIJCATTONSUBMITALDATE
�COYN'IRIOLX
1of $ nie �� PFIONE
CO ACTOR'S NAME; ' lQ / IJCN
/rVl�/e/V
NIC
❑
el Vy /fvG1t�UBR: �� /� LIC NO:
J�
ADURI�A/��l"/�Jl
Y. / ( ��, �'�
CONTACT: PHONE:
/f
''�'�iOG1 /S -<ISG -f'696
7
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG 11LPj�1' )MB MO
El (/LTJ`
PFRMH'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm tmt I am licmrad under ptovixioru of Cluper 9 (cmmmrmmg with
&don]Iknof DlvlvionJMlM1e Busimssam Rnrwiam Cmc,am my licence in in
full face am ffm.
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANUS
Li¢nx Clw tic.#
UP T03(p AMPS
Date Contracts
]Ell - III(10 AMPS
ARCIIfRCI'1 DECLARATION
I urdmum my Plans Nall be 1 as Public nernny.
OVER Iqp AMPS
SQ. FT. II.O(Ri AREA
uSQ. IT.
SIGNS ELECTRICAL
hianvd Pmfcaaiimd
OWNERBUILDER DECLARATION
IZ—SPECIAL CDiCU1T/MISC.
lam eam" die CRATEON
1 hereby affirm tut 1 M eaesp Econ the Cmtnalmis law fimdo the
TEMP. METER OR POLE INSI'.
ain, e: A.,
Cmc: Any city mammy
following mason. (Scolio. ]0loloi Pc.
lam
1, de cl
which ni. a permit to CnnatN[I, Wteq Impnrvm, demur ah, or repair nny st.I
PrnNtto fileas La wtemenl
priaeits
theepplons
POWER DEVICES
liocm palsountto
Thutrunceacmith ScOit 7Nepvvidas Of the Comnxreia am!e law(Chapel
Obi
9(commerc xcioN
OIIOIoe Division Sof the Buslrauand.Anyi
SWIMMING POOL ELECTRIC
VALUATION
ICode)
1frcrm
m Not he is exemp Ibcmfrom and t� huts for the elleeW exemption. Any violatiou of
Section]031.5bya.yeppliamfmapermitusbjem Ne vppl4antmacivil pesWlyo
OUTLETS-SWITCIIFS-fIXTURIS
nes more than Eve hundrW dullans(SSM).
❑ I.u.nwnendthepmpcny,urmyempuymwwilhwegemthcirmlccmmp ation,
NEWRESIDENTIAL EI.T:CTR _SQ. FT.
STORIES
TYPE CONSTRUCDON
will do the xvrk, end Ile awcturc it rot intended m offered fa axle (Sec. 7044. Busing
" Profeasiae Cale: The Caureclans Lice se Law does not apply to an owner M
popery who builds or impmvc thereon, told who does such work himself m through his
wncmpluyw,providW Nut suchimpmvcmcnm are notinunddaoffmWfaadc If.
OCC. CROUP
PES, UNITS
however.IhebuildingoeimMve tlaoldwiiNnorey ofcmnpleritn,theowner-
bdldm willhave the burden of Mo inp thm fa did n bdld err improve fmr purpme of
QTY. PLUMBING PERMIT' FEE
'Ie.).
❑ I,mnwnmofthcpq¢ny.m.cxdmivdy contmcung wlihll loud curvectmsln
FLOOD ZONE
AM
canu.et Ne Project (Sec. 7044. Btuireu and Profeaiau Coal The Camnanmix
LiaiseLawdoea nm apply to..rofpmperry who builds no improves thctcmn, want]
PERMIT ISSUANCE
'wmcontmcu(msmhpojcctxwiNecamrixlor(s)IicrrtwdpursuonuutM1cCmOoclNs
License law.
ALTER- GRAIN &VENT'- WATER U( )
FEE SUMMARY
❑ I am eaemp wdcr Sec. B & P C fa Nis trason
BACK FLOW PROTECT. DEVICE
O
SANITARY Y N
RF.CEIPI'#
'Owrcr Uure
WORKMAICOM1"IdSATIONDSMARATION
❑ Ihneby xlfnm Nu lhaveamlifiweof casein to<If-i...e.aaaxnificadem'
Worker:Canprn®tion Inummeaa«nifim cnpythrof(,S , T, C.) which
erec. 3800at
DRAINS- FLOOR,ROOF,AREA,COND.
SCHOOL TAX Y N
RECEIPT#
FlXTURES-PER TRAP it��
PARK It Y N
co'cra all cams. 'si dm this pcnNl.
Policy ♦
GAS -I?A. SY NC.40l1ll�IS
GAS -F Y. VER4 PA)
RECEII'I'M
BUB_DING DIVISION FEES
Conraloy
PLANCHECK FEE
❑ Cmi6ad copy is bcrehy Tumishccl.
GR4p.1iR5irDUSTRL WC OR
Of e�e
GRADING FEE
❑ Cmifncd copy is filed with l city impectio. division.
CERTIFlCATF..OF EXP.MP ION FROM WORKERS
COMPENSATION INSURANCE
GREWAP
SOILS FEE
S - A-STORMEA.3WF1'.
ENERGY FEE
Thin section aceto tbecompetNiftMpenmt oformehmdred ddlm (SIM)
or a)
WATER 11GTER W/VEM'/FJ.ECTR
I cmify thin i n tie plrfmm c of the work fm which this Pemot is issued, Islmll
not empWy soy penin. in any manure v to becarc subject to tic WmId, i
PAID
Campewtimn laws of Glifania Dule
WATIM SYSISJ EATING
Due Rmeipr#
Applies
NO]ICE 10 APPLICAM. If. after making Nis Cemiftate of f cmpl n. you should
become subject to the Workei a Cmnpenseton pmviaiani of th<labs Cock, you mum
fmhwith comply with such prmisiau m this permit stall he 4mned revoked.
NEW RESIDSOHAL PLMB. SQ. FP.
TOTAL:
BUILDING FEF:
CONSIRUCfION LENDING AGENCY
SEISMIC FEE
I hmeby affirm that tete is a cmnumctimn lmul agency fon the perrammnce of
the wm6 fin which this pemtit u ivum(Sil (S3MI, Civ. C.)
IcmcLn
t1ECfRIC
Neem
laadn'n Adams•
QTY. MECHANICAL PERMIT FEE
PLU GP
1 <etnify tut 1 have read this appliratan am sine thu the above infamuim u
connect. legs to comely with ill cit, ad county onti. ard.stetc law ncllonpto
PERMIT ISSUANCE
MEC AL ITE
building cnawo ctirm, and hcrehy ountwi r, menwtiver of Ihia city m enter upuo the
above rm.tmlei popery fm im ee on p
pupea.
ALT1Jk OR ADD TO MSCI I.
CONSTRUCTION TAX
(We) agtcc to save, imemNfy and keep horn e,n tle City of Cupertlm gatimu
liabilitics,judgmcma, coma ond.,in awhich mayln anywryacc�uc erg't ry
AIR IIANGLING UNIT GO 10,IT0(X]CIM)
inof en ting of Nla pemL
�
AMHANDLINGUN(OVER 10.1)(00CF14)
10
SipatumufAplAkent.wla , a�e
EJOIAUS HOOD(W/DUCD
PAID
HEATING UNIT (TO IWJ000 BTU)
DISCLOSURE
HAZARDOUS Ming
Dote Receipa
occu,n hxrardousd S.6d
Will b,,hi,he icvmorfumneboillConic, Cha stores hanand
ss deltout b} the Cupaino Mwicipel Cmc, CM1uper 9.IA and to Health enxl Safmy
HFA'PING ONI'I'(OVER IM,tigi BTU)
TOTAL
VENTILATION FAN (SINGLE RISIDI
Code. Seetiam 25532(x)1
11 Ydn C1 No
IS CE ATE
' to o on future building
Will .pplie.n gocapant uta cEdpnentadcvias whichsmit
BOILER-COMP(JHPORIM.Ixlo BTU)
PAID
BOILER - COMP(OVER 101y"BTIB
ha atdwm au cwta.irub& as defued by the Bay Am Air Quality Mam6cnnum
District
❑ Yn ❑ No
NEW RP_SID11J1'IAL MECH.-SQ. IT.
JUN
I lave read the Mssrdous nmteriils tequiremmm oder Chq. 6.95 of the
27198
California Health & Sat ery Cmc, Sectiots 255(15.25533 end 25534. 1 umemum slut
C �1y
iftFe nen pmbllity to notify the
huildingdons m cudy have atemmb Nin it is my rcml
mcrupa.t of the rtyuiremrnts which mute be mm Prim b issuance, of a Certfinle of
N /1
ULL4
1' WFr
Occupva
ISSUED tl
Owxr s autlnrircJ osrnt Dau
TOTAL:
OFFICE