28355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO e I [ r
N -ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ry O c C
BUILDING DIVISION BUILDING PROJECT IDENTIFICA'f10N G O 5 J
ILUING ADDRESS' SANITARY NO. APPLICATION SUBMHTALDATI:
i99
INR♦ LOTI l�
WN ER NAME: RTONE COXIJAA, POR'S NAME: CNO:
d W d r d IV Fp e-dS r, 456- 912 6 NIC CONTROLN
.a>'+-�- i zz�arr� l to n G 2-
RCHIIY:LT4NGINEER: LIC NO: ADDRESS:_5q ;Z:o(
❑
CONTACT: PHONE QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE. r[/t �1
LICENSED COSIRACOR'S UECIARATION APPLIANCES-RESIDIPcTAL R� '-IO
p.Z I herebyaffirm Dal lw licens<d aWefprmisiomsofCapler 9(c«merlcvlg with 1rt �` `...108 DESCRIPTION
wo OF dforce andelra rivorr3MDe Blssiress and!Pmfmlav Cmtic,aM mYlicoruuPANrl
Section
in
UPT pAMPS `��� toF�
G Ii1Uty License Can Lic.N
♦nam Detc Contractor 201-IMO AMPS
7~10 rroil(.a ARCHITT:CTSDI?CIARATION OVER I"AMPS S .Irl'. .Il'.
O Z O I urgereulM my plat bull he used as Public records. 1
Fye; SIGNS EECIIUCAL
LiN J
ty S, nn iPrufeuvul Rolle 1 `�
25W a OWNER-BUILDER DECLARATION SPECIAI,CIRCUIT/MISC.
X041V., 1 hereby affirm that 1 am exempt from the C mmarnols Licrna Lew for the
W 3 won following reason.(Section 7031.5,Business odd Professions Code:Any city«roomy TEMP.MISTER OR POIJ?INS(.
f_fS�g whicM1rtquirnapemdltocnnnnrt,cellon,imprave,dennlisb,«repvrwYxmncurc
E''Y5 Pis«m isiswatrce,elsoaquim
riaxxcttLL this
licmllfmsuchpvnutto prd eYteTenl
POWER UEVICFS
Cap drat W u nmd punowto thepomewmof hComnmols Utsemo "a,(Chepre09(cmmnn«ingwith 5etion]0 )ofDivsi3ofthe BusioorSWIMMING POOL
ELECTRICnofessisCode)
VALUATION
W� «that he i3 excmp Berefivmoal to besisf«the WlehMeaunptlm. civil Ponhy of OUTLETS-SWITCHES-EIX'NRFS
�a notmSectiore dJm.Siv anrvilmd doloam lar a500). euFjcdnthe applicwnn.civilprnahy of
T� not more than five hundred dalton(35010).SCF NEWRISIDENTIALEI.1?CTTt SQ.FT.ElI.vowrlerofthc progeny,«mycmploycce withwagnesthcirsdcmmperrution, STORIES TYPE ON.STRU N
and dotework,Coe he,Ccrreiffacthneialedmow diveano apply
I writer
cert Profmi«n Cade:The C«auctas Limve law don m apply lm w owns M
pmpeny who Wilds mimprovex thereon,wdwMrkra xacb woo himalfnrdrvugh his
emPlnym,pravWed thubuch improvemrntxwe rid imendcA«offered f«wle.
It, UC .OR P RFS.UNITS
however,the W ildhng m impravamcm ie rMd within one year of cmmplalan,the swear- TOTAL
builder will have the burtlen of proving dal M did not bund or improve for propose of
n1e')' QTY. PLUMBING PERMIT E FLOODZONE APN
❑ Las thecip-1 Peale U44. eaclosirelyc«arening Cocei)Tha Cmctmeto
cmmmacl IW pmjm(Se.]1114. .Ifs old Pmfesv«a Code:)The Cwttacmnd
who",fawdan not epplytawowrcrofprapeny whroe,1 paorimpmvex dram,wd PERMIT ISSUANCE
whonse Law;Lr xucb prujcnx with a umtranar(x)licrn¢d pranuwuo the Convvcurr's
License law. ALIIiR-IyRnlry&v' - ATFR IFA) FEF,SUMMARY
❑ 1 am axempt uMcr Sec. .B A I'C f«this rcasan B PROTECT.Ub'VICE SANRA Y Y N
Owrer Det` DRAINS-FLOOR,RODP,A CON REf.E1PTN
WORKMAN COMPENSATION DECIARATION SCHOOL X Y N
❑ Iherahyeffirmthal Mveunnif este o(cnnanuo al[-inwm,nreccrtfcatenf RECP,IPTN
Werio,'cnmPem+tlon lmmaree or acriiEW ngy lhvwf(Sm.JSW.Lah C.)which FIXJURIS-PRIAA PARK FEE Y N
m el l employe's uMcnhis pomit. GAS-IA. .4 01ID,ETS RECEIPT N
Policy A BUILDING DIVISION FEES
CornPwY AS-EA.SYS OVER PLANCHECK
❑ CenifiedeoFyisherebyfumishW.
❑ CmificdcopyisfilMwithd 6tyin [iondivisim. G PASIONDUSTRL WASIti1 Cf:PI'OR RgUI
CIRTIECA'THOFEXHMPTIONIROM WORKHRS' OR SETRAP IIS FIJI
MNIPENSATION INSURANCE
(This urian rledtrtbu cmlPlnd ifthe Permit is for me handed dollars(SIM) SEW R-SANITARY-STORM EA.2(I(FT. ENERGY FEE
«les)
I renify that in the PeRrxnwnanf de wort for which this Permit is issued,l.hall WAI' IWATERW/VINTIELECIR
not employ troy Peron in wY n n. In ba urn sii*ct to the Wmkcm PAID
ComPcnwiml Tawsaf California Dom sn WAIlit YSTEMMREATING Dae ReciptN
O z Applkm
z NOTICE TO APPLICANT:IL after making lona Cenificucof Eaengtiwr,You should NEW RISI YIIAL SQ.FT. TOTAL
became subject to the Worker's Campewuan Pmvisiars a De Labor Code,you most
� � f«dwith comply with such Provivors«this permit shell be,deemed revoked. BUIIDINGFIiE
W Q CONSTRUCTION LPDING AGENCY SESMICIL?
I hereby affirm Nat therms a conorrictinn lrndlngage for Joe,Perfotnwrce of
U O Ibe work for which this Penni.is issuM(Sec.309],Civ.C.) TOTAL ELECTRIC FEE
0 leralv's Name
Conder"Address QTY. MECIIANICA L PERMIT PEE PLUMBING FEE
Lia n 1 certify tom 1 have reed This application erd none that de obave inforroohon ie MECHANICAL FEB
nan. larr«In comply with all city and coumy ordinance;aN rule laws relating to PERMIT'ISSUANCIi
building constructor.and hctchy momonac apmcn love mint citylo emer upontM1e CONSTRUCTION TAX
U z ebova-mentioned Property for imection plvprses. ALTER OR ADD TO MEO I.
(We)apo to save,irdernat mrd keep hermlm do Cry M Cupertino a aiw
Ii Wilitin,juJgrtlents,cow anal ex(ernes which may In any way "`te a w'J it Bt HANDLING UNIT(TO to,"CFM)
u+ec Male pwtng of once permit �l//
AIR HANDLING UNIT(OVER 110,000 CITU
Sipatmeof Appliantraem Doe EXHAUST HOODOMMUM) PAID
RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTS!) Dom 1I
If
Will Be applicant or future Wilding o«uram store or herdk hazardous material HEAPING UNIT(OVER IW,IXp BTU)
as defnwl by rho CuPenlno Municipal Cade,Chapter 9.12,and Ibe Health rad Safety
Civic,Selico 25534(.)]
El Yes 11 No VIN'1'l1ATION PAN(SINGLE RPSIO)
Will theapplirvxat.f. buildmg.parit au «
equipmentdm
zaeviwhichcmil BOILER-COMP OFF OR 100,000 BTU) ISS-ANa E9 ATE
.
hazardous au camarmi.es lefirred by the Bey Area Au Quality M1tolegenrnt BOILER-COMP(OVER 100,000 BTU) L/
District? 11o El - 7 1995
YNo NEW RESIDENTIAL MIiCII. SQ.IT.
1 havered the hvaNwa materials repimmrH ri er Outlier 6.93 of the
California Heald&Safety Cob,Sect«a 25505,25533 and 25534. I ImdersaM Ilial ��()L �UNEk LINO
if de building doe ort curtently have a enam,that it is my resp«uibility to rwtfy dr
«colam of 0e requirement;which most W met prior to insurance of a Certifiome of
Occulmncy.
Ower«autbmisd agent Dae TOTAL ISSUED BY:�
OFFICE