28913 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 28913
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O e,4 Co 5(VC7 G4 (� ,
OWNER NAME .N/ PHONE- - CONTE R'S NAME' �hSTQ CONTROLN
PAW
A CHITECIENGINEER: LIC NO: ADDRESS -/ ❑
6AtkiAvICT J rGGae
CONTACT: PHONE: BUILDING PERMIT INFO
9 (/� ❑ COnsnitant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
O ,�, ❑ ❑ ❑
LIC&iSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm draft I am Hennaed un&r Provisions of Chapter 9(rnmnercing JOB DESCRIPTION
OQZ with Satim]000)of Division 3 ofthe Busimta ant Prufcasiau Cde,end my li,rnrc is RESIDENTIAL-
I
ESIDENTIAL
F O in full Tone rN clTcn. PERMIT ISSUANCIi
�u55 Liee.Clan Lie.N '❑SFDWL ❑KTCHFN REM1fODEL
�ZW Doc Cmtnclof APPLIANCES-RESIDENTIAL ❑ADDRION El PLUMBING RE-PIPE
ARCHITECYS DECLARATION ❑MULTI-UNff ElS'IRUCrURAL
Z O�Z 1 uldemwho my plena shell be used M public rand. PANICS MODIFICATION
O Z-O UP TO 200 AMPS
F'W 1-werum Pmfo.irmal ❑IMPROVE HIMNEI'REPAIR
OWNER-BUILDER DECLARATION KKAM S MPROVEMENT
L eT W 6 I hereby affirm that I am comi from the Contravoi License Low f«the OVER IOW AMPS ❑BATH REMODEL/REPAIR DFAtOLR10N
x 3 a U following radon.(.c m 78315.Hwimu and Profusions Code:Any city or duty SIGNS ELECTRICAL ❑OTHER
u1 Y, which oNoires a permit to amswal.oh"ito mere,dem.k4b,m repair any.trvcwm
Prior to in u.uarte,else ob,titca de applicant for s«h permit to RR a signed sum,ment SPECIALCIRCUITIMLSC.
p Qf thOl he is Ii, p.t to the pr,,,ions M the Commctor's Lice.Law lCItsPer9
a�p0 (umm,«ing wish Sati...... )of Division 3 of tha lludoavad Pmfea.inns C,i,, •IP,MP,MF,PER OR POLE INS9L COMMERCIAL:
1E a e a that Ic in escmq there(..eM the havia for the alleged ademption.Any violation of
LL. ❑NEW
NANT ADDITION El DEMOLITION
SERVICE Six oml]OJ15 by anyepplicantfma00), dubjm.the applicant to a,ivil tenuity of POWER DEVICES—ret ❑TENANT ❑FOODSERVICE
not mare dtmt rve htmdrua aallme 65(p).
f=C p no
U,a lcoftM prmperYmmYotirmo.with eredf rsal Traded .Boni ass
SWIMMING POOL ELECTRIC IMPROVEMENT
rill do Re w«t,and the.tnscwrc is rr imcMcd aaRctcd f«sale ISa.]OLI,Buaincu ❑OT......
W a end Pmfi,..na Cale:The Cmvacn:♦Li,enc Yaw doe,n pply won owrer err OUT,EfS-SWITCHES-FIXTURES
popery'Ito bui1J.m imprwcr Ihaum,sed who h himself m Wrnr
his own employ..Providrl shat such hoomvemrnn « Rad for NEW RESIDENTIAL UIECHI SQ UT.
safe.If,however,the Ir hing«inspmve,m,m i, o wi i lion.the SQ,17,FItOOR'AREA SISQ.FT'.
owner-hui Wer will Mere the ha nnfpmv' b di uildfmpary
post a
❑Las owner of the a lye trmting Tic talo TOTAL: OCT 26 1
conillYCl lhe pntJR,(See,
'Ify band nl Tll[Gn laf]Li- 1995
arse low docs tun epplyw aro a arpmt�^fryy ho .«' po.v thne«I,and QTY. PLUMBING PERMIT FEE
wlnaovacts f«Loch gnjecn wi a I«�)I« ant to the Comractnls
Littmm law. \
011, Ur UUt-tli I1NO
'0latn cacmp order Sa. ,H&PCf«dlismmon PERMIT155UANCF.
ALTUR-DRAIN&VENT-WATER(E)G�
Dtne VALUATION O•wter
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
IlaerchY afmetermlt
uer pcy olperjury th ore offollowing daWations:
Fl I love"will maiatdmaCerif¢of Cim.enl to sdbimumf«W«kct,ComMn- DRAINS-FLMR,RODE,AREA,COND. STORIES11 TYPECONSTRUCUON
wion,m provfJ for by Scrim 37IU of the labor Code,for the per'oom ce of the
wah for which tier.Gromit is ie . FIXTURES-PERTRAP
O I lave ad will maintain Warner',Comps m,nmm Insurerlcx,a.mryitd by Seelion
3700o1`11u Lahr Code,for the pednmmtcanftle w«k frrwhichthis pcnnllnosueT GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
Aly Worker's Cwnpenaalim hu artier ad Policy
Cmeia:,�A�_7rsn f-I Policy No.:/ T 6/vY� I+ GAS-EA.SYSTEM-OVER 4(EA)
cERHFICA Ol l EMPTION FROM WORKERS'
COMPENSATION INSURANCE GRPASErINDUSTRL WASTE INTERCEPTOR
(Thu.seetion t�td b emmlNetd ifthe permit is f«me hunad d
rull.(SIW) BUILDING DIVISION FEES
or I6aJ GREASETRAP PLANCHECK FEE
I enrythat inthe'morma teemthe wart f«which this palmic is sand,I Jul] SEWER-SANITARY-STORM raFA.2W FT.
not employ any pso r N any nrdonor w as to become e sto the Wotton'Cmryr.eENERGY FEE
Oz ami on law of Celiymlia Urge WATER HEATER WNUIELECTR
z O Applicant GRADING FEE
to NOTICE TO APPLICANT.IL aft«mating this Cmifeue of�empion,you sli WATER SYSTUS11REATLNG
hecotrc ohjw to the Workrr's Con,emalim provisima of tM labor Code,you must SOILS FEE
{IJ Orrhwith comply with euch pm,mor,«thio lamtit shall be demo,mvoAed. WATER SERVICE
a �
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FT. PAID (late Re
Y
I..) O IMIr$yah,hif,thatfmis ea,bil( ,.innlcndlmg.g,tey Rothe perammlec of
� .. the wart for wni,n tri.perm is issud(sa.3W].sera c.) .
O U Lt, e.Name TUTIL:
LU 1<nJee,AMne, TOTAL:
p„ I,miry Thal 1 have tcsJ this'PEcadon oho swte Out the above iWo nwion is BUILDING FRE
vJ arrtct.I agramcomply wish ill city and rnumY oNivmsaM su¢laws rtletittS to QTY, MECHANICAL PERMIT FEE
Ula buildin,emoruelion,eN toothy amboro, rcrcnmlivcsofthielcity m,me,ugm the SEISMIC ITIS
stove-memionul property for tnspalim ptuln.ea.
(W.)age:muve,indcmrify and kap harmlcv the City of Cupertino apimm PERMIT ISSUANCE ELECTRIC FEE
Ilvbilitie.,juJemema curls not eap,r. which rwy in a,,wayteu c.,emn rasa City ALTER OR ADD TO MUCH.
in mnuy eofthe granting of this pem. PLUMBING PEE
APPLICANT UNDERSTANDS A:NDo COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0WCFM) MECHANICALFEE
SOURCER J .5.
aAIR HANDLING UNIT LOVER B.0CFM)06A CONSTRUCIONTAX
SI .tApplcarmCrmnnm Date
EXHAUSTHOODOVIDUCry HOUSING MITIGATION :E•
HAZARDOUS MATERIA1S DISCLOSURI3
Will the applicant or fuwc building oeeupam swnemhadle hazeNmsmateral HEATING UNIT(TO W.000 BTU)
an,&fi«d by the Cuperum Mutlicipal Cada.ObWa 9.12,ad Ile Health oho Safety
Cod,Section 25532(.)? HIA'I'ING UNIT(OVER I W.M0 BTU)
❑Yes ONo VESTIIATION PAN(SINGLE RESID) PAID
Ome Recey N
Will the applicant«fuwa ba-Wing by lth mttyAc Air Qo ardevicewhich BOILER-COMP(3HP OR 100,W0 BTU)
emit n.,...tau.air cmtamlwntr a.Jcdiad by the Bay Arne Air t)uilily Munagemem
Ulavict9
❑Ya ON. BOILIR-COMPIOVLR IW,WIBTU)
I Crave reed tk hexutMara m-,•^"t,tryuirtmmlx undo Clupn 6.95 W tic Cdi- ATR GUNDTIIGNER
ISSUANCE DATE
forms Hat&Safety Code,Sectimis 25505,25533 aml 25531.I anderatand Jw if the
Wilding&u on cureoly lo,..wmmanhmll is my r ,nsihihfy to notify(W, ap,nl NEW RFSIDFMIAL MECH. SQ.FT
d the,tequitrnmu wheh mus be ncf Pror to uauaree of a Cenifate of Occu�ey.
O rcr ear.utbmt e]agent D., TOTAL: ISSUED BY:
-OFFICE -