28094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD
BUILDING DIVISION ING-EITCTRICAL PERMIT IN 28094
� ^O
APPLICATION/PERMIT PLUMBING-MECHANICAL YV {x,Jl
BUILDING PROJECT IDF,N"I'IFICAI'ION L
BUILDING ADDRESS: �`�r.' SANITARY NO. APPLICATIONSUBMITALDATE
90 0DW LOT» gel yyag
WNE . NAME: P ONE: CONT IT 'SNA IC ...777 _
W NIC CONTROL
:INE' ,CMO: DRESS 1^,/'/�//V'w
61 zti f� v&. S.aaEl
C NTACf: ONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
(/{• / )
B E(ECT
PERMIT ISSUANCE �, _ PB M5"
LIC CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Jf'Oy/`, UM
p04Z IhcrebyaINztl amlicc scprovisomso r9 coewitem with LOB DFS pN!
tr00 Seetian 7(00)o
r Division3ofte Busirwsand Pro[cslonsCoJc,and my license i
�
in PANELS
FFy++WF 1.111,"
-andcffem
FZuI License Class Lic.»� UP I'02o0AMP5
w= are Commaor �_ 201-1000 AMPS
�mZ ARCHITIiCTS UIiCLARA'1l0 • SQ.17.FLOOR AREA $/SQ.Fi'.
'L rn— OVER 1000 AMPS
O Z-O I undersand my plans shall M used as public mcnNs.
F
—, SIGNS ELECTRICAL
Q Liccnail Prof Ionil ��O ►G2.
x�
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOa V 1 hereby affirm that I am cmmq from the Contractors L:Anse law for the
tL30.o¢s which followingreama Permit
to constr, t.sines and improve,
demolish.
Co dc:Any city county TEMP.MET17H OR POLL INST. V N
(22 7. which requires ne,edwrecures theaper,improve,demolish,or repair any structure
5e5}5 that heor islicensed .alsonto the provisions
of the ch Commences
file a License
Lies(Chapter POWER DEVICES
py�j a.CI O 0(c he is licensee pursue,us the provisions of IM1e Comtacries,License Law(Chapler
a XaLL 0(commencing whh Section?000)ofDivision 3ofNe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
m—m or that he is exempt therefrom and the basis for the alleged exemption.Any violationof
Z< Scene.7031.5 by any applicant for a permit subjects IM1e applicant to a civil penally of UTLETS-SWITCHES-FIXTURES
out more than Five hundreddo11ara(S500). ` (�
WL. ❑ 1,aaowneroflhepropeay,ormyemployaswilhwugesaslheirsolecompensaion. NEWRFSIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
will do the work,and thesltucture is not imendcalmoffered forsale(Seo.7044,Business
and Professions Code:The Cmmrnmurs License Law docs not apply to an owner of
progeny who bsiIdsorimprovesthereon,and whodoes such work himsc forNmughhis
xnemployecs.providedNt such improvememstenotimendcdoroffered fmsale.If, OCC.GROUP RES.UNITS
however.the building or improvement is sold within one year ufcompletion,the owner- T A
builder will have the burden of proving for he did not build or improve for purpose of
sale.).
❑ I,as nwnensflhe pnmpeny,am exclusively contracting with licensed commmors as QTY. PLUMBING PERMIT FEE FTGODZONE APN
un n-mr,the project(Sec.7044.Business and Professions Code:)The Contractor's
Lice se lawdacs not apply loanawnerofpropcny whobsildsor improve thereon.and PERMIT ISSUANCE
t wbocrdeartsfor such pmjects with a rontramor(s)licen,d pursuant more Contractor's ALTER IN&V T-
Licc„Law. WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK ROW PROTECT.DEVICE OUTSIDI3 FEES
SANITARY YN
Own Ua� DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPSyy ATIONDECLAR(TION SCHOOLTAX Y N
❑ Ihemhy affirm thaI)haveece 'lcammfcnnsrnno self-insure,oramnificte of FIXTURES-PER TRAP RECEIPT»
Workers'Cnmpemotime lnwrance acrnifed espyin re (See 3800,Lah C.)which PARK FEE _N
covers allemployu'x under thi emmit. GAS-EA.SYSTEM-1 INC.4 OUTLETS -CEI
Policy» BUI L VI NFP-S
Company GAS-EA.SYSTEM-OVER4 IFA) PLANCHECK
❑ Ccnilicd cop creby fumisM1CJ.
❑ Crnified yis fled with Ne city inspection division. V.
♦ GRFASEANDUSTRL WASTE INTERCEPTOR
l GRADIN
C17RI'[FICA]E OF EXEMPT NFROMWOR GREASETRAP SOILS FEE
COMPEN. TIO SURANCE
( n milionnccdism"eompl 'f m etmitisforo,e hyndr ill 100 SEWER-SANITARY-STORM EA.200Fr. ENERGY FEE
rele". s �
I'enify that in the peof, ework for permitisi. ed,lshill WATER HEATER W/VENT/ELECIS
of a ploy any pars in n so m object to e Workers PAID
z Co. annion Uses a'11 i . Dam WA :RSYSI' BEATING Dam Recei tp
Q Appl 'ail ciao
ZQ NOT EI'OA� :ILa'mroy ing ris Cemneirmin emplion,you should RESIDENTIAL PLMB, SQ, IOTAU
Fmom.. heco cmbjctmNc Ws A is Comm` sat provisions ra f dd LabCoda,yourrust
C4 7 firth ith comply with sat m his permit shall edeemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING GENCY ,
W
SEISMIC FEE
p Z hereby affirm that here is acouswction le ing agency for the performance of
U Q IM1e w k fill which this permit is issued(Sec.3 .Civ.C.) T ELECTRIC FEE
Under Nam
OU Lender. Address QTY. MECHANICAL PERMIT FEE PLUMBING FEB �.
LU I c Miry Nat 1 have mad his stiffalio,and sem that the above information is
lL comae", greeacmnplywithallcit and county ordinances and state laws relating am PERMITISSUANCE MECI IANICALIEE
F' Do buildings svmuction,and hereby aria rcpresenttives ul'this city to enter upon the
U above"men nedpropenyfmi pectionpsrpous. ALTER OR ADD TO MECH. CONSTRUCIONTAX
(We)ah m save,i mnify and keep humorless the City of Cupertino against
liabililicejudg . . and expenses which may in any way accrue against said City AIR HANDLING UNIT(10 BLASI CFM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
.tgnturcAppl'manVCommtor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dale a it #
Will the applicant or future buiTJing Decagons Blom or handle hararduus mamrinl
ser defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100,000 BTU)
Code.Section 25532(a)?
❑Ycx 11 No VENTILATION PAN(SINGLE RISID)
BOILER-COMP ft tISSSUANCE DATE
Willt,it oniceninum, r,dif.ied occupants,Are.Aen Quality
c Management (3HPOR 100,000 BTU) k- /i p D
• haaarJmus ,it cmnmminums as de6neJ by the Bay Areu Air Quality Managemcnl
Dixvicr? BOILER-COMP(OVER 100,000 BTU)
11 Yes 0N NEW RESIDENTIAL MECH. SQ.FT. AUG 10
1 have read the hauadous materials requirements under Chapter 6.95 of the 1995
Calms mitt Beach&Safety Gdc,Sections 25505.25533 and 25534. I undersand that Cary uI, L
Bin,building Js mol turmoil,have a tenant,that itis my responsibility to nmi
if Mdoesfy the ur—tl1/INr,
erupanl ol'tire requirements which must be mel prior am issuance of a Ccrilieate of
occupancy.
Ownernrmint rmd e,cnt Ute
TOTAL: ISSUED BY:
OFFICE <'