28270 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 28270 aw ��O
APPLICATION/PERMIT PIAMBING-MECHANICAL l�lj
BUILDING DTVI' ON BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONS'aU�yB�MfITALDATF,
UNI'I'p LOT# � �ZV
OWNERS NAME: PIIONIi:_ O N'1'NACTOR'S NAME: LIC NO:
DS NA Z NIC COM'ROLp
1R.I ITI:CDENGINEUR: �C NO: UR`SS: ❑
CO 'ACI': PHO J
2 SAL/ QTY. ELECPRIC PERMIT FEE BUILDING PERMIT INFO
rY11'IY�K9/`IJ L 7 q T
-� BLDG ELECT PLUMB MECt 00��• PERMIT ISSUANCE LTJLECLam(
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL /OH FSC IPTION
WOO Thereby off that[3mlicenBuinssand Professions
Chapter and mmendag with }) �
M=Z Senion1ncle,. Division3of NC Business and Professions Cale,and my license kin PANELS
/
~W full force and effect.
200 AMP
F-�,a� tic CnscC sTConamicoarECTSDE ,ARA'f10N1 � 201TOUHp AMI Ss S .FL �R2
Z8 Dc
1understand my plans shall be used a%public r¢ords. OVER IIXID AMPS
NF; SIGNS ELECTRICAL
< 7, Licensed Professional
OWNER-BUILDERDECLA ATION SPECIAL CIRCUIT/MISC.
yyp1F 1 Mrchy affirm that I am exempt from tM1 onunctors Lice a Law for the
uxi3ay following maxim.(Section 7031.5.Business rofessions Code:An irymcounry TEMP.METRR OR POLE[NST.
_FapQ which re4uiresapeonittocamorua.alter, prove,demolish,orrepair ystrecture VI
ci:(2 prior to its issuance,also"vices the app' antforsuchpmi
erlmfileasign sw¢ment POWER DEVICES
�y p that he,licensed pursuant to the Irrov,ions of Inc Contractor's License Lu (Chapter
aKC� 9(commencing with Section'1000) ivision 3 of the Business and Professit sCode) SWIMMING POOL ELECTRIC VALUATION
ly_y or that he is exempt therefrom c Permitmlheasegedexemant to Any vio tinned UILES
hZ� Section't(GiSbyanyapplic for
permit subjects the applicanuoacivil pen of SWITCHES-FIXTUR[S
O not more than five fund dollars(5500). ton
❑ I,:uowncrofthc "petty,.... to wit NEW RESIDENTTALELFCTR FT.
ycmp Yccs wages asthnr pcm� —SQ. STORKS TYPG CONS�T/RUCTION
SvI:SS wlildo lnew.k.nd c Imeucisnot imendedorll forss cm, sines, / X
and Professions Cede The Commmor'sT.i not to owner of �{/
propenywhobaildsof provesmene and chwnrrhim through his
ownemployces,provid Lha himpmv nt n ' t d edforsale.If, (5CC.GROUP RES.UNITS
however,the building or Ipro e I s. biror a am : ,ilmosear-
builder will have the bur n of vi hat he did nm bui imp,ve f ..'rose of
vie) \ TY. PLUMBING PERMIT FEE IOODZON1i APN
❑ 1,arowncr of LM1e pro cry, ex a velytdKen wig cemedco mcim Q
otimpun the project(Sec. o<q Basi and T eq Th e C wetor's
,\I\
License Law does not apply I anownerofproperyw build^rimprovesthe on,and PERMIT ISSUANCE.
whocommnsforsuchprojecl.wilhacnnuuaor(s)I'eased a uammthe Co Rican, ALTER u7
License Law. E FEE SUMMARY
❑ I am exempt under 5«. ,B&P C fm LM1is aso BACK FLOW PROTECT.DEVICE. OUTSIDE FF.FS
Date SANITARY YN
Owner WOR7MPU1;AT
PENSA'1'10 DECLARATION DRAINS-FLOOR,ROOF,AREA,CON.. LIL RECEIPT0
SCHOOh'1'AX Y N
t, ❑ Ibereby uffrm thmilicate of nxnl bsdf-insure,or a cenifi rcof RXTURI'S-PER TRAP I RECEIPI'q
Walken Compensatioo acenir copylbereof(Sec.3800,1ab C) hichPARK FEEVN__covers all emplmyce's ue GAS-FA.SYSTEM-I INC.40UTLETS RF,CEIPI'pPuliry N BUILDING DIVISION PEES
Company GAS-CA.SYSTEM-OVIiR 4(EA)Cmired copy is i'be' PLANCHBCK FEE
❑ Cenifiedeopyise city i«peelion division. GREASE(ESDUSTRL WASTE INTERCEPTOR GRADING FEE
CENI'lIEXEMPTION PROM KE GREASETRAPSOILS FEIiNSATION INSl1RAN
(Thissenion need; complemd ifthe pe it
for undred dollars(5 ) SEWER-SANITARY-STORM EA.200FT. EN FyI; 3'` Ot7
or las.) /,
I Certify that in the pc o
cc ofor In ¢hlhispemtitisms IS
11 WATER HEATER WPIENT/BLECfR
not employ any person i become subject Io a Work PAID 1Xr-9S-
Conlpens:nmeLawsofCalfo WATER SYS]EM/fREATING Date�J Receipt'
Q z Applicant
z Q NOI'[CETOAPPLICAN If, gthis Ccnificme o!' mption,you should NEWREMDENTIALPLMB. SQ.pT. TOTAL.
become subject mthe W.
istion provisio:u oft bort Code,you must
� >
forthwith comply with sac prmhis permit shell deemedrevoked. BUILDING FF.ElDCON TRLENDING ENCY SEISMICFEE
� z I hereby affirm that th re iction len gagencyfortepedermaace ofIfeworkfor which this pe tisec.3 ,Civ.CJ ELECTRIC FLE �'1ipLender's NameUUnder'.s Adds. QTY. MECHANICAL PERMIT' FEE PLUMBING FEE
vertily Wm 1 have read Ition and stale That the above mbornaeon is
F1 correct I agree to comply with all city and county ordinances and state laws rclatingm PERMIT ISSUANCE MECHANICAL FEE
_ fn buildingconsWction.:nd hereby aothodacrepre,entadves oflnis city toenter uponthe
V Z above mentioned property for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCfIONTAX
(We)agree motive indemnify and k p harmless the City of Cupertino against
liabil...is,jadgme ,ants and expenseswl' hmuymany wayaccfueagainsl.,aidCity AIR HANDLING UNIT(TO 10,100 CFM)
eof Ie;walingo di,perml
1 S ^� AIR HANDLING UNIT(1111 SJBd CEM)
ramnof Appl,an nova v Date EXHAUST HOOD(WMUCT)
PAID
I IARDOUS MATE IA DISCLOSURE HEATING UNIT(TO 100,000 BTU) ` Date Receiplp
% Will the applicant nr future building at I store or handle havrdous mamrial
as defined by the Cupertino Municipal Code.Cli 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) [,
Code,Section 25532(a)!
❑ �
1
Yes (No VENTILAI[ON FAN(SINGLE REST Of
Will the applicant or forum building occupant use equipmcm ordevitts which emit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hmardoas air conh:minant,m defined by Lbe Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) (��r,
D:strial u P A
❑Yes qNo NEW RESIDIiNT1AL MECFl. SQ.FT.
1 have read the hoevdaus materials r:.quimnerlla under Chapter 695 of the n��
California Health&Safety Code,Sections 25505,25533 and 25534.1 undersand �]
that
if the building does not currently have a tenant,That it my r sp:nsibdity to not fy the C
«apanl of the meats which Inua he met prim m isst-,c of a amiirryme of
owne�pF influenced" � {� /Y h r o f f/�U
O ISSUED BY:
OFFICE