28027 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1CTRTCA, PERMTTNO.
PLUMBING-MECHANICAL
BUILD]
NG DIVISION APPLICATION/PERMIT DRGPROJECT IDENTIFICATION
28027
WILDING ADDRESS: _ SANITARY NO. APPLICATIONSUB IDTALDATE
/o
YJ '7 S• IJc nza aCvd s UNIT# LOT#
WNRS AME: PHONE: N'TRACTOR'S NAME: LIC NO: N/C ��Jii CONTROL#
c( Call; r o 0 8 2
ARCHITECT/ENGINEEW LIC NO: ADDRESS:
CONTACT: PHONE: ' BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
•" .. RLDD ELECT PLUMB N
PERMIT ISSUANCE '7LeI7(� �fL�t/� ❑
LICENSEDCOMUACI'OR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Thereby affirm that l am licensed underprovisions ofCTapter9 fcomm<being with
y.,yzo Section 7")of Division 3 of the Business and Profusions Code.and my license is in PANELS
,W—f. full force and effect.
License Class Lic.# UPTO2DOAMPS
Dale Contrnelan 201-1000 AMPS
zOya ARCHITECTS DECLARATION OVER IOt10 AMPS SQ.FT.FLOOR AR EISQ".'FT.
O Z I Professional
rof ssi my plana shall be used u public record.
OZIz—R SIGNS ELECTRICAL I1Y /Vl
hPLicensedProfe io al
gyy OWNER-BUILD RD the Co.TION I SPECIAL CEtNIT/MISC.
OpW,U I hereby affirm that 1 am c In the Contrector'a License I<w for the
t�3O yfallowing maws.(Section 70 . .Business Pmfeasions Cade:Any city or county TEMP.METER OR POLE MST.
worloeyuiresapermit onsuuel,amr,imp e,dno,111h,orrepeiranyslmctu,
cots1>.7� primmitsissurrom. rtyuhe¢Ne applicant fors pconatoflea¢ignedmatement POWERDEVICES
tea'4O
That he is liven unuam to the proviskma of to Co don's Lim..Lew(Chapter
4❑ SWIMMING POOL ELECTRIC VALUAT IN
a' o� 9(commenci w'nh Section]0(10)oFDivinon3of thea ens end Rofwsiona Code)
W_y orthatheis xempWrrefrom and the Innis for to alleged!< prion,My violation of OUTLETS-SWITCHES-FIXTURES
t z Q Section N. .5 by any applicant or a p mit so th pylic t w u civil penalty of "a"•
yFD
or mom mfive hu re Joll (ES NEW RESIDENTIAL ELECIR _SQ.FT. STORIES I TYPE CONSTRUCTION
Co nd Lasa nnofte opo sw.f wage ems cmnpensiiess
y °J will Probe ark,C m endedoros fs ono apply
to 44,Business
and Profess s C trecmra Litt aw dna rwt apply to an owner of '
proprtywhtbudds. p ca there ho doze such work huramlfor through his OCC.GROUP RES.UNITS
ownemploye ,provide th suchi o vcmentsertnotimendedorofferedformle.IL
however.Neb 'Idingorro em is sold within one yearofcnmpledon,to owner-
build.rwillhav comde proving that he did net molder improve fo ,hu,om.1'
sale.). °
❑ I,as owneroOhe property,emexclusivelyconvactingwitlicenud mntroctonw QTY.; - PLUMBING PERMIT FEE ------FLOOD ZONE APN
anawct the project(Sec,9814,Business and Professions Code:)"a Comore ols
License LewdocsnotepplywanownerofMw nywhobuild.aimprovestereon,end PERMIT ISSUANCE
whocammels forsuch projects with ucomractor(s)Iicenmd pursuanuothe Conan,mes
L.".La W. ALTER-DRAIN&Vf:NT-WATER(FA) FEE SUMMARY
OUI
E FEEN
❑ 1 om exempt under Sec. .B&P C for Nis reason BACK FLOW PROTECT'.DEVICE ID
SANITARY Y N
Owner Dan RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOON,ROOF,ARPA,CONU. SCHOOLTAX YN
❑ ers'C. affintton Insurance
ificsm ofconmmtose(Scetu<.or LafC.)<tec,hich FIXTURES-PER TRAP H9CEIPTG
Wakors CompensathatI avec ori cateof amseopy terself4m e.or6sb CJ which PARK FEE N
covers all employee's under,this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS R #
Policy# BUI 1 Obr ES
Company GAS-EA.SYSTEM-OVER 4 THAT PLANCHECK
[ICcnified copy is hereby lumishW, e
❑ CenifiW copy is filed with The city inspection division. (IREAsro USTRL WASTE INTERCEPTOR GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERSGR SOILS FE
COMPENSATION INSURANCE
(This genion rteednet becompleted if Ne permit is(aranehundreddollan( *916SAIT Y-5 GA.2010171'. jD
C
orleal
I certify thetin the perfomtanca of the wmkfor which tis permit is iss RHEA /VENT/ELECfR
not employ any person in any mvmer no m w become¢ubjeet to Ne ark
Comperualm.Laws of califo..I., Dam W TE S STEM/IRBATING Date recipt#
Q z Applicant
z NOTICE TO APPLICANT:If,efwr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y become subject to the Worker's Compensation provisions of the Labor Code,you must FF.Bfordwith empty with such provisions or this pemut s1W I be domed revoked.CONSTRUCTION LENDING AGENCY ET hereby aff Net Nem iss construction lending agency for the performance ofz TOTAL: FEEO the work far which thio permit is issued(See.309].Civ.CJLender's Name ' . G FEELender's AddressQTYe MECHANICAL PERMIT PEIiI certify tat I have must tis application and show Nat Ne above information iscomes I agree to comply with all city and county ordinances and stew laws=1stingw PERMIT ISSUANCE AL FEE�"' hildingconstruction,and herby autharim representatives ofthis city tremor upon the TION TAX
U above-mentioned property for inspection purpmes. ALTER OR ADD TO MECH.
(We)agree Io save,indemnify and kap hmmless Ne City of Cupertino against
liabilities judgments,costs and expenses which may in any way same against said City AIR HANDLING UNIT(TO I B,fIBB CFM)
in conae,moc of the granting of this pemtit.
AIR HANDLING UNIT(OVER IO,OW CFM)
Signature of AAPpli�curn/CCoontmcter Date EXHAUST HOOD(W/DUC) PAID
HA]ARDOUS MATERIALS DISCLOSURE HEATING UNIT TO IOL"BTU) Date Receipt Is
Will the applicant or fmum building occupant atm.or handle hamrdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT TOYER IOQO00 BTU) TOTAL:
Cale,Section 25532(a)] VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP CLUP OR IM,"BTU) �.SSUANG6DATE
Will to applicenmrfuwre buildingoccupunmaeequipmnt or
edeviceswhich emit !!44 Y• lVJ
harmdous air contaminants as defined by the Bay Ams Air Quality Management BOILER-COMP(OVER 10Qo00 BTU)
Dia"n' JUN 271995
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hmsMaus materials requirements under Chapter 6.95 of the
C.Thfomiu Health&Safety Code,Sections 25505,25533 and 25534.1 understand Nat CITY uI- �VI'tHIINU�
ifthe building does nmcurendy haves tenant,that it is myresponsibility Leon Ne
mcupont m the re,doonums which must he met prior m issusmce of u Certificate of
Oecupumcy.
Owner or amhoriecd agent Date ISSUED BY-�
OFFICE