28410APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
$'
®
CITY OF CUPERT'INO BUMMING - MEC T NICA1
APPLICATION/PERMIT PLUMBING CF]BESNTCAL
ISUII,DINf: DIVISION HULLOING PROdKC'I'IDEN'1'IN'ICA'1'ION
I'IICAL iRMIT NO. 28410 ^ • 1 0
L V! 4
9
BUILDIN^G/ AD(DDRRtHSS`S���)x,�r`'�
�{.Jv ✓v ��\y ` UNIfN LOT#/oS
SANITARY NO.
APPLICATION SUBM///LTT��,AL DATE
[
OWN[ PHONE:
D)RjNgME: 1.1. NO.
N/C
x
/CONTROL
^ Cq Lf
`PERMIT
ARCIII'TECT/ENGINEER: LIC
ADDRESSs-141 „- /- ( r
s
,sN.O�
/ �r
CONTACT: �—Lb
\l�/`V
01���_ -��1�
QTY. EIs,,EECT/�RRIIICCC PERMIT FEE
BUILDING INFO
B_ I.D(: ELI❑';Cf PLUMB ME❑CH
` LSF
PERMIT ISSUANCIi
ZWz
� 00
yr Z,
GF -dm
rn Q y
Fy2
40te—
:lz tanj
N
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed under Provisions of CTuprer9(commencing with
Section 700.1) of Division 3 of the Business and Professions Code, and my license is in
full foe Class affect,
License Class hic.p
APPLIANCES "RESIDENTIAL
PANELS
UP T020U AMPS
LOB DFSCRIPI'ION
\
UPN/ w •�
Date Co.'.or
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
201 - 1000 AMPS
SQ.IT. FLOOR ARCA
S/SQ. FT
OVER 1000 AMPS
SIGNS ELECfRICAL
$$
LhY•mne Profcaxinnel
=y W Q
4OyU
a13ay¢
OWNER -BUILDER assn DIfromDECLARATION
1 ngreas n. (Se that I am eacmpt from the Cornerstones Ca License Law for he
following reason. (Section 703 L5, Business anJ Professions Cade: Any city ar county
SPECIAL CIRCUIT/MISC.
TEMP.MEfER OR POLE INST.
^V4OJ
Yonas
y K OO
roW
�ZQSectinn)UI
wt:
a3—
which rcyuires a permit to coremmt,Mer, iniprov, demnl lkb, or opainuty Mmome
teent
far such pcnuo fileasigncJ stam
Fri nnuia issuana,aBo requires the apPlicamni
that he is Iicensd pursuant to the provisions of the Contractor's License Law (Chapter
9(commencing with Section 700B of Division 3 of the Business and Professions Cade)
or that he is exempt herefrom and the basis forthe alleged exemption. Anyllviolation of
LS by any npplicmt lora permit sunjenr the applicannUucivpenahy of
not more than five hundred dollars ($500).
❑ I,mownmofthepropeny,ormyempleymswilbwagesaslheirsolecomperuation,
will do the work
POWER DEVICILS
SWIMMING POOL ELECTRICo
VALUATION
'20Ow
OUTLETS - SWITCHES - FIXTURES
NEWRESIDENI'IALELECIR_SQ.FT.
STORIES
TYPE CONS' 1' RUCTION
who doesOCC.own
TY. PLUMBING PERMIT FEE
FLOODZONE
APN
❑ Lisownerofinepropcny,an cxel cly contracting with ie tsedcommnnam
Al
construct the project (Sec. 7044. 6 ess and Professions Code: The Contractor's
License Lewdoesnolopplyno erofprepanywhtbuildsodmp vestherwn.and
PERMIT ISSUANCE
ALTER -DRAIN&VENT-WATER(EA)
FEE SUMMARY
who"reams fznsucIt x with acontrectons) licensed pursuant t the Comaxon's
Lile se Law.
❑ nl an exon n under Sea B & P far this reason
PACK FLOW PROTECT. DEVICE
OUTSIDE Id;I:S
SANITARY YN
RECEIPT
Owner Date
WORKMANCOMPENSA NDECLARATION
❑ I hereby a firm that l have a carinicatcof intent If-in.Fure,o n xmficamof
0 1 Com action In once or nifi P ti co .800 Lab CJwhich
rsailempl ca" 'sperm-
policy#
DRAINS- FLOOR. ROOF, AREA. COND.
SCHOOL TAX YN
RF.CF.IPF#
p1X'1'URES-P13H TRAP
PARK FEE Y N
RECEIPI'p
GAS "EA. SYSTEM -1 INC.4 OUTLETS
BUILDING D ISION FEES
Company
GAS- EA. SYSTEM -OVER 4(EA)IFEE
q
PLANCHECK FEE V
❑ Cmified col is It
GREASMIDUSTRL WASTE INTERCEPI ORGRADING
F£F.
❑ Certified cop is file dt c city inspection divisio
GREASETRAP
SOILS ME
CER' FTCAT (1'EXEMP ON- 1WORKERS*
CO ENSATION INS ANCE
SEWER -SANITARY- STORM EA. 200F1.1?NERGY
PEE
pTtisseatinn rte. of he,complmed ifthe it is foron Mind dollars 1$ 100)
m ins.)
I ttnifythat in Ill rmencc of lh mkforw this permit is issued. I shall
not employ any parson i any mann orae subject to the Worker%
Z Corepens:t ion [.Los, Cali lit. I tc so us
Applicant
a
z NOTICE TOAPI'LICANT:If making this CF 'tr epuo
ATER HEATER W/VENf/LLECTR
PAID
Da tear #
ATER SYSTENUTREATING
E RESIDENTIAL PLM1IB. SQ. FT.
T AL:
(-i,, become subject'. the Wonka x compensation proves mus(
> forthwith comply with sucM1 s ns or Mis its deem ed.0
RU 10 % NG
^
l L lw
•1 .I .I.
TOTAL:LLE
RI £E
7 Z 1 hereby affimt thin th p tion Irn age y for he ormance of
V O 'he wink for whiehthis pc it i7as (Sce. 3097, b )
fl. Lenders Name
F Lender's Address
U I certify thin I have ad this cep cation and state at the above information is
>. corrttl. lagan to comply ith vll city and county o antes and state laws existing ro
.a' buildingconstruction. an eexti,tt horizerep artifices of this city to enter upon the
U Z uhovcmentioneJ ansae for inspection It osn.
(We) agree to save indemnify a cap harmless the City of Cupertino against
liabilities,judgmenls.c 1. evndes a Ir It yinanywayaccmeagainsrsmil City
Q TY. MECHANICAL PERMIT
Pf, INO FEE
PERMIT ISSUANCE
MEC NICAL FEL
ALTER OR ADD TO MECII.
CONSTI1 CHON TAX
AIR HANDLING UNIT (TO 10,(10) CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
eomeq he yra in t Permit.
EXHAUSTHOOD(WMUCI')
PAID
cof pplicw nmraa r ate
HEATING UNIT IT 0100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Raaiplp
IIIiATING UNI 'I'(OVER 100,000100,000 BTU)
'TOTAL: i
Will the applicant or future building osamant snort or handle namNoe, material
as defined by the Cupertino Municipal Calc. Chapter 9.12, and the Ileahh :tad Safety
VENTILATION PAN (SINGLE RESIDI
Co t, Section 25532(a)7
❑ Yes ❑ No
Will the applicant or future building occupant use equipmentordeviccswhichemil
hi,mdme; air contaminants as defined by the Bay Arca Air Quality Management
BOILER- COMP CHIP OR RK.000 BTU)
ISSUANCE DATE
rI�� pp p�
tr IAB RY
BUB 100,000 BTU)
District:
NEW RESIDENTIAL MUCH, SQ, FT.
❑ Yea ❑ No
I have rcud the hazardous materials requircmems under Chapter 6.95 of the
SEp 20 1995
California Health & Safety Code, Sections 25505, 25533 wd 25534. 1 understand that
if (he building does not cumenrly have a tenant, that it is my responsibility to notify the
cocoanut of the mquiremems which must Is, mel prior to issuance of a Certificate of
r Ur u INO
�'CI
ISSUED BY:
OOccupancy.u
Owner amhorieeJ agent Data
Owneror
TOTAL:
OFFICE