28399APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDRICAL
APPLICATION/PERMIT PLUMB MECHANICAL
BUILDING DIVISION BUILDING PRfIJF.CTIDP:N'I'IFICAT'ION
PERMITNO.
p A n
O JJ
UILDING ADDRFSS: 1 '�/ D 'J� ^�'�`
`O3� `2l �IiGA�( (f UNIT# LOT Or
SANITARY NO.
APPLICA'T'ION SGRMTITAC DATER
I I I �
VVV
SN h ./� PBONIi C�
l
CONTRACTOR'SNA 10 LIC NO:
N/C
CONT/Nr�OLp
ARC] IITBCI'/INGINFER: I/'�` LIC N770:
"Enw
AD ESS:
❑
^
}V'�
/ 4.� 9
CONTACT: PHONE:
QTY. [ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
IN
BR F PI I1M ECH
PIiRMl9' ISSUANCE
rL�l`'
LI that[aDCONTRACfORSIJECLARAT'ION
amlicerudunder provislessioGTCoe,9nd (commencing with
I herebyaffirmDivision
APPLIANCES - RESIDENTIAL
JOB DIS IPf10N
PANI3L5
3claorcehadof Divisimn3nf the Boniness and Pm@ssiovc Code, and my license is in
full Tome end -Rest.
UP T02W AMPS
/�
"Vvr%0w 1
FL
DateClass Conor
Date Contract
, Y ` ` W
201 - 1000 AMPS
DECLARATION
ARC be used
1 understend plun.s shall h aced ss pontic rccortLs.
OV Ut IWO AMPS
SQ. FI, PL000. ARLA
F
$/SQ. FT.
J`
SIGNS ELECTRICAL
nd
Licensed Rof<ssional
DECLARATION
OWNER-Bcentin
SPECIAL CIRCUIT/M15C.
1 hereby affirm that I oat exempt o n the Comtmet License Lnw for the
T]iMP. MEDiR OR P01.1? INST.
Routine. Co
Cude: Any city nr county
firli.wwhich requir
construt,ter,i
which requires
s a permit to prove. demolish. structure
cmnwe, aheq improve, demolish, or repair any
pemso
its permiuo file tatemert
issuance, m statement
heslensedalsorequ,h the applicant
POWER DEVICES
floe mile Co cishogLa
that he is licensed pursuant to the provisions mile Contractor Bitsi or'c Lid pro Lawn,(Chapter
9(commencing with Stttinn]OW)ofOivision3nfthe Business end Professions Cade)
Code)
'•-
SWIMMING POOL ELECTRIC
VALUATION
inom he isevemee
ptthfromend the basis forthiti legedexemption. Anyviolationof
Section 7031.5 by any applicant for a permit subjects the opplicnm to a civil penalty of
�
IFPS- SWITCHES -IsIXTI1RE5
moduaf ehundmddellars($500).
❑oneproperiy,ormyeinp]oyeeswithwagesastheirsolecompensation,
STORIES TYPECONSIRUCfION
NEW RESIDEN'ITAL ELIiO R_SQ. IT.
willdo Neu and, corm is not intendedoroffred fmsale(See .]0sbL Rtcimess
and Profen in, Code: The tractor's License Law does nm apply to an owner of
pntpeny m bni ldsurimprovcs on. andwhodoes such workhimselforthmaghhis
Ioyeeaprovideddatsuchim ements are not intended reoffered forsale.If.
(ICC. OBOUP
RES. UNITS
T
how- er, the buildingor]mprovememisv within one yearofcompledon. the owner.
had erwillhavethebuNenof proving thath "dmotbuildorimproveforiurpoaof
QTY. I'fAMBING PERMIT ITif;
).
Lasowncr#dhepr oyy,a exclusivelycun0ac gwithlicensedcouthatorctn
PLOOD'l.ONli
ppry
some Ae r Je e . B and Pref. ons Cod J The Comiecmr's
.icenx La who oldsmrimproveathemon, and
PERMIT ISSUANCE
who contracts s c projects with ncneme most lice sedpursuunvothe CGmnaaors
License Law.
AM IiR- DRAIN& VENT'- WATER (HAL
FEIi SUMMARY
❑ ] ant even under Sec. , B & P C for this reason
BACK FLOW PROTECT. DBVICE
TSIDF. FBI_
SANITARY Y N
RECEIPT #
Owner Dore
DRAINS -FLOOR, ROOT, ARBA, COND.
WORKMAN COMI'ENSATIO , mm; cIfimimN
❑ ero'Coyaentan'thatl haven ren aerate f sy there l6in 380Loid, C.) hiof
Wmrkeri Compensation Insurance or acral copy 0errof(Stt. ngW. Lab C.) which
SCIIOOI. TAX YHanchN
RECP.IP'1'p
pl%PORES-1'FiR TRAP
PARK FEB YN
GAS - FA. SYSTEM -I INC. 4 OUTLETS ��
covers all employee's under this permit.
Policy#
RECEIPT X
BUILDENC. DIVISION FEES
may'
OAS -EA. SYSTEM-OVIiN OIPA7
PLANCHECK IsEL 2 O
❑ <d copy is hereby fumishnl
GRFASE/INDUSTRL WASTE INTERCEPTOR
GRADING 192.E
❑ Cenife 'hthee' inspection division.
GREASF'IRAP
SOILS FEE
CERTIFICATE OFEXEMPTION FROM WORKFRS'
COMPENSATION INSURANCE
SHINER - SANITARY - STORM FA. 20OFT.
IiNF.RGY ME,'
(Thiaseeionneed nutecomplaedifthc pera tis fiamic huabooddollars($100)
WATER 11 EATER WNEN TAO.EC'HO
I ecrthy that in the performance of the work for which his permit is issued, l shall
not employ any person in any moaner co as to hecame subject to the Worker%
PAID
WATER SYSTEM/TREATING
Compensation Lowsof Califomia Date
Dee R 'tX
Applicant
NOTICE TO APPLICAN'CII, after making this Ccnafcateof l?xcmptimn, you should
NEW RF.SIDIzNTIAL PLMif. SQ. FR
TOTAL:
become subject to the Worker's Compensation providom of the Labor Code, you must
forthwith comply with such provision or this permit a hall be deemed evoked.
BUILDING PFG
00
CONS' I' RUCTION LENDING AGENCY
SRISMICFEI? S6
I hereby affirm that them is a construction lending agency for the performance of
T
ELRCTRIC FEE
the work for which this permit is issued (Sec. 3(19]. Civ. C.)
Lender's Name
Iandcr's Address
QTY. MRCHANICAL PERMIT FEE
PLUMBING ME
MIiCHANICAf. FEE
1 certify that 1 have read ibis applicwioo and state that the above to forrod on is
erect. Jargon, m comply with all city and county ordinances and code laws rcieing w
PERMIT ISSUANCE
banding construction, and hereby authorirc reprtunutives of thiscity m cater upon the
above-mentioned property for ire "cion purposes.
CONSTRUCTIONTAX
AU[ OR OR ADD TO MECII.
City hi
(War) ug to snvc, inhmi1qdkKpnnin
City ofCupertino eginnliabilities,))/•
ems, ay in anye rues 'nin.
tiny Cary
AIN HANDLING UNIT (1O IO,WO CPM)
in eon 'e of sir :
AIR HANDLING UNIT (OVER BIDS) CTM)
7
EXIIAUST HOOD(W/DUCT)
PAID
Si,me of Appli n 2.m ue Ia
11RATING UNI'I(TO IW,OW BTU)
HATAI DOUS MATERIALS DISCLOSURE
Data Receipt It
Will tiro applicant or I'umre bulIding occupant store or handle hmurlous material
u. defned by the Cupcnino Municipal Code, Chapter 9.12, and the Health and Safety
I MATING UN IT(OVRR 100,000 B'I'U)
'1'O'1'AL:
VENTILATION FAN (SINGLE RMID)
Code. Section 25532(x)?
❑ Ycs El No
Wilhhee licant nrlmurebuildin aro amuse- mrdeviceswhichemit
PP g 4uip
I1011.IiR-COMI'(3HI'ON IW,OW BI ED
ISSUANCE DATE.
If1 p B a�
P
BOILER - COMP (OVER IW,t%111 BTU)
h
Jiron air conmminents az defined by the Bey Area Air Quality Management
Air
ia e?
W
U
❑ Yes ❑ No
J U` 2�
NIiW RESIDENTIAL MECII. SQ. FT.
1 have maile harNus
N nomammas re Laircments under Chapter 6.95 of the
California Halth & Safety Code. Sections 25505, 25533 and 25534. 1 understand the
^I
0
lithe building doesnnt comamly haven tenant, thin it ismy respmmiffiddry to notify the
(. P
occli,m OI'tho recidan tent, which must be met prior to Issuanre of a Certificate of
0
Occupancy.
ISSUED 9Y:
Owner m authonxed agent Dee
A1.:
OFFICE