28151APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOHCHAHNO- KLKCI'R ICA],
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT N
IDUriFICAI'](/N
PERNHI NO.
28151
BUILDING ADDRESS:
I�* ciy �/a UNIT# LOT NEss
SANITARY NO.
APPLICATION SUBMI ITAL DA' ll7,
Ills..
OWNE 5 SMF PI10�'ti�� _��
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CONT)IACroR:S AME,: LIC O:
I/' 1
f
N/C
❑
CON'IROLN
RCIII'ILCI'A'NGJIFV
INBER: LIC NO:
DDRB 5: 0 0445UI e
40C
CONTACT: PHONE.
QTY. ELECTRIC PERMIT IFF.
BUILDING PERMIT INFO
BLIH'i ULE PLUMB aylliGFi
PERMIT ISSUANCE
� � El
LICmland ONTRACfOR'S DECLARATION
1M1ercby Affiv ICENSEDCONTRACrpmv DECLARATcr9(commencing with
APPLIANCES - RFSIDFMIAL
A _ IJB)ES ONj_
"'i/// f`. g�.�/
PANELSfull
Scelion]BOIIIof Divixlon 3ofthe Busmesnmd Prormsiom Codaand my license isin
forcand effect,
License Class Lic. #
UP TO 200 AMPS
...a////)��)��.� ^_
i
Dle
Date ConTSD
-I00)
ARC![ he used UECLARecords
I understand my plans shot[ he used v public records.
100P.MPS
OVER IUp AMPS
OVER
50. hT. FLOOR AREA
LSQ. F1'.
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDERr DECLARATION
SPECIALCIRCUIT/MISC.
I ngmby that 1 am exempt from the Cmm�cs License for the
TEMP. METER OR POLE INS'I'.
following n. (Se Co by
To3,re,, alta, and Professions Code: Any city'Locay
wiirM1 riyuims
which Coale) alter, improve, nr rcpeim any sbemrt
alsore tyres
t e, hdeomliml
the for permit's
issuance. cocrit; statement
se
oslecrimialsorequiresto
POWER DEVICES
that hor
she provisions the Co Lice La
that he is rcansrd with
the provinom n the Contractor's ss Licenu c,n rC Coder
Stein. andProfessions Code)
9t
Division Sof the ed
SWIMMING POOL ELECTRIC
VALUATION
hat he in exempthSereimmand the exemption.
Se Inst he in 1.5 by A hmcfrom end the beams for the Althea exemption. Any violation of
Section 7031.5 by any applicant for apermit subjects the applicant wacivil penalty of
OUTLETS -SWITCIIFS-FI%TURFS
not mom than five hu Bred dollars ($50b.
Isny,onnyemployets wen wagtaa.mainaeerrinpen.mmn.
NEW RESIDENTIAL ELECfR _SQ.FT.
S'I'ORIIi5
'1'VI'Ii CONSTlcllC'1'ION
will dom Ins work. ens the atmewre Is wt imenJedomfruel ferule (Sec.7EEL Business
And I'meaxlons Code: The Cobracto(a License Law domes not apply to an owner of
popery who build, or improves thereon, and who does such work himself or through his
me
on employees, provided that such impvmnents not l decoded orof4ted for solall:
OCC. GROUP
RES. UNITS
A �\
wever, the buildingor improvement is sold within onac yearofermpletion. the owner-
hom
builder will have the burden of proving that he did not build or improve fee purpose of
QTY. PLUMBING PERMIT FEE
al.
❑ I, as ow, tier ofthe Property. umexcluaivcly commetingwiIII licensee ninaanon or
11.000'/.ONfi
AI'N
common the projm (Sec. ]UM, Business and Profen,mr, Csde:) The Comintern'
LicenseLrwddesnot applysoanownerofpropeny who buildmrimprova 0ereo J
PERM SUANCE
whoennmel,oa,eenproices wish a contrectoss) licensed puuumn to the Cool cor's
Lwe Lew.
ALTER - DBA .VENT-WATER(G)
FEE SUMMARY
❑ 1 Am exempt undo See , B h P C for is nasoA
BACK FLOW PROINT. DEVICE
OUTSIDE FEES
SANITARY N
RECEIP #
Owner Date
URAINS - FLOOR OOF, :A, COND.
WORKMAN COMPENSATION DF:CGRAI'ION
SCHOOL I'AX T N
I hereby affirm that l have a mnificdc ofcomem b self -insure, amniBam of
oroces'Conrpensation Insurance or a certified copy thereof(See.3g ,LaM1C)wLe"
RECEIP`F#
FIXTURES. PER
PARK ItiIi Y N
GAS-EA.S S 'M- INC4DUTLEFS
cat all employee's under this permit.
Policy N
RECEIPT
BUILDING DIVISION RES
Company
GAS - EA. SYSTEM -OVER 4 Bap
PLANCI IECK FEE
❑ Ccoifiad copy is hereby famished.
GREAS NDUSTRL, WASTE, INTERCEPTOR
GRADING FE.E
❑ Cmifcd copy is laded with the city inspection/isfone
CERTIFICATE OIr FIXEMITION HRS' r
F.TRAP
SOILS FEE
COMPENSATION INS(Thlssenlon
SF. ER -SANITARY -STORM G. 200fT.
ENERGY FEE
menlnot becompleted if theperndrtddollurs )
orI
ATER HEATER W/VENT/F;LECfR
certify that in the ptafmrmancofthe work fomied, 0.111
Is
not employ any pca%on in any to r m toct to Workers'
PAID
WATER SYSTEM/1'REATNG
Compevaionhw—d California. Dates
Date ReceiptN
Applicant
NOTICE TO APPLICANT: If. After making thi Certipeam f f r.you. 1
'he
NEWRESIDENTIALPLI B, SQ.FT.
TOTAL:
m, m e suhjen m the W ..mrs CompenAabmn p ov. oro u' he I: , Code you must
forthwith comply with sucM1 provisions or rniA pe Illandl N, deem vokW.
BUILDING ME
CONSTRUCTION LENDING ENCY
I hereby affirm that them k a comwction lendings
the work for which this permit is issued(Sec. 3097, Civ. C.
/
SHISMIC II?E
/ TOTAL:
ELECTRIC FEE
LenJdA Name
L cod&r, Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that 1 have read this Application and state that the above'Infa used is
correct. l agree to comply with all city anate d county ordinances and state laws rtlttmgw
PERMIT ISSUANCE
MECHANICAL FEE tal
building construction, and hereby authorize representatives oftbis ii"'. 'upon the
ahnvememiimed prol'cny for inspection purposes.
ALTER OR ADD TO MECIL
CONSTRUCTION I' AN
(We) agree o save' enmity and keep tombless the City or Cupertino against
Iitilhodiea,ryJ dexPsmszwhichmaymany wayacerue against id City
IL AIR HANDLING UNIT (TO 10,00o CFM)
in nscy gof this pantie
AIR HANDLING UNIT (OVER 10,000 CPM)
igdmu t Ap li co Dale
EXHAUST HOOD(W/DUCI)
PAID
ORATING UNIT (TO 1W.K 1 BTU)
IIA%ARDOUS MATERIALS DISCLOSURE
Date Rtxm N
Will the applicant or future building amurynt store or handle h-adoua material
As defined b) the Cupcniomo Municipal Code, Chapter 9.12, and the Ilwlth and Safety
IIIiA'TING UNIT (OVER 100.000 BTU)
l L:
Cndc, S«unit 2553200!
11 Ycs C3 No
VENTILATION PAN (SINGLE RFSID)
Willlheu iteadorlubrenu l,in Imes . t ordevicm which emit
OP 6oc:Nsxn yopmcn
Nous me oonutminants m dAincd by the Bay Amo Air Quality Management
°nal
❑ Ycs ❑ No
BOILER- COME (31111 OR leO,000 BTU)
ISSs]'ANAIi DATE
JUN U 5 1995
BOILER -COMP (OVER 100.000 BTU)
NEW RESIOPMIAI. MF.CH. SQ. FT.
1 have mud the hanrdoos de.enels requirements under Chapter 6.95 of the
California Health h Safety Cade. Sections 25505, 25533 And 25534. I understand that
CI1 Y ser Im'Urr tj I INV
if the building does Are cement, have a tenan6 that it is my respomibiliry m nbify the
mupam of the requirements which matt be ma prior In issaudce It a Cenifcem of
Occupancy' -
ISSUED BY=y1
Owner or nmhaizN agent Urate
L:
OFFICE