28500" _APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
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CITY OF CUPERTINO '. BUILDING- ELECTRICAL. -
BUILDING DIVISION ` ' APPLICATION/PERMIT' PLUMBING. MECHANICAL.
�/�
PERMIT NO. 28,500L
I 2 }(',C O O L
L IJ J
BUILDING PROJECT IDENTLFICAT'ION
BUILDINGADDRESS:. -
S pia e. .•4 -e -e ct' P, CR, 5L So)
SANITARY NO.
-
APPLICATION SUBMITTAL DATE
L?j�7- fr
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OWNER'S NAME :nn (nJrr,O �^f ,^� k�PHOVNP
CTo 1
C NTR CTOR'S NAME:_' ' LICNO,
� NC..�s/or 52.29Y�
NIC
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1` `_ `(L /C� 1o0-730-71
55
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^^CONTROLIt
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1/ C
RCHITECT/ENGINEER: LIC NO: -
)y..r ',
ADDRESS. -
1365.' V L2
CONTACT. PHONE:
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EUILDING 'ERMITINFO'
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❑ Consultant Fees Paid by Applicant (Initial)'
n. . ,. 1 i ..
BBf�(D�C� F.LE , , PLUMI MECH
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LICENSED CONTRACTOR'S DECLARYDON
I hereby ntfinn Nm I am licensed under provisions of Chapter 9 (cmnnnencing
QTY ELECTRIC PERMIT PEP.
JOB DESCRIPTION
with Section 7000) of Division ] ofthe Business and Professions Code, and my licedse is
in full forceonl effect. -
License Class Lic.#
Date Commemr
PERMIT ISSUANCE. -
RESIDENTIAL:
<O SPD WL TCHUN RF.MODIi1,
❑ADDITION PLUMBING R&PIPE
[]MULTI -UNIT El STRUCTURAL
.:,
APPLIANCES -RESIDENTIAL.
''•
-ARCHITECTSDECLARATION
..'lundersumd my plan.i shall be used as public renrNst'.
PANELS � s -
• i-•'
UP,02WAMPS
_.•"MODIFICATION ,
r[]INTERIOR []CHIMNEY REI FAIR,
IA1PROVEMIiN
Licensed Professional
20L1011(1AMPS _
'• .OWNER -BUILDER DECLARATIONp
1 Therebyainrm that I um exempt !mm the Carame ate., License Law for the
following reason. (Section 7031.5, Business and Profession; Code: Any city or county
which rectums a permit m concomet. Cher, improve, demolish, or repair any structure
❑BAl'H REM :I/REPAIR []DEMOLITION
_ .
C OTHE
_ _
OVER IWO AMT'S
_
SIGNS ELECTRICAL
prim to its issuance, also requires the applicant for such Permit o file a signed stammem
SkCIAL CIRCULDMISC.
-
thmheis oOviivsiiosinnsnmJfothfeLsaaiwun('
TCMI', METER OR POLE INST.
•: ' r
Code)r9
thCe Businessland Prmeel
(commenmg with Suersduiannnt7m11t)h(peoprf
That he is exempt therefrom end the basis far the alleged exemption. Any violation of
Semiun]03t.5 by any aPPlicam for permit subjects the applicant macivil pewlry of
,it re than rive hundred dollars ($500).
[] NEW AA DITION ❑ D LITTON '
[]TENANT �,// OD SERVICE
POWER DEVICPS
WIMMING POOL ELECT RIC
I,isowrenrflhep..*,ny,ormydnptoyeeswithwagesasthcirsmle'nimpensmion;
Tvo he work, and the structure is not intended oroReredfnr sole (Sec.... Business
Cad R slam Code: The Comrecmrs License Law aces not apply to Ca owner of
IMPROVEMIi
[]O'I'HIiR
OUTLET'S-SWTI'CHES-FIXTURES e
pmpery w r huilds,or improves themon, and who does such work .....
his own employees, provided that such improvements aro nm intended or offered for
NEW RESIDENTIAL ELECTR SQ ET _
SQ. FT Ph00 AR FA
$/SQ, PT
sale if however. the Thudding v; improvement told nh one year if completion, the
owner builder ill have Ne h en f pmv NCI h it'd m1 build p for par
you of sale.).- '
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❑h (ifthepc)Y eve t thl d t mrsm
n
]o B ti t t s L
Li -
'• "
QTY. PLUMBING PERMIT FEL'
reuseconstruct it., a.eet y
's L t er ly t p h las mpm them...and
1.
c
who mntmro foram, c cased pars nano the Cnmrecbh
u
PERMIT ISSUANCE
_
License law.
1 lith exempt render Soc. - - -:, 11 & P C far this reason
"
ALTER -DRAIN & VEN'T=WATER ([S)
VALUATION
1 .
L,� -Q
Dae -
Owner Date
1. 0 WORKER' 'OMPI!NSATION OECLARA'IION
_ BACK FLOW PROTEGE DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
I[]
-` D
_
DRAINS- FLOOR, ROOF, AREA. COND.'
- -
(have Cnd will mainminCCeni(Icor of Cnncennn calf -insure far Worker's Gnnpcn-'
aomkfa provided for by Section 3]1X1 of the IaMu Code. !or the perfommnce of the
Nis Island d..
work base
SY) 1
-
U
t'YI'li CONSTRUCTION,
f.
FI%TURES -PT.R TRAP
aid e y a by Seuion
❑ I huvo and will maintain W k
me
-
forth pef r eofthe
c of the w rkfor
-
fmankwhichN' p tuissued
CAS -F.A SVS'TEM I INC. OUTLETS. ° r�
• . .. APN
MyWor er'aCompene oliv
Ca Worker'a Compensation insurance ranter dna Rdsy number me x
Cartier_ � Pohcy Nn
CERTIFICATE OF EXEMPTION FROM WOR KERS'
As f.COMPENSATION INSURANCE
Opicacidwitneed nmbecompleteAifthe permit isImonehundred d.f ta,SI OB
others) -
JH, ��
H
' i0fiANNODIVISIONEnns
GAS EA SYSTEM -OVER 4 EA,)
,' GREA_SIMNDUS'I RL WAST 11 INTERCEPTOR -
GREASETRAP
PLANCHECK PER
SEWER -SANITARY -STORM EA. ITs'
..
I certify Nat in Nove perfnance of the work for whichauk,smtit is issued. I shall
,lot employ any persany on in carman an um b
s ecome object the WmkCp, Canape.
perr
-
ENIiRGY FEE
WA'I'ERHEATpRW/VENT/I?LECTR.
A li Lnws of CCiifornia, Data
Applicant
GRADING FEE x
NOTICE TO APPLICANT If, far making Nis Cenlficme of Exemption. you should
become subject ro the Workers Compensation provisions of the Lobar Code, you must
WA'DERSYSTE1,14REATING -
SOILS EEE
forhwith comply with such provisions or this permit shall be deemed revoked.
WA'IHR SERVICE
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NEW RESIDENTIAL ELMS. %Fr.
' CONSTRUCTIONLENDINGAGENCY
. I hemby affirm that there is a connmetion lending agency for But performance of
PAID
Date RCCCIIB#
the work for which Nls pennii is Isiued (Site 3097, Cl, C.)
Ixnders Name
"' TOTAL: -
l.ondees Address
BUILDING FEC 091 Ar
1 certify that 1 have read this application and state [hat the above information is
reel. I agree meomply with all city dad county ordinances ami sate laws relating to
building construction, and hercby auNdriu representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
S17 ISM IC FEF.' IOU
'
PERMIT ISSUANCE -
ELI!CIRIC FF.1?
aMvementihneJ propcny for inspection puryous.
(We)agree to save, indemnify and keep harmless Ne City of Cupcmdo against
AI.TERORADDTO MECIL
PLUMBING FEE
liabilities,judgments, costs and expenses which may in any way oceme eguldI.Ouid City
in consequence of Ne Scenting of this permit.
'AIR HANDLING UNIT (11) 1O,OW CFM)
APPI ICANT IT DERSTANDS,AND WILL COMPLY WITH ALL NON -POINT
SOI/I�CF/�^itEGitA////T���IIOONS.
I -
MCCHANICAL FEE
AIR HANDLING UNIT (OVER In,OW CFM)
CONSTRUCTION TAX
p •�
t�rS/22 /lr
Signatuuof Applicant/ mnlmeror,- - Dote-
RDOUS MATERIALS DISCLOSURE
EXHAUSTHOODIW/DUCT) eu
HOUSING MITIGATION FEE
_ HEATING UNIT TIO 1 W,WO BTU)
Will Ne epphe morfuture building occupardsrore or handle hazardous material
as dehred by the Cupertino Municipal Code, Chapter 9.12, unit the Health and Safety
Crile, Section 25532(a)?
'
I THAI D46UNIT(OVER 100.100 BTU;
_- h. ,
❑Yes ON.
Will the applicant nr forum building oreapam use egalpmem or devices which
emit hazyninux air contaminants as defined by Nn Pay Area Air Qualhy Manngemenl
Distinct? - ' �� 'a
❑Ye5 ON. r
PAID -.
Dom Receipt#
VEN'r16ATLONPAN (SINGLE RESID)
BOILER 'COMP (7HP OR IhI1,f1H0 BI U)
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TO'I'AI: '
BOILER -COMP (OVER'100,000 BTU) ,
AIRCONDITIONER .
t
' Ihava mad the hmm�lnus mamrinls reyuirenrrntx undo CLuparfl95 mf the Cali-
ISSUANCE DATE '
NEW RF.SIDCNTIAI. MECIi. SQ PI'.
fnmi Health A Safety Galt Sections 25505 25533 and 25531 1 understand that if Nc
bmld'Or gdees not curtemlyhaveamnem, then Y. y pomibiirymmufy Nc occupant
s
of Ne requirements which must be and piton ofd Ccnrfcaanf Occupancy_
ISSUf:D BY:
Owner or authorized agent Dam
-�'fOTAI,: ,.
OFFICE