28009 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OF CUPRR'I'INO nmcarnT;^P.LKUI RrCA. PERM]pNO. 28009
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APPLICATION/PERMIT 1'LW1BISf.- F.CIIANICAI.
2 8 0 0 V
BUILDING DIVISION BUILDING PROJP,CI'IDIENTIFICAI TON
BUILDINGADDRESSS� SANITARYNO, APPLICAITONSUBMITI'ALDATE
V I UNIT 0 LOT N
OWNS 'NAME:' y PHONE: CONTRACTOR'S NAME: L5�
035 9�
k� `IqG—Aloo N_
ARCHITECIDEbOINEER: LIC NO: ADDRES�dS_� nG�� N-V C� El PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE. CEJ(
BLr ELECT PLUMB ME❑CH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL f0 DESCRIPTION
g04Z I hereby affirm that l am licensed under provisionsofehapter9(commencing with L�gtf G�i Mn[y f
FOO Sediun]fKKl)af Division Jof rhe Businen and Pmfcaaiona Code,and my liameis in PANELS / 4
VF full Somatic!effect. II
FZtVy. License Class�C3. Lic.N UPT02MAMPS Sell�p G!'s
m7w Data 7'/'S Sf"' Contractor s1 ! 6/en� 201-1000 AMPS
Z O,N? ARCHITECTS DECLARATION OVER 1000AMP5 SQ.IT.FLOOR AREA S/SQ.IT.
OZ—CI I mdemund my fdaremall he xsod.e public mcords.
1=vsf'; SIGNS ELECTRICAL
yEJ Licensed Prssfcasbnal
yed6 OWNER-BUILDER DECLARATION SPECIAL CIRCUTT/MISC.
YOc. I hereby uffinm that 1 ren Attempt from the Contractor's License taw for the
m 3 a y following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
which reyuires it permit a consuuct,After,improve,demolish,or repair any suucture
�W} prior to its quires issuxnm,.I,.rethe Applicant fill such perm.file A signed moment POWER DEVICES
of C a0 O that he is liecn¢d pursuant to the provisions ofthe Commctm's License taw(Chapter
d� 9 c with Section](KKUof Divi.inn 3.Uhe Bminnamed Pnsfessions Code SWIMMING POOL ELECTRIC
xo (mmmen ing wi ) VALUATION
,Mm ,,hot bets crempnmbefirom and the breis forms alleged exemption.Any violNonof
FZa Section 703 LS by any applicant for a permit subjects applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES !'!' Gd
5=0. not edam than fiv0). �OVVe hundred dollars
sFo ❑ T,aanwncrofthe property.ormyemployms with wngcsnstheirxnlccmnpemation, NEW RFSIDEN'1'IALELECTR SQ.II'. STORIES 'TYPE CONSTRUCTION
willdothe worried the structure is not amended reoffered for We(Sm.]OM,Business
and Professions Cale:The Contractor's License Law docs not apply to an owner or
pmpcnywhobuildaor improves thereon,andwhodsea such wad himselforthroughhis
cmpinyux,pmvideJ tbm mach impmrcmcntxwc mat inendel orolRrN(nrsWe.If, OCG GROUP RES.UNITS
however,the building or improvement lssoldwithinorm yexreformpleion,themArmo 'TO'T'AL: (•�//f
builder will have the burden of,eving that he did not build or improve for puryuuof J / K
ulc).
❑ ].As owner oflhe Property.ant exclusively contracting with licensedcamraRon to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.70414.Business and fortifications CWe,)The Contractor's
Limm,Law does not apply to an owncrof propsnywhnbuildsorimploveatheeon,and PERMIT ISSUANCE
whocentncts forauch project:with a contraemr(a)licensed pmnuant to the Contrvetors
License LawALTER (FA) FEE SUMMARY
❑ 1 ren exempt under Sec. 6&P C for This reason tlACK FLOW PROTECT.DEV ICE OUTSIDE FFF_S
SANITARY Y N
Owner Dae DRAINS-FLOOR,ROOF,AREA.COND. RF.CEIpTN
WORKMAN COMPENSATION to RATION SCHOOLTA% Y N
❑ IhertM1y affirm th llh enl t f n Aclf ff f RECEIPT.
W.,mrs'Con,cadibmi 1 rnfedc ,th f(Sm.3800 Lab which FI%TURES-PER TRAP PARK IFE Y N
crimerriPolcy xllempl`yeeG9tdctg�rmLL Jit cw BUILDING DIVISION IFES
til AA// 1I's�r 11 )) GAS-FA.SYSIIiM-I TNC.40fI1LETS RE FIFTS
Compo
/, GAS-FA.$YSTf M-OVER 6(FA) PLANCHECK HE Ccnlied r
icopy hereby fumiahed.
❑ Cenifted copy is fled with the city inspection division. GR9t SidBNDUSTRUSWASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXESIVI'ION FROM WORKERS' y^^ GRPA`E i(FRAP } SOILS FEE
COMPENSATION INSURANCE '
leas !
(This,mion need mol he cmindt,difthe permit is tarots htuldrsd1,Slao(31f10) SEWER- ANITARY-STORM FA.200F'T. ENERGY FEE
or
I cenilY that in the perl'urmance ofthe work fugwtiidh Nis permit is ismav,l aha � WAS HPATER WNEMJELLCfR
mol employ any Amon to any manner so•mtis become sex^je`I m Worts PAID
is
Compensationlawsof Callfornis. Dabcse ` ✓ \ ti A EM/rkaA f�O
h Use ReceiptM
O O ApplicantY/T\ t,
NOT ICE TO APPLICANT:If..fm,making this Cent eo Ea�' ILN Iiiatiildld R' IACPLMIL SQ.Fr.
m
Z V_] tecoesubjecltothe Worker's Compcnkation prevision Pylic{faMrPrttsde,yyrmue1
4f 1
0 ish m
7 forthwith comply wsuch provisions ur W.Pedt shalQbe QeCamMedd/ eked/ / ��'r'� BUILDING FEE
FN
y CONSTRUCTION LENDING AGENCY A'�I� SEISMIC FEE
Z I hereby affirm thaubee is.c.sedrui leading agency f(Che performane of s.;..
c
U O the work for which this permit is issued(Sm.3t)q).Civ.C) y.ns a. TOTAL: ELECTRIC FEE
ll. r. Lender's Name 5-- �, —YN
O F lender's Address QTY. MECIIANICAL PERMIT FEE PLUMBING ME
U 1 cenily that 1 have rood thin application and:gue that the utwv<information is MGCHANICAI.FEIi
La correct.l agree to comply with all city and county mdtndncp And sue laws relating to PERMIT ISSUANCE
Imo-' building construction.and hereby Authorize represendevesa(this city to enerupon the CONSTRUCTION TAX
U Z shave-mentioned property for inspection purposes, ALTER OR ADD TO MECH.
(We)agree In save,indemnify And keep hartnleas the City of Cupertino against
Iiabilittn,judgmcom.cosu andeapenacs which may in any way accrveagainst said City AIR HANDLING UNIT(TO 10,000 CFM)
in wnseyucnee of the gaming of this .it.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicnnVContmctor Dae EXHAUSTHOOD(W/DUC I
PAID
IIAZARDOIJSMA'rF.RIALSDISCLOStJRE HEATING UNIT(10 oti,wo H'fU) Date Receipt.
Will the applicant or future building occupant store or handle haramtrua material ❑GTING UNIT(OVER 100,000 ETU) 'f L
as defined by the Cupcni no Municipal Colo.Chapter 9.12,and the IkAhII And Surety
Gale,Section 25532(q]
13 yes 13 No VENTILATION FAN(SINGLE RPS.) \
BOILER-COMP(311P OR I(M),(NN)B"IV) ISS ANCED
Will the applicant orfutum building occupant use equipmemordevims which emit A B D
hnardoue air contamtnanu as defined by the Bay Asa Air Quality Management•
District? BOILER-COMP(OVER I00,00U RfUJ
❑Tres El No NEW RESIDENTIAL MFCII. So,.FT, JUL 1 2 1995
I have mad the hazardous materials requirement;under Chapter 6.95 of the a
Culitnmia Health&Safety CiAe.Sections 25505,25533 And 25534. I undersand that C�/Y U
Bthe building does not comedy have a anent,that it is my mspanaibilily lonatify the Qt- t/ur J^
,occupant of tir�es re�'d/omater,whi h// r M met prim m tssuanee of A Certificate of tt l•�
Occupancy. /yu� %A
Owner nr authotuod agent Dae TOTAL: ISSUED BY:
OFFICE-