28351 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO -- --isui��7F7;-^i.00TRC.i, -- - - - r'RM17iv- -BUILD l is mvlsloN APPLICATION/PERMIT PLL'MHING-MECHANICAL I n p q J
s, BUILDING PROJECT(DENT 1F CAT_ION -o-r T'b;4/,i,l L O J
BUILDING ADD^R1ESS SANITARY NO I AI'PLICA L/Y4111]u[sMt UAL DATE
LOT X I
W�{'iRS NAME ,!//' �PH/pN E. O Cf0 'S NAME
9� LfCN
/ J7e A"T N/C C�RUL#
F,C F/ENGINES LIC NO _ S. /� // I ❑ //�,� /�
CQ� . `o: iS,?L;a. =BUILDING PER
INFO
/�// /� QTY. .�,.�'". <.ELECTRIC PER T' ><.t••�y FEE U' _
TG�37J/ , E.+. . . .r. ELF. LUMB N�ECFY/
PERMIT ISSUANCE TTT�YY�LYDYYLG..,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL SH Dg p[gCk1I'PIO
gyCg Ihereby atfimrthat
xon smliccnsedunes and provisions ,Chate. (commencing mmrncin%wnh M�rfJ�JIA/i�/I
WCO SerlKKee andtef Dtvuirn3ofthe 8m'nresv and Pro(nnons Cade.and my brenxnin PANELS
F-, use and effe Conrme � ��� UPT HIDDAMPS
�r 301 IOfX1AMP5 _
F�.z ARCHITECTS DECLARATION }cy4!a .t I✓i. SQ.FT.FLO R A EA g FC
'ZOu, lundersund my plains sM1all be used as public records. l/•� OVER IWO AMPS r
SIGNS ELECTRICAL
Licensed Proic,ou'l
i'XCG OWNER-BUILDER DECLARATION SPECIAL CIRCUI'f(MISC.
XOC 1 hereby affirm that 1 am dempl rant the Contractors License Law me be -
lD��m following reason,(Secoan 7 0315,Business and Professions Code.Any city or county I TEMP,METER OR POLE INST
which requires a permit to constroa,tiller.improve,demolish,or repair any structure
POWER DEVICES
toNat he is licensed pursuant to the provisions of the Contractors License Laws(aChspret I — (
o•P.oa' 9(commencing with Section 7 000)of Division 3 ofthe Businessman Pmkssions Code) SWIMMING POOL ELECTRIC
Xmm VALUATION
wt but he is exempt thercfmm said the bases for the alleged exce,uon.Anyvoslauona OUTLETS-SWITCHES-
F-Za Section 70315 by any applicant-for apeimnsubJcclathea,preca toamvd Penalty of _ - FIXTURES /'•
X40 not more than five hundred dollars(S5(W). — - 2oi0�
�F� ❑ yssownaoftheproperry.mmyemploytts with waguasfievsNecompensauun. NEW RESIDENTIAL ELECTR _SQ.FT. I STORIES TYPECONSTRUCTION
L 3. will drehe sions and a she Contractor torinten ease Law does not apply 1044.Business —
and Professions Code The 's License Law does not Noun m an owner of .
It .hk propenywhob.phovoimpbe'suchereon,:uMwha doe mummodbebmselfm far ub.hitI OCC GROUP RES.UNITS
I wnemployces,promded thatsuchimprovemrnrsae nolinrendedoroffercdforsale.If.
however,the budding or Improvement is sold within one yearof completion,the owner-
bomWrr will have the burden olme,ong that he did tat bald or improve for purpose N /-
a❑)14a ownerofthe PropenY,amexclusivelyconuacung withlsemcd ronuat to Q i PLUMBING PERMIT> i- '} PEE7NI FLOOD ZONE APN
MV a 1 G :LkaC `Yhb • br�Y
consnna the pmJar(Sea 7044.Bunness and Nafessiam Cndr:)The Contractor's I 1 PERMIT ISSUANCE
Uce,smem Law saes itch prof m rn ownerorpmpcny whobuilds orimproves Comm",and
we'rese mess forsuch projects with nennuacmils)licenses DUrsuantmthe Canrtactors
ALTER-DRAIN&VENT-WATER(EA) a,? '`5b,4 mow^=i
E] Iamex rq. - ,'P EE SUMMARYv a.«`c'%^hxjJrj
❑ 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE Ina .v~ OltTV mt FEES
_ SANITARY Y N
3 rte I DRAINS-FLOOR,ROOF,AREA.COND (SCHOOL TAX YF.CE1PrX N--
wncr
WORKMAN COMPENSATION DECLARATION
❑ Iherebyaffirmthatlbave aerntficem of conxmmxlLmsure,oracertificme of /� RFCEIP #,.
Workeri Campensenon lnsv.rracemfred copy thereof(Sec.38W,lab C)worst I L,FlXTl1RE5-PER TRAP ' ��' (PARK FEE Y N__
covers all employees under this permit GAS-EA.SYSTEM)INC.40UTLH`S t RE('FTPTX
Policy# _— — __ BUILDING DIVISION FEES
Compass; — -- GAS-EA SYSTEM-OVER 4(EA) IPLANCHECK FEE
[I �� O
Cemfied copy is hereby fumished.
❑ Cenified copy is filed with the city inspection division. GRFASMNDUSTRL WASTE INTERCEPTOR GRACING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE _ _ _
Ur 7rsseenot need nos Mforesse handooldalu (SIM) I SEWER-SANITARY-STORM EA.2001"T ENERGY HE
las,
Icemfythatmtheperfor nceaftheworkforwhahthinpe .,,isesued.l shall WATER HEATER WNENT/ELECTR
not employ any person m any manner sit as to became sub(tts ro she 1Vorkeri — -- — - I PAID
Compensation Lawsof Canaria. D, WATER SYSTEMGI VATING I Date Receipt#
O Z Applicant —
z _0 NOTICE TOAFMICANT:If,aftnrmakag iMs CertiF mo(Ex mpno , ou should I I NEW RESIDENTIAL PLMB. SQ FT. TOTAL.
C become subl ecrto the Worker's Compensation previsions f,ha Labor Code,you must BUILDING
forthwith comply with such provisions air this permit shell be deemed revoked. FEE
—�
y ❑ CONSTRUCTION LENDING AGENCY I SEISMIC FEE —X
a z I hereby atfimt that here is a construction lending agency for the perfoimnnce of T ELECTRIC FEE
U Q the work for which fit,perms is Issued(See 309],Civ C.)
Lenders Ner
'vri" 'e PLUMBING FF.E--
F I<nderx Add, _ Q'1'Y.IF^°}�;4„tiMeCHAMCAL PERMIT .., ,.� FEE,'^”
Wig _ l�-
U f ecmfy that f have mad'61a application end sate that the above aformmion rs '` •'"- 1^``'"`'"`.'v.r'..•w,-;;&w. X„'{'��•ri/b"s,r..me.
F correct.l agree to comply with all city and.ourryordmamces and state laws relaungto ` PERMIT ISSUANCE � T� MECHANICAL FEE
building conswcuon.and hereby uuthonre representatives ofthis city to enter upon the e`7
U Z above-menuaned pmpeny fonnspection purposes. ALTER OR ADD TO MECII. —�I CONSTRUCTION TAX
(Wet agree avc,indemnify dnJ keep hannlosihe City of Cupemno against --
ItabJitins a costs and expenses yacerue agatmtsm,CUy AIR HANDLING UNIT(TO I U,OIS)Cr&H 1 —
m u egronung oft e i AIR HANDLING UNIT(OVER I EpsW CF1,D
way
,,ISlgnemhu of Apphca-T/Commcmr, / Date EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0M BTU) I Date RecmpX
Will the appbwrh"I future building ixcupant score or handle ham mama( HEATING UNIT(OVER 100.000 BTU) TOTAL.
as defined by the Cupenna Municipal Code.Chapter 9 12,and the fieelth unJ Sefery
Code,Section u
n 327
❑Yes 0 N I VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the upphcanmrfumrchmldingoccupam useegmpmem nnlev¢eswh¢h emit I BOILER-COMP(IIIP OR I04,004)BTU)
haenrdom air comummants as defined by the Bay Area Air Quality Management
Drsmap ❑Year El No BOILER-COMP(OVER IUIt.g1)BTU)
NEW RESIDENTIAL MECH. - SQ.FT, l j
I have read the hazadous materials requtheri under Chapter 6.95 n1 the
fdre building does of currently h mans ant.that it is and 25534 I undernwmJ that
dempart of rennmtcurendyheveast he met prior rsuance at a tonmtity the
I !✓rx. V
occupant of the reymtnmems whth must he mcr pnono issuance m a i1•mfium of
Occupancy
Owner air,awhnnrcJ agent Date _- _ K• � ISSUED BY AY/L`V\l
OFFICE K