28690APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES • USE,BALL P,
CITY OF CUPERTINO ;
BUILDING DIVISION APPLICATION/PERMIT -
' 'yf•[ :• BUILI
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BUILDING ADDRESS.
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OWNER'S NAME: "PHONE: CONTRACTOR'S NA
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ONLY
:IECHANCAL "f, PERMIT NQ ^ ^ ^ 0
1ECHANIFIC L k8 t6 LJJ
P IDBNTIMICATION .. , -
- t SANITARY NO. I APPLICATION SUBMITTAL DATE
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--ARCHITECT/ENGINEER:4a8 _ IUU Iss:'lgL 5 ❑•. ,
CON'IP ONE:-
'AC'U - _ _ -z ,s = BUILDING PERMIT INFO
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❑ Consdtant Fees Paid 6y Applicant (Initial), -BLDG - ELECT 'PLUMB MECH.
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LICENSED CONTRAC1nRS DECLARATION QTY. ELECTRIC PERM IT c FEE -
1 hereby firm that I I ti under p n or Inapt 9(,e s - JOB DESCRIPTION
'� a Z dh 3 t 7
mfull foce nd offeet 3 f th 'Be'i neas
a I Pr fes,inn. XC3d and n y llco PERMIT ISSUANCE
�tRESIDENTIAL' ❑KITCHEN REMODEL
UVIceroisCl LC:kL 1 ❑SFDWL
FZy DComt APPLIANCES- RESIDENTIAL❑ADDITION El PLUMBING RE -PIPE,
CTS
DECLARATION ❑ MULTI -UNIT STRUCTURAL .
Z O N Z 1 understand my plans shall he used s public recalls MODIFICATION
PANELS- r _ e _ ❑ MODIFICATION " r.
O $ (3 r '• r UP TO 4o0'AMPS'
. J Pfnal ' El INTERIOR ❑ CHIMNEY REPAIR
O Licc +,.
201 1000AMPS " IMPROVEMENT
OWNER BUILDER DECLARATION i
OVER IOIXIAMPS ❑ BATH REMODEUREPAIR ❑DEMOLITION
1 hereby affirm that I am exampt Even the Couturnmrs License Lawthar the _
C.l f Ila t gre'. ,(Set ]031513 : e add Pone,s e,C ry y 'ty SIGNS ELECTRICAL _ Q OTHER
Ci tL F which itquiresa porrint to viontract.altdo, improve,d e Y any . t ucture / n
pearl ts assonance, abondminee,the pPlm t a peranawfile. r,dalmentrat SPECIAL CIRCUIT/MISC
y
16ath I -amaximestamitothaprovvid IM1 t t L (CM1 Pf r9
0 (eto .
amgwuh Sect 701 3 fIM1e dP . dr
Profess G) P , TCMMPTHR OR DOLE ' 'COMMERCIAL:
bar -
That is exam tM1 s b f tb 11a t d xe pt I A y Y f El BWG/ADDITION [I DEMOLITION
Sealio 903 by yapplicantf permit hl L0e a"limint1 peraltyof POWER DEVICHS El+ENANT ❑ FOOD SERVICE
IF a., ..In t fire hundred do.11 . ($500)t ,
0 ❑ I a. ner Ithe Property rmyempl yee with wab a. Ih r le pancro a s SWIMMING POOL ELECTRIC -IMPROVEMENT
❑OTHER
will d th k d Nstructuret' t ded off d f I (S 704 BusinessT
adfor. fmadmis CW- Th C tat L' d i ,1yi f OUTLETS= SWITCHES,FIXTIIRB.S
".Pon h b Ids ar p IM1 d h k himself th gh N �' aZ
his ow empl yee, pri ded that a e t: m' t 1 I fferedf r NEW RESIDENTIAL ELECTR. �SQ FT. C,M
i' le. If however the building g r i pm t a t Id ith n o y f Ido the / 1 Q
���fff FLOORAREA $/S .FT.
nown b Id II ve th g shat he did u¢t b P fo P I (1
pose L ale 7 rCY)p°\"P, - t� S7Vi
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ny cl \ely 1 hembitterst w •J r TOTAL' -.).
con imctth p ) 7044 B d1r/�I�ffi ) C t L -
L 'd to 1 rIFP Pe ly do Wilds p 1n i QTY, PLUMBING PERMIT 1FEE• �GrC/y/l/n,•o
Ce ncommns l u mods Neta the cptt as) license t uciumbeContractiors
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1. cam Law' . - +"
Ivm exempt under Sec.
it Cformis revsun PLRMIt'ISSUANCE -
ALTER - DRAIN & VHNT-WATER (EA)
Date :VALUATION
O ner•' _
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-erjryn of the followingJI t
�,a Al ION DLCLARATION•t
_ BACK PLOW PROTECT.DEVICE, ':$'
_
JJJ���•i///
z DRAINS_: FLOOR, ROOF, AREA, COND.=
NEW RESIDENTIAL' FUND. SQ. IT.
]•IhrC :eG elf'su r W k C pen-`
eatlo of the Labor Code for the performance of the
STORIES TYPECO
,
-
, FIXTURES"PERDOM`
TOTAL:
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workfnwh ch Nis pemalixi"ued.' •„i' _11 I
Ic nfy ihllh ad this oPp] vidur and state that the above information is
correct. l agree to comply with all city and county ordinances andale laws refining In
build'n construction idM1ereb autharizere resenttircenflhiscil is emm� on the
'❑
I have ad will arraimmin Wc,kaea Courapentatn Insurance, required by5 tion
3700of the Labor Cade, bar the prfmianc fth work for Fl hth' pennu-s issued.
My WorkeJJ,,s C��omP n��sa[nn lniurance carr er toil Polity u e r:
'.
OCC.GROUP
GAS - EA. SYSTEM- I'INC. 40UTLETS /
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION
Cartier _`11�•M AI nPfcy Nd:
GAS-EA'SYS'fGM-OVERO(EA )
Will the applicant or, future building occupant store or handle hazaNdum material
CERTIFICATE OF EXEMPTION FROM WORKERS
-
-
-
COMPENSATION INSURANCE
(Tn fon need not be c'onpleted'fth permit is fewcom hrndm4 dallms IS IOW)
of less) '- -
be
GREASF_ANDUSTRL WASTE INTERCEPTOR
"
B 1 IVISION FEES
PLANCHP.CK
t -
.GREASETRAP /
SEWER SANITARY STORM BA: 200 IT '
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Ic any that nth performancenFth workf heh thisdiPermit ka issued h II
st be b it tl W k 'Com
solemploy Y P Y BQ lu Pen-,
satins Law of CullfrmaD /,
Applicant
ENERGY P .
W... ERI._.IER.W/VFNT/F.LECTR
-
GRADIN F
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NOTICE TO APPLIGAAAE If, otter conking this Cam tette nftcute Exem�h a ou shnulda oa should
_
:ht WATER SYSTEM/I'RHATING
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'become subject in ibe Worker, s n t e a or Cnde you must-
forthwith comply with s ch p nv sinus non s permit shall be deemed iovoked
s CONSISUCTION LENDING AGENCY
1 by ffi that the t i nlending ageneyforthe perfturamme of
the work for which this permit s (Sec 3097 Civ CJ .
Lender's Name -
., t _
.. WATER SERVICE
.SOIL rE p
PAID
Dai ReceiptIf
NEW RESIDENTIAL' FUND. SQ. IT.
AIR HANDLING UNIT (TO 10,000 CFMJ
1' TOTAL
-�
Lend f. Add ..
TOTAL:
BUILDINGF
Ic nfy ihllh ad this oPp] vidur and state that the above information is
correct. l agree to comply with all city and county ordinances andale laws refining In
build'n construction idM1ereb autharizere resenttircenflhiscil is emm� on the
QTY MECHANICAL PERMIT FEE,
SEISMIC PE .. -
INCE DATE,
9 y P y, P
abovo-memioned property for inspection purposes.' :
(We) agree to sa4a, indemnify and keep harmless the City of Cupertino against
liabilities,judgments; costs and expenses which may in any way same against said City'
inconsequence ofthe granting of this permit .
PERMIT ISSUANCE
ELECTRIC P
ALTERORADDTOMECH.
PLUMBING FEE,
AIR HANDLING UNIT (TO 10,000 CFMJ
MECHANICAL FEE
'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATTONS. i^
AIR HANDLING UNIT (OVER I0,000 CPM),•".
CONSTRUCTION TAX
,. II /
...
Signature of App' on am ator - _ .Do a
H ZAM5US MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION
tHEATING UNIT (TO 100,000 BTU)
Will the applicant or, future building occupant store or handle hazaNdum material
as defined by the Cupertino Municipal Chapter 9. 12, and tho-Heahh and Safely
,Coca,
Code Sectinu 25532001 -
HEATING UNIT(OVP=R 100,000BTU),
„
•
Will the at, rmd t r rp, a hmlding occupant use ea Air Qu or devices which
h N cam nacos as deCI. by theBay Area A' Quality ty Management
PAID
Date
.VENTILATION PAN (SINGLE RESID)
BOILER -COMP (THE OR 100,008 BTU)
,4-
Dist
Dish et$ E'
❑Yes El .• -
BOILER - GDMP(DVER IW,IH111BTU) -
"r _
-
AIR CONDITIONER ' - �
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1 have mad theharaidom, materials radefirear,ons under Chapter 6.95 of the Cell
- ISS
it NEW RESIDENTIAL MECH. 'S - ,SQ. PT
`
fomia Health & Safety Code, Sections 25505 255.13 wrid 25534 1 understand that if the
building does net current) have a tenant, that it is my respo isibiliry to notify the occupant
of the requirements which m.t be met prior to issuance of a Cemneate of Oeeupancy.
• Y
11 so
ISSUED BY
Owner or aulhorred agent -Date
s �•'s TOTA1:
'.,;OFFICE. x
INCE DATE,