S 3201 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
rCITY OF CUPERTINO - BUD,D1Nc-ELECTRICL PE IT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 3201
' BUII.DING PROJI'ICT IDEN'I'ill[CATION '
BUILDING ADDRESS'. SANITARY NO. APPLICATION Sli
11BMITTA1.IlAl
04x- v4-t-t- i�-L
WNI?IZS N F: PHONIi: 'S CON'I'kACTOR'S NAME: L C
lAJ\ IkD ' NIC CONI RIII,M '
1
1 RCII"� /gHGINEER: LIC NO: ADDRESS: ❑ 3
'A
CON CI':/!YI" PHONE 13UILUING PLRM1TINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SUCH
(�0- q;111Gv � r /
LJ4CENSED CONUPRACTORS DECLARATION QTY. ELECTRICPERMIT FEE
I hereby affirm that I am lieen.m ander provis;nns of chapter 9(sm nauming JOB DESCRIPTION
O e(aZ wldtS«'Linn](XXtpd b ian3 alibi lh,xlness unA .unJ my liaunxc is ��4:
WOO PERMIT ISSUANCE
.WF intuit limceu Jef s ss DWI. DKITCHENREMODFI,
RUU LicenseQ s 1.iag APPLIANCES-RESIDEM'IAL ❑ADDITION El PLUMBING RE-PII'li
F-Z W Dme Co on I
redly ❑MULTI-UNIT ❑STRUCTURAL
ARCI31'I'ECT'S DE PANELS
ZOrr�z tun .Rtan pbms dndl lcunda am,is r.. MODIFICATION
OZ-M UP TO LIO AMT'S [I INTERIOR ❑CHIMNEY REPAIR
Fa4FW Imemod Prdcaslounl 201-I0O1 IMPROVEMENT []SWIMMINGPOOL3
OWNER-BUILDER DECLARATIONOYER IIXXIAMPS D BATH REMODELIREPAIR DDEMOLI TION
y9 W 6 1 hereby affirm tom 1 um exempt from the Cnnlmelor's License Law for the
Li�ySSOyU o1basingrn,lSeellon]031.S,11-inco.nd Professions Cock,Any city m county SIGNS HLFCI'RICAL El OTHER
mso
413 W y which requires a permit m construct.uheq improve,demolish m repair any mmaure
of ran,nn its issuanec.alno requires the applicant far such permit m Bleaxigned anaunent SPECIAL CIRCUTUMISC.
;!ty That he is licensed pursuant m,heprovasions ofthe Contmcmrs License law(Chapter9
a�p0 !commencing with S,,man]I10DUd Division 3of Rv Business and l'ndeaium Codc)or I HMP ME TER OR POLH INST. COMMERCIAL:
d 11 m e' thus he le exclnpt N.rcfrnm anA the basis'for the nllcgN exenlptinn.Any vielntiun of
[:1 NEW BLDG/ADDITION [I DEMOLITION
4X1 m Section 7031.5 by unyapplicant fore action subjects the applicant n a civil pcoult,of 1'OW DEVICES DTENAN'I' ❑FOOD SERVICE
not more than Eve hundred dollars(4500).
?O Dl,mowner ofthc property,nr my employees with wages auhcirsole cmmpensaion, 5 MM NO POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended nr nliered for said ISee AH4,Broin.. ❑OTHER
end Professions Coddoes
,:'foo Contmcmr'e Licemc In. not imply m ua owner of ) LP.T5-SWITCHES-nxTURES
F 6 property who builds or Improves there ,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NE R' 1 iM L LLECTR SQ Ff.
sale.If,however,the building or improvement is sold within one ycurnfomodebot,the �'1 ^ SQ.RR FLOOR AREA S/SQ.14.
owner-huilder will have the barren of proving that he did not build or improve for pur- 27 7 IJ /'�
mum of sale.). / 0
D L us owner of the properly,an,exclusively conau,ling with Iieensed conhncmrs 1. 'I'f1TA1,:
amxwet the project(See.9044,Business and Profesaians Cadc:)1'he Con..... s Li-
nsclawdoesnotapplytoenownerofpropertywhobuildsorimprovesthereon,and QTY, L I PERMIT FEE
who contracts for such farmers with a commends)licemeci pursuant to the Contraclnt's
License Law. PERMIT ISSUANCE
ED1 nm oxenipl nadir Sec. .It&I'C for for,os".'a
ALTER-DRAIN&VENT-WATER(EA) VAI Date .UA1'lON
_
WORKER'S COMPENSATION DECLARATION BACK FLOW PROPECK DEVICE
I hereby allmin under penally of perjury one of the following declarations: J /
❑ Ihavc end will nainwin a Corti 11,zmoI Comma In eel I imm,Ba'Warkee.,Cam aro- DILAINIS-FLOOR,ROOH AREA,CON D, S'ITIRIES TYI'I)C(1N5'PRUC'fl(IN
saran,as provided for by Section 3900 of the Labor Code,far the performance of the
work fur which this)emit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Contpensmion Insurance,as required by Section �-
3]IXInflhcLabor Calc,fnn per'or' 3 ceof the work fn which this permit is ismed, GAS H- 'STEM1t-1 sr� UI'LET 4 OCC.GROUP APN
My W LkCompenswia ru "artier A Pa',y n colic:
Carrier CLAS-1? TEM- ER4(BA)
C.R IPICAT OP EXP.M ON PROM WORKIIR
COMPENSATION INSURANCE GREASE. D S'1 h Wt§'1'
B 1LDINC DIVISION FHIS
(Th'yy��ecfiu n t�d9 fJW(�gn9 ts�f r tyh lredd II ISllll)) v'••' ------ ---
nrlcea7 j e to (n V -'F�J /G/f / um a ars GREASETRAP PLANCHLCK :H
Ice yt win the pe rmnnadif777FFF Ii is s permit k toed,l shill SEWER SANITARY-S'FORM EA.21X1 PI'. /
not employ any person in any manner sit as to became object the Workeri Compen- ENERGY IT"
,Z sation Lows of Califomia.Date
Applicant -- GRADI r iii
? NOTICE TO APPLICANT:If,atter,nukinghi,Cenihcam of EVempfian,you nh.nld WgTER SYSTEM/TREATINO
b .subject to the Worker's Compensation pro ,,kens of the LaborCode,yon nmef SOILS THE room
forthwith comply withauch provisions or this forms shall o,Jeered revoked WATER S17RVICE
Q. z CONSTRUCTION LENDING AGENCY f NEW RESIDENTIAL PLMB. SQ.FT. PAID
Z Ihereb IBrnuhanherersa construction londin for the rformunecut Date ILaerptM
hereby gagcncy pe
L) tots work far which(his at rah Ls Issued(Sec.3099,Cls.C) en Ma drL
Lender's Name TOTAL:
V Lender's Address 'TOTAL. /
�•n Lf� PCONSTRU
G ITI
[.., 1 certify that 1 have read,his application and state that the above information is
h corrcm,I agree n.comply with,Jl city and county ordinances and swm lawn miming m QTY. MECHANICAL PERMIT FEE
U f� building cnnwrurcion,and hereby aulhnrim reprenmanllves of thin city minter ulmn the _ SEISM PI?P
a use-or limned aropeny for inspection pu:pnsex' I PERMIT ISSUANCE Nr/ 'I
(We)agree m rave,indemnify and keep harmless the City of Cupertino against IC .4'
liabilities,judgments,costs and expenses which may in any way acme against said City AINER OR ADD TO MECH.
graining of lhi.x per n it
AD�L, ;h,
RSTANDI?')J VL COMPLY WITH AI. NO Po N`I , "' AIR HANDLING UNIT([( 111,1100 CPM) x NICA FEE
,- _
s + AIR HANDLING UNIT(OVER 10T00CFM) " ION TAX Dam EXHAUST HOOD(WMULT)HAZARDOUS MATERIALS DISCLOSURI! O MI' CATION FEIi
Willtheapplimm.,Colo.surfing twenpan store or handle hmnrdemnacnal HEATING INTI CIO 100,000 BTU) +') 31,
as refined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety /1
Cadc.Section 25532(,)'! HEATING UNIT(OVER 100,00D B1 Go
❑Yes Nn - PAID
ch VENTILA'HONI'AN(SINGLE RESID) Dme Rcccip
Will @e an c mm i future building by the[l use ea Air Qu or devices Management
tit hmallous air armaninanlox JcfineJ hY the ltaY Arca Air Quality Management BOILER-COME(3HP OR IfD,lN1U BTU)
Dinnet? - BOILER-COMP(OVER 100,0(X1 BTU)
D vex
I b renal the mearrons materials requirements under Chapter 6,95 of the Culi- AIR CANOI'f10NER ISS ANCE DATE
quirenan
furain He' I &Safety Cate.Sectio 5505.25533 and 25514.1 un .land tom if the NEW RESIDENTIAL MECH. SQ.ET.
buil ' g not currently have t.tots it is my respnnsibi rymn ify the awcupant _ X— i T
.r a m(Icomfuts,ine t mm issmyr t ,aaney.
Uate TOTAL. ISSUED I3 Y:
OFFICE
lt "I'iP.08TITH1810ARD NEAR FRONT,OF BUILDING I" 3 " A A 2 "•
CI•IY OF CUP4►t'1•Q•10: ' - ' t ,. I No;,•
1 BUILDING DIVISION' lr�' «;4"P.JBUILDING PRW IDRNTIPICA I4 ':ct.]' _
1 BUILUIt ADDRESS: O ♦ ���,�` �Cf /�/i. 4,�r ; SANITARY NO APPLICATION SUBMITTAL DATE
f '�•'J OW 'R'B PHONE: CONTRACTORSNAME: - NIC /CONTROL#
/ n
r: GINEBR;:,(.• LIC NO: ADDRESS: .T' ❑ / y
r r vit.''u,�rff cftiriJ�Ya/f 1yy d lw Irltt,({ Y't4 F':n• l ^ :'• ".Y.'•`.:t:iBU1LDING PERMIT INFO< '
kI W� .141,NSPE�I'fON$k"1,�f ¢r >IS)DATE s�$I IN$PEC.j ❑ Consultant Fe III by Applicantl !niHel) LDO ELECT PLUMB ME
k I� 'fNF y� +.;•'.'Ir .Hn /gam ��H
u,:?w'�•P.7 ,�;4�It
FOUNDATION/PIERS/H.D.S. INSPECTION RECORD
NOTE: ALL GRADING AND DRAINAGE 108 DESCRIPTION
LIFER GROUND
- PAD/SETBACK-CERT SHALL BE INSTALLED TO COMPLY WITH SFDWL ❑KITCHEN REMODEL
THE APPROVED PLANS AND CITY OF ❑ADDITION ❑PLUMBING REPIPE
ARAGE SLABS/PREGUNITE CUPERTINO STANDARDS. ❑MUCH-ueIT ❑srauCNRAL
MODIFICATION
• ',POUR`NO CONCRETE,UNTIL,ABOV ,HAS•REEN SIG•ED• TO ARRANGE INSPECTION ❑INTERIOR [I CHIMNEY REPAIR
UNDERGROUND/SLAB CALL AFTERNOONS (1:00 PM - 4:30 PM) ❑IMPROVEMENT 0DEMOLINGPOOLS
BATH REMODEI/ItEPA1R ❑DEMOLITION
PLUMBING 777-3228MONDAY TO FRIDAY 24 HOURS BE. E)OTHER
ELECTRICAL FORE REQUIRED INSPECTION. JOB ADDRESS
-DD NOT POUR PCOOR'UNTIL ABOVE HAS BEEN'SIGI) AND PERMIT N ARE NEEDED WHEN PHONING.
.... .. .,... .._.. ...,, _.. .. ._._. . ...NE.. COMMERCIAL:
PLUMBING ATTENTION CONTRACTORS: GNEW RLDG/ADDITION []DEMOLITION
MECHANICAL - a NO PERSON(S)SHALL PERFORM WORK ON ❑TENANT
#ENT [I FOOD SERVICE
' THIS JOB SITE WITHOUT BEING IN COM-
IM
ELECTRICAL PLIANCE WITH WORKERS'COMPENSATION
FRAMING VENTS INSURANCE REQUIREMENTS.
INSULATION SPECIAL INSPECTION REQUIRED ❑
INSPECTION DATE INSP.
' PLACE
_NOSlJ9F1.00R;UNTH•ABOVE;HAS.HEENiSIGNED?
ROOF SHEATH/DIAPHRAM
PLUMBING . - (C
TUBS&SHOWER PAN
MECHANICAL
ECTRICAUPOOL BOND
RAMING/STAIRS/E.EGRESS
INSULATION/VENTILATION
VCOVE,RI ,WpRK',UNTIE'ABO•__HA$BEEN:S[GNED'°'i%?
EXTERIAL SHEARIHOLD DOWN
INTERIOR SHEARMOLD DOWN
SHEETWROCK/SHEETROCK SHEAR -
• EXTERIOR LATH/W-SCREED -
SHOWER LATH
`.NO;TMEbR PIiASTER;IINTE,IABOVE HAS'EEEN,SIGNED
SCRATCH COAT '
SEWER/WATER
OCCUPANCY. '=
ELECTRICAL
GAS
PIT W WK
GAS TEST
GRADE
FIRE ` 77
HANDICAP
ELECTRICAL
PLUMBING
MAR Q 8 q9
CHANICAL
'NERGY
• VISUAL FINAL ONLY CERTIFICATE OF OCCU
DING ' A IMPORTANT: I UAt• +pRTE
PdI11 ,� Ea •¢,�„ { �?'>6P[k� PLEASE READ REVERSE SIDE BEFORE. --Imo`'”-•• •� '
UhTI�( IFHQ L S SI EI DI OJf CALLING FOR FINAL INSPECTION I I —7- Q
YNSPECT R LL
APPLICANT'S POSTING COPY