S 3111-APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
BUILDING - ELECTRICAL
PLUNIBINC.-MECHANICAL
IIUII,DING PROJECTIDKNI'IEICATION
PERMIT NO
S 3111
BUILDINGADDRESS:
9�y off) Tc
SANI'T'ARY NO.
AN ICSFIONSUBMI'ITALDAIIi
OWN, I'k', O I'l1UNG /
CO 'I'RACI OIi'S NAM :: LIC NO:
NIC
❑
CON 'TROI, b
ARCHITECENGINEER: LIC NO: ADDRESS:
CON'IAC'c PHONE:
BUILUINC PEkMI'I' INFO
BLDG ELEQE' PLUM MARCH
❑ CDnsullanl Fees Paid by Applicant (Initial)
❑ ❑ ❑
I.ICENSI D CON' I' RAC 'I OR'S DECLARATION
1 hereby affirm that I .m licenced under provisions of Chapter 9 (commencing
wish Section 70110) of Division 3oOhe Bnsines.und Prnfecsaim, Covellay Incense is
in full fume and an, Z /
Q'pY. ELECTRIC PERMIT
PERMIT ISSUANCE
FEE
JOB DESCRIPTION
RESIDENTIAL;
❑ SFDWL ❑ KITCHEN REMODEL.
License Cluxs Lic.p
Data Carona ur
APPLIANCES-RESIDEN'I'IAI.
❑ ADD[ TION ❑PLUMPING BitPIPE
MOI)IF❑NUI:1'1-UNIT ❑STRUCfURN.
ATION
CHIMNEY
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
[I RAI' it REMOTELOREPAiR ❑DEMOLI1ION
EITHERfollowing...
e'e
. RCI11'IECTS DECLARATION PANELS
I intentional my plansshallbe u.al as public records
11P 10 200 nM15
Llcco.W Pnueo,innul. 2101-1000AMPS
OWNER-RUILDIiR UEU,ARM IONOVER IofNIAMi'S
1 hereby affirm that 1 am exempt from the Commi License Law for the
(Section 703 1 5, Business send Professium Coda: Any city ser county SIGNS ELECTRICAL
which require— permit to construct, alter, improve, demolish, or repair any structure
prior to its lssmance,lolsoregnno,,bc upplin,nl too uch pill itm Glc aeignclmmenrent
than he is licensed mirsaam it, the on,aim., ol'the Contr a or's license Law (Chapter, 9
(corancncing with Section 7000) of Civilian 3ofthe Business and Prafcwime, Cole) or
that he is exempt Ohercfmm load the basis for the alleged exemption. Any violation of
Section 7831.5 hyany applicant fur n permit mhjecls the applicant o a civil penullyof
SPECIAL CIRCLE I'IMISC.
'TEMP. METIER OR POLE INSE
POWER DEVICC,S'
COMMERCIAL:
0 NIiW BLDG/ADDITION C3 LEN OLITION
❑T17NANI' ❑FOODSERVICE
n initial Il.,, live hanOhul dolial, ($510).
IMPHOVENIEN'I"
'❑ L ax owner of the property, tinny employees with wages as their stoic compensminn,
will do the work, and thc.wcture is nm intended or offered OUT sale (Sec. 7044, Business
and 14afeehns Craft: The Conlacar's License Law Jas Out apply m an m -mer of
SWIMMING 11001. ELECT RIC
OUG-EIS-SWI 'I CHES- EBX'IV RES
a El OTI IIiR
pmpcny who ln,lidx oT impfnvcs thereno. and who AnesXuch work hinunll or through
Impnanentc am not inlunded a off d tar
,nded till, ch tv
his awn anployccs, pmsu
wlc.If, howevcr,lhc biotin,or improvement is cold within one year ofnnapletion,the
NOW RESIDENTIAL 131J7C!'R tiQ IPI'.
SQ. FT.I LOON AREA
S/SQ. Fn
onscobuilder will have Ihe burden of proving that he did not build or improve for par -
owe Uf sale.).
❑ I, r of the pmpYny, an exdmivdy conanotin, with licensed contracmrx tot
xt theP(Sea Contmcaro nd
mw La the Project apply to an owner Ofprof Pmfno bei ds or improves
nurse law Arses not apply man owner of pmpcny who buttalsmimpntvcs thereon, and
TOTAL:
QTY. PLUMBING PERMIT
FEE
who contracts for xuch penjecry with a carnations) licensed pursuant to the Contraemr'.s
Licence Law.
n I Outcxcnip(anlsr Sec. ,I)&PC lin dioue on
PERMIT ISSUANCE
-
VALUATI ON
/�•Y `\
ALI ER - TRAIN & VENT -WAFER IEA)
Owner Dam
WORKERS COMPENSATION DECLARAI'ION HACK FLOW PROFECE DEVICE.
val
1' have and wul'finiamia l omficnfq JnrynncnwIl.i el4rw kir dcclum.Co
❑ Ilnrvc send wilhn.imain nCanlBcum tot Conwnno self-ituurc kir Wudur4Cuugwm
s not, as provided for by Section 37M of the Labor Coda, for the performance of the
which this permit is issued.
seem' have and will maintain Worker's Compaitomlon Insurance, as required by Section
3710 of the Look), Coda, for lheirerlbnn'neeol he work lar which Ohio peril is issued.
UItAINS-IrLOOR. ROOIs, AREA. CON 1).
PIXNRIS -I'lik TRAP
GAS -1:SYSTIiM-I INC. 40UTL1?'TS
4P't'ONS 'I'IXUCfION
,R P
YN
My Workers Cuptpcnxatian lnmrnnc . order'ad thole b
Camicc ffiid]2. ✓rS �5Policy No 3eLVC�f/
GAS -EA. SYSTEM -OVER 4 UA)
r Cl;kTIFICAFIi OF EXt1.11'I'ION FROM WORKERS'
INSURANCE
GREASFIINDUSTk1. WASTE INTERCEPTORCOMPENSATION
BUIL
.ION FEES
Ihhissunlonnccdnol becomplemd iflMpermillsf nmchundmA Jallurx(511X8.
(or Los.)
IoyanyOhion, in anyimm Ur,u tU1haworkfonvhidt 11m1hPermit isi.xsued shall
U... employ any penton in any manna so as to hrome>uhjecl to the Waders Co.,. -
GRIiASE'IBAI' _
SEWER -SANI'T'ARY -STORM PA. 2IXIIT.
F.Y[RGV ItiE
'anon Llows of California. Calc
Applicant .
WATER HEATER WIVENTIELECTR
GRADING IEE
j NUI ICE TO APPLICANT: IL allm making tilt, Cerificom of Exemption, you should
' become subject to the Worker's Compensation provisions of the Labor CONI, YOU must
forthwith comply with n.. It provisions or this permit hall the deemed revoked.
WATER SYS' I'EMORLn'IING
WATER SERVICE
SOILS FEE
CONSTRUCTION LIINOINGAGENCY
I hereby afinn far is a cnn.nmction lending agency for the Performance of
the work for which this permit is issue) (Sec. 31)7. Civ. C.)
Name
HE RESHA:N'I'IALPI.MB, SQ. FI'.
�l
PAID
Dam ',uo
TOTAL:
L'all(�
hunter's Address
TOTAL:
BUILDING hTiE
ecriiy aha I Enlivened this apphato.lou and slmc,h I Ihe above iakea ation i.x
'1 'meet.) agmu menmply wish all city and county ordinances and stale laws relating to
building conUmclirn, and hereby suthorile represemmives of this city to enter upon the
QTY MECIIANICALPERMIT
FEE
SEISMICFEE
ELECT RIC FEE
ahovo-mcmioned pmpcny for inspection Purposes.
(We) agree no n;wu, indnnnify anal keep lamnia" Thu city tot Calamine "ainw
Iinbilhlus.j.d,onals, clookinal cepcnse, whkb may in any way rearms ogoinstsaid City
PHRS11T ISSUANCE
AIT ER OR ADD TO MECH.
PLUMBING FEE
in consequence of the gaming of Ohio permit.
APPLICANT UNDI: STANDS AND WILL COMPLY WITH AL1. NON -POINT
AIR HANDLING UNIT(TO I0.000CFM)
MECHANICAL FEE
SOU kC . Ei( ut ATI )NS. C/�
_//1!AK
AIR HANDLING UNIT (OVI1N lll,O)CI'M)
CONS'fIWC'fION'TAX
Signmurco AppliaMComnutnr / One
EXHAUST HOOD OV/UUCP)
HOUSING MITIGATION THE,
HAZARDOUS MATERIALS DISCLOSURE
WIII the.pplicam or (name huilloaRoccapaut 1 ... nor handle hlouvduux material
HIiATING UNI T'(TO HXII)(XI BTU)
as defined by ,he Cupertino Munldpal Crile, Chapter 1). 12. and the $Icahn and Safety
Calc. Section 3532(')711(�,�
HIIATING UNIT' (OVER 100.000 111'U)
E] Yes `-'"'
VENTILATION PAN (SINGLE RESID)
PAID Doc Receipt Or
Will the applicant ill Laurie bu'Jdingnocupunt me wuatitun or(]'vices which
air com�ants as defined by the Bily Are. Air Quilty Mamtgentcnt
enol Immrdoas mm
Holl.lik-COMI'(311PO111101001fI'W
T' L
Galata?BOILER-COME'(OVER
100,00BTU)
❑Yes 0/1.
ISSUANCE DATE:
-a
ial. gnlrmnmtp o ir, Chapter(05olhe Cali AIR CON DI'I'IUNER
duuc xtvm
Ihavcrc;d,he hwmm
humin Health & SuRty Cafe. Sections 25511.5, 25533 and 25534. 1 undcrotnod that it the NEW RES IOEN'lIAL MECH. SQ. FIL
building does not em -nil, have. mrnanl. that it is myrspnsibility m mnifY Arc coutilin
oxide ayuirtntenn which must M nxI prior t nuance of u Cenificae of
Owner or suWori'eed ahem ).
TOIALL
-
ISSUED HY: / -
OFFICE