28928 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY c
CITY OF CUPERTINO BUILDING-ELECTRICAL - I'IiRMUNO, a., w y8 w(NJJ.��
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL '`J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO.' APPLICATION SUBMITTAL DATE
122) 2�d1oHDo G¢f ' . . . >t ,
}
OWNER'. NAME: I'NO�ryd/1I1-� V CO k'S MB: LIC NO: 1I11
rb "h J h I, 1'1 S 11 2 1`f N/G ,GON'IROL r'1
4RCHITIiCJ'IENGINCCR: - LIC NP: . AI DVIV1;b /Ys yr 2.1 fa O -
coNTacr: vHDNE: BUILDING PERMIT INTO
„ ❑ Consultant Fecs'Paid by Applicant(Initial) PL12D e :CT PLUMn MEc
❑ a,
LICENSED of CON QTY ELECTRIC PERMIT FHE '
1 hereby vffirm that 1 am licensed mess and
rf Chapin 9(c tense is JOB DESCRIPTION
�pZ with Satinn]Ot10)of DivmumJaf the Business antl s p eC dmyllcensc rs' RESIDF,NTIAI: -
F W 0 in full forec and eRee .ProfSI n ' PERMIT ISSUANCE - l
�UUF License('gy. - Lic.N ❑5 - WI. .; KITCHEN REMODEL.
NZ4 Date- — cCmnrunnr ' APPLIANCES-BE toHWIAI. ITIONJ OPLUMBINGRE-PIPE
ARCHITECTS DECLARATION _ _ MDI. -UNIT 'El STRUCTURAL
Z O Z 1 understand my plata shall be used as public rccuNs PANELS
�i �� MODIFICATION.
OZ +O _' IJPTO 200AMPS
l- .WJ Licensed Profeexional ❑INTF,RIOR - El CHIMNEY REPAIR
2111-1f)00AMPS _ . IMPROVEMENT
..1 Oat I am eUIhDCR DHCe ConlrION r
Q I hereby effimt that um exempt Infra IM1e Contmcpr's License Law far the OVER 1000AMl'S ❑RATE RI?MODEWitI?PAIR E3 DEMOLITION
�❑0 As U following reason.(Section 7031.5,Business and Professions Cele:Any city or county, [IOTHER f
1+13 LL 1 which refutes ELECTRICALs a paremi to consumer,alter,improve,demolish,or repair any structure _
a`O prior to its issuance,also re the applicant for such permit file a signed[- 4 PP pe g I minnem - - -
rn SPECIAL CIRCUIT/MISC.
>.
bar he I teemedin rvenu thep oftheContractors nd se La (Chapter
Qo (om b lh5 I ]1X10)of ovation J f1h e If f: Code) TEMP.MGT'I1R OR POLO INS'('. COMMERCIAL, `
a c q 'Shed h x1.5 b there) d the basin t "alleged d exw ml Any violation of [I NEW BLDG/ADDITION . ❑DEMOLITION
Y Section
of..than five
any hundred
dollars fsot ,cant for a subjects the applicant to cisd pen Jly of ('OWER DEVICES
H Z y
of mom than five huntlrcJ dollars(5500). I . .❑TENANT C1 FOOD SERVICE
Q ❑ I,as owrortfthe propdhy,or my employees with wages as their sole compensation. SWIMMING POOI,ELECTRIC IMPROVEMENT
will do the work,and the stmeture is not intended or offered for sale(Sec.)t144,Business ❑OTHER
al and Praacoon,Coda.'The Cnndocpdx Limnnsa I.L.
3 not apply tar an owner of aaUTLETS-SWI'I'CHBS-PIXT'UIt BS
property who huilds or improves thereon,and who does such work himself or through
his own employees,provided that such in lmvemems are not intended nr offered for NEW RCSIDENI IAL'ELECTR SQ FC'
We.If.however the building or improvement is sold within one year ofcomplaiomtbe
eSQ.fR.FLOOR AREA f/SQ.F1'.
r- llJer will have the harden of provin8 that he did not par-Posts
or for pa
paseof'Lsole.). s
0 1,ns owner of the Property,can exclusively c:mp:aling with licensed a craclom to
consumer the pmjeal(Sec.7044,Rosiness and Profession,Caste:)The ConWclar's li-
cense Law does not apply mun owner ofPcopedy who builds orimpmeew thereon,and QTY. PLUMBING PERMIT F17F 00
who contracts for such pmjccts with a contrecmr(s)licensed pursuant o the Commodes
License Law. PERMIT ISSUANCE -
❑Iamexempt under Sec. ,B it PC for this re,nson -
AMHR-DRAIN&VEN'P.-WATER(EA) '
Owner - � Dunt -- - - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE I�^
• Ihereby affirm under Penalty of pejury,one of the following declarations:
❑1 base and will maintain a Certificate ofC a6 lelf-jusure f W k .Cmper DRAINS _FLOOR,ROOF,AREA.COND. 1
,union prosided( bySection 3700 oflh Labor Code,fir the Perarromew orthe STORIES TYPIICONSTRUCTION
work fill which lie Pet I is uad1rFIX TURES PLR'I'RAP: I /
❑Ih Wwll mans W keesCompensation Insu rcgrtd byS non
J]o0 fthelnbor Coda far performance of the work for which thispennn is issued, GAS EA.SVSThM-1 INC.40UTLFTS
AP
NI
N
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMVI'ION FROM WORKERS'
N
COMPENSATION INSURANCE GREASE/INDUS,RLWASTE IN I ERCEPTOR
0his section need not becompleted ifthe Permit isforonehundred dollars j511Nq - BUILDING DIV.ION FITS
or less.) GREASP.TRAP - - PLANCHGCK FEE
1 cmiify that in the performance afthe stork furwhich this purnot ii issue,[,half I
- not employ any Person in any manner so asp become subject Is the Workeri Compen- SEWER.SANITARY-STORM IA.200 FT.
ENF.RCV FEE �•
Z salimn Lvwx irl Califnmin.❑:nc (..V
O A plicnm WATER HEATER W/VENT/CLECTIt
,'�.� o-y P ' _ - 'GRADING 1:1 r�
� F.-1 NOTICE TOsim the AN T:Work IL Cradafter makingthis Cisimes of of C Labor iodyou should WATER SYS'TI?MMEATING
' .become urhjccn m the Worker's Compensaninn provisions of the Labor Chic,you most SOILS PRE
Gil faMwith comply wilhsuch previsions or Permit shall he deemed revoked. WATER SERVICE
� z ^ CONSNUCHDN hIiNUING AGIiNCV NEW RESII31iN'ITAI.('LMB. SQ,FT. PAID '
V O :I frwhichirm l hnnM1vrc issued(Sec,inn lending agency fnr the perfol'lnanve of Date Itmeiplp
IkxH Ladersforwhichthisperndl is issued(Seo,3097,Civ.CJ i
Lender's Namc
� � 1<nder's Address - - � TOTAL:: TOTAL:
04 1 certify that 1 base rthis applicvninn and slate that the above information is - BUILDING FEE
ti V4 correct.) ead spree nr comply with allcityand county ordinances anti state laws relining to 'QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby vulhmiizrepresentatives of his city no enter open the SEISMIC PER -
above-mentioned pmjcby let inspenion purposes. -
(We)vgree mmve,indemnify and keep harmless the City of Cupcnino agaimt PERMITISSUANCE ELECTRIC FE
liabilities,judgment,cost and expenses which may in any tayacemeagaboo said City ALTER ORAUDTO MICR.
mcnasequcme of grmning_gf spennil.t� ^ PLUMRINGI ?E,
APPLICANT I' S'TFN AND WILT WITH ALL NON POI T IH HANDLING UNIT(TO 10,111111 CPM)
SOU CB RIC 1 JNS.' 1' MECHANIC LFEC 1
AIR HANDLING UNIT(OVER.10,000 CFM) t
CONSTRUC'ION TAX'
Sig u pplicanUContracarDat. EXHAUSTHOOD(W/DUCD HOUSING TION FEE
HAZARDOUSM LOSUNF, '
Will thavpplicvuor fulue hnildiug owupalt tam,or hmndlc huzerdousnotcriul HCA'TINGUNI'T(TO100,000fil IJ) t
as defined by the Cupertino Municipal Code,Chaper,9.12,and the Health and Safety 1
Code.Section 25532(x)'! HPATING UNIT(OVER 100,001)BTU) 1}'r X15 �[
❑Yes 0 N
VENTILATION PAN(S INGLC HESID ,
Will the applicantor fuwre building nuvpan[use is Au¢nt or devices which
vale sip N
•emit haznnlnm air etntvndnunla ns tlefined hY lha Bay Arci Alr Quality M:magmn¢nt 11()ILER-COMI'(31{P OR IIN41NN1 BTU)Wry
- _
Divi , s _ TOTAh:
❑Yen FI No BOILER-COMP(OVEitloo'canTO)
AIRCONDITIONER ., tirTfllvU
Ih' aJ nh h d u :c 1 y re l d Ch tel 695 fth Cali ' ISSUANCE RIATE
frouni.Health&Safety Cal Sections 25X15 25533 it 25534,l understood ih t ifthe NEW NESIDIJNT'IAL MECH. Sfj Fh
of
the requirements
lc s4ich l nt ionto y, tern.b'llyt ify the mwpam
f Ne rey mom wh ch :1 he tenon: ace aft cird
fracture ofcertOce upvncy.
Owner or amhanzcd agent Date T
ISSUED BY. -
OFFICE "