28866 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO.
BUILDING.DIVISION APPLICA'PION/PERMIT PLUMBING-MECHANICAL 8
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. - APPLICATION SUBMITTAL DATE.
to
OWNER'S ME: PHONE: CONT ACT'OR'S NAME: LIC NO:
F — CO t NIC CONTROL Of
ARC 'TECI'/ENGINfi LIC NO: ADDRESS: ❑
CDNT�A^C�I': _�t{ONE:
3A-010) BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) p1.DG C�' PLUMB MEC"
LICENSED CONTRACTORS DECLARATION QTY ELEC'T'RIC PERMIT FEE �IT•R/• ❑ ❑
I hereby affrot that I am licensed under pmvisions of Chapter 1 lcomntencing JOB DESCRIPTION
q00IZZ ith Section 1000)ofDivision 3ofthe Basinessand Professions Code,and my license is RESIDENTIAL:
�OO w PERMITISSUANCE
In full forty and effect.
y.W m ❑SFDWII •�PLUMBINREMODEL
aU License Cla Lic.M pppLIANCES-RESIDENTIAL {�7�J�DITION PLUMBING R&PIPE
Date Contmcmr ` ��
ARCHITECTS DIiCLAR ION (J MULTI-UNIT ❑$TRUCfURAI.
OZ�V=j^ Iunderstand myplanssha]I be mostaapoblic records PANELS � MODIFICATION
UPTD HILI AMPS
q ❑INTERIOR ❑CHIMNEY REPAIR
r-4 9 Licensed Professional 20161000AMPS IMPROVEMENT
Oat I a.eUILDER DECLARATION OVER Ilg10AMPS ❑BATH REMODEUREPAIR.❑DEmou I ION
Q 1 hereby affirm that 1 am caempt from the Comracuds License Law fnr the
3 GL U is
following reason,(Section 7031.5,nosiness and Professions Code:Any city or county ❑OTHIiR _�
Wp which rc vires a rmit m construct.alter,improve demolish,or re saua.re SIGNS ELECfRICAI.
ya 4 pe pore pair any
k'�OJ
bar
slice intent ptirsson1.dam he applicant fnr CmarasrminofiieseLowd latee,m SPECIALCIRCUIT/MISE.
yQ� tbatheirsiigwid,SoninrteN)ofOlson.,,3oftheStracnss adProelaw(,Cole)r9 COMMERCIAL,
q0 lcomn¢ncing with Secsion 70W)nf Dlvlslon3af NO Business and Profession,Cole)or TEMP.MIgER OR POLE I NST.
L a c C that he is exempt therefrom eM the basis for Ne alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION '
a1^
x V• Section 7031.5 by any applicant far.pennitsubjacts the applicant civil pen.Ity.f POWER DEVICES m ❑TENANT ❑FOOD SERVICEnot more than five hundred dollars(5500). IMPROVEMENT
.F.SO ❑ 1,as owner.f the property,or my employees with wages an their sole compensation. SWIMMING POOL ELECTRIC
cell do the work,and the stmcwreis not intended or.Rerc ole W,Quite []OTHER
1-2and Promitcloms Code.The Contmctnr'e Llcmtno taw Jr t apply to n mf OUTLETS-SWITCHES-FI%TURES
property who bull&or improves thereon,onJ who Nxis elr s ark him f `t git /A
his own employees,provided Nat such impm et of intended grief ryfl for NIiW RESIDENTIAL ELECTR SQ FL A
sale.If,however the hullJing orintpmvemennnx 1 Inn. a one "on,the SQ.FT.FLOOR AREA $SQ.FT.
col milder will have the burden of pro, Na JiJ no u J .prove for par- OCT 12 1995
pum.f s.leJ'
❑I,ax owner of the prove lu,v y co with IicensM contrncmrs to r -
conswct the project(Sec.7 c wv unJ fcs� Code)The Contractor's Li-
censeLawdoesnotapply rofproperr't�y It Iasorimpmvestheremi,nad QTY. PLUMBING PERMIT FEE CITY OFUotEKANO
who contracts for such projects anth,
area licensed ptumaano the Contractors
License law. - PERMIT ISSUANCE
[:J1 am exempt under Sec. .R&P C for Nis mason
Owner Uma ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑Ihaveand will m.intuati Cenll7autcof Consennnself-Insure for Wnrker'SCompen- DRAINS-FLOOR.ROOFAREA,COND. STORIES 'I'YPB CONSTRIJCTION
sari..,..provided for by Section 3]W of the labor Code,for the performanm of the
work for which this permit is issued. FIXTURES-PER TRAP
n havc and will maintain Worker's Compensation Insurance,us required by Section
37M of the lab�rtCorrdWWe,for the perpfomunce of the work for which this Permits isnismi GAS-EA.SYSTEM.]INC.40UTLETS OCC.GROUP APN
Carrier:rg t=r crap T olio N1rxYu :501'e-14 GAS-EA,SYSTEM OVER (EA)
^,sr 1E [icy
CERTIFICATECOMPENSATION
NPROM WORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR
(Thissutmmuto l antleacntn Natediflh.peank isf.rmtehundreddollocOSIIIO) P .DIN (VISION FEES
or less.) GRE.ASE'BAP 1'LANCHI3CK
Iranifythmintheperformun..fNeworkfx which this permit is issued,l shall
SEWER-SANITARY-STORM EA. FT.
m
Is
nemploy any person in tiny manner so as to become subject to the Workers'Contpen- I..NERGY rh
17 z soden laws of California.DateWATER HIiATF.R W/VEN'1'IELEC,R
7 O Applicant GRAD]
G NOTICE.TO APPLICANT If,after making this Carte from of Exemption,you should WATER SYSTEMffRP,ATING
abecome subject to the Worker's Conspe.selion provisions of Ne Labor Code,you mon SOI
Ik7 foMwith comply withamb provisions orchis permit What[be deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ Pr. PAID
L)0 Humby.ffirm Nut Nereiaac.mwni lending agency(.rhe performetwe of ate Receipt#
Ne work far which this permit is issued S 0 J,Civ,C.)
Lender's Name TOTAL:
'W Cedars Address TOTAL:
1 certify that I have mad this application and state that the adwc information is BUILD( G FEE
Frh corzect.l agree to comply wiN all city and county ordinances and sone laws relntingm QTY. MECHANICAL PERM IT THE
V z building connmction.and hereby audition representatives of this city m enter upon the SHISMI'FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE
( e7 agree is saw,indemnify mW lie ham Jess the City of Cupertinn against ELECTS F, /r
Iiabiliti ,judgments.ens'te and expenses h' m.y in anyway accma against said City ALTER OR ADD TO MECH.
P-
in con. quence of the greni !this pe PLUMBING FE
AP AN INDERS'AN SAND LCOM ,Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,000 CFM)
MECHANICAL FIe
SOI E s 1LATI0
10_I1__q5 AIR HANDLING UNTT(OVER 10,000C FM) CONSTRUCTIONT
Sign mmuf Applica Cnnaanor Date •/ EXHAUSTIIOOD(W/DUCT) HOUSING MIT]GAT10 FEE
9ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haandoos material HEATING UNIT(TO 100,0!51 BTU)
as defined by the Cupertino Mummpa Code,Chapter 9.12,and the Health and Safety
Code,Seinen 25532(0)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes Nn PAID
VCNTILA'1'ION PAN(SINGhF:RES[D) Date H �iptJ
Will Ne applicant or future building occupied use equipmeal or devices which
emit hazardous air amour rem,as def by the Bay Area Air Quality Management BOILER-COMP(3HP OR IW.000 BTU)
TOTAL:
District^ BOILER-COMP(OVER hx),"it ru)
❑Yes
^ I hav d the hasoNous materials rVId
r Chapter fi95 of the Cali AIR CONDITIONIiR ISSUANCE E
fomi.H &Saft Cet. s 2550i4.1 undemte.d that if the NEW RESIDENTIAL MECIL SQ.FT.
n some rtemlytr eant,thatbilitymnrnify Ne rcculxmt
'nim ichor sprinnenificme nf02uryln.y.
In
Own t nse a en rz Date - TOTAL: ISSUEDBY:�!1
OFFICE —I=' •-
. �A�Er•I.� UKI 7b ��ern1T' � �sy I 9• x •95
a-�53O izlc�}R-�O f�� t7
CU�t nT► N b CA,
GRIDLEY COMPANY GRUM COMPANY
18 3.THHIIR,D STREET A 8.THI OST OU8
1 0408)3740800 008 60408)37'40800
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}. Repeoe oddin0 6D40 window
• whew Bow double french door
system w/rew header. MOVED
MASTER ( J RE MoDE1 OCT 121995
` - BEDROOM
f}RE�S 8M: INSPECTION DEPARTMENT
SEE P►a
CITY OE CUPERTINO
BEDROOM
CLOSET
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PLOT Pig
10ECdED BY
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