28656 (2) �- "APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL.POINT:PEN ONLY, ` -"4
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CITY OFCUPERTINO BUILDINGELECTRICAL - �yPERMIT NO.
MFexANICAL
BUILDINGDIVISIO -APPLICATIONPERMIT PLUMBING ^ ^ VJ
,IVB
t BUII.DIN(:PROJECTIDENTIFILATION " -
_ ' ' BUILDING AUURP.SS ++ ^+ '� �i - n ^. y " SANITARY NO. I APPLICATION SUBMITTAL DATI
qj
OWNERS NAME: - �` H/ ONE CONTRACTORS N+ � *',LIC NO 1 a
_ e I NIC - CONTROL N
ARCHI TF.C, GII E: IC NO ADD,RE+SS: 06��W. p/ '� ""' :ACJ - ,
'CONTACT - ' PHONE' •+ BUILDING PERMIT INFO
W r ' ^' 21-2-:74 '`❑ Consultant Fees Paid by.Applicant(Initial Lr10. ELECT, 'PLUMB -i MECH ' r
oa ❑ o
LICENSEDCONFRACTORS DECLARATION na QTY. ' ELECTRIC PERMIT FEE l
I eny Item in t{ f d d v : r charter 9(1. g _ _ JOB DESCRIPTION
awith Section](MIO) [D 3 fOeens .ad Cdeand tylcenses
00 RESIDENTIAL:
License
yQIPPRMITISSUANCE 's'
tulle deffaL - ' ❑SFDWI. ^I D KITCHEN REMODEL'
FUU Date Class. Ce. cinr APPLIANCES-RESIDENTIAL, _ i<. •N"
_ ❑ADDITION -1 0PIAMBING RE-PIPE
had' HITS DECLARATION v,e - - •o - -❑MULTI-UNIT ❑STRUCTURAL
02nd 1 PANELS' ,V:"
I dt built a�KL bl' N t MODIFICATION
J �� UPT02lN1AMP8
ine d P 1 Y _ - 171 INTERIOR El CHIMNEY RGPAIRt�:
L
2111 IOW AMPS IMPROVEMENT'� - OWNER BUIL DLR OFCI)RATION OVFRd000AMPS BATH REMODEUREPAIR^ElDEMOLITION
p I h ff by that l are exempt front the Contractor,I en Ethic O c
{iisS5..O V falloWngrea n (Sect a?0315B .in. edP f .Cod Ay ty ty SIGNS CLF.CTRICAL ] ❑OTHER
which '
q res a permit t t 2 11 r improve demolish, r ren any someone - f s-
�0
prior to t e also'eiluires the ppl t for suchr tiofle stogrod.et mens S PECIAL CIRC U I I'/MISC. _ -
yThai he licensed prt the pros isionsofth Coul for,Li,etoc L (Chapter 9 _
'(coo g with Section 7000)of Division 3 of the Boone.,, d P C'.i .Code)., - TEMP METER OR POLE INST. fCOMMERCIAL:- •�
0.fa m a' that h mol therefroma J theba ._' f Ih Ileg J e pt Any violation of El NEW BLDG/ADDITION ❑DBMOI ITION
�"y Sect ]o3156y nny PPl moot ap rnet objects me ap,plicath,n a civil penalty of. POWERDEVICES t „0TENANT L FOOD SERVICE
^�, GI reih fivehund edd 11 :(SSW)
1 of p pry myempl y with g ih al ren t' SWIMMING POOL ELECTRIC IMPROVEMENT 1
will dolhewa k andmest whefan t mended r rfe df 1 (S c TUD Bu ss -- ❑OTHER
and Professions Code:Th C t t Lcense Law does r apply to'a u'n of - OUTLETS-SWITCHES FIXTURES '...
prop ty who bills;r impbries therem,and who does such workhimself or moragh - ♦ Yn
his own employees,pe8vided that such' prove vents Ire not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
+ sale if,however,the building miniprovements sold within oneyearofcoidplet mi theSQ.Fr..MOOR AREA v $/SQ.FL.:P
owner4milder will hue the huulen of proving that he did not build or lgnefar pun ' - '•° `
PrOse of
EP
27 1995
r ❑I )z f thep p nY exclusively ing th I ce W c nuacmra to TOTAL: / s
cont uh p ) t(S ]1114 B d P .t Col )Th C t r L' s
crea,Lawd e: t ,l,Iran ncr rP p ny 1 Wild p ,l co and QTY PLUMBINC.PERMIT ,FEE �y I.UYt1���I�
ho t t f nauehp 1 cos wim uu nt t rOI'cenecd Pumua ti the Comm tors ;��'I s �C ') q
License Law + t PERMITISSUANCE, r ,I ° -
❑ImnesemptunderSne B&P C for this reason q
@.
+owner Data ALTER-DRAIN&VFN 1'-WATER,(CA) - VALUATION
-
WORKERS COMPENSATION DECLARATION. I BACK PLOW PROTECT )HVICE y - Is
Ih rehy orf le tK Wty of pep Yo fth f II ng Je I t ns - -6 Ip '
.❑ l have and will maintain aC Certificate ofCoussumto self-insum for Workers Co pson- v DRAINS'-FIAOR,R EARFA,COND. STORIES TYPE CONSTRUCT ION
ashen as provided for by Suction 9]00 of ih'L b Cade,fo the per urmance f the' ,. -
workforwhichohisper t' 'sued' FIXTURES-PER AP
E I have and will mamom Worker s Coarpmeadion insurance, required by Section -
I]WoftheLabor Code for penton nonce of the wort for wh I Ih:p - lisi issued x GAS F.A.SY. M-I INC.4 OUTLETS -
MyWorker's Compensation lneumececarrier and Policy mmberare t - uOCC.GROUP t. AEN'
Career Policy No. GAS-EA YSTEM-OVER4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' +•-
COMPENSATIONINSURANCE i G : SFINDUSTRL WASTE INTERCEP'T'OR^
Ul . Dion need tiro completediethe pennulsfnrn ehu dr ddnllary(SIM) - BUILDING DAT 9ION FHP.
or le s) - ORBASE TRAP
-. a � '- - -'� PLANCIiLCK PER
1 contrition fit the pnilmonateridolue weakf which this permit is issdleall SEWER SANITARY • RMFA.200
mot npl y h y p n y t h bj t t U, W li C open - ENERGY FEE e
Z Ration Laws of Califofn .Dat WAfFR III. TNR + R st
0 'Applicant - GRADING FEE �S
NOTICE IO APPLICAN T.If,after making this Certificate of Ebrumquima yon should WATFRSYS . .)TING
,a ems+ beembe subject to the Worker 0 Compensation p v sins of the Labor Code,you must - .SOILS PEE
forthwith emrply with suchp o,this spprout shotlh d d revoked. F R EA'i :.
Z CONSTRUCTION LENDING AGENCY N 'IUENTI L SQ.PT. PAID
1 h by B' Ih t tl t i I dig age i.y I ,h pcnf.nn.ce of � - D 'Re ipt M
'u thewokor,wbichmes Permit is issued(Sea 3097Civ.C). _
U Lend Namer v •, '' TOTAL:
Ixndere Address 'TOTAL:
W
y ]a unity that 1 have rad this applleau n and tate that the above C information on is BUIL
fn amret I g 1.comply with all ity and ry k' a •e d.ot la elagt
uno QTY' MECH) ALPERMIT FEE p
UZbuilding .veauthorize
construction,and hereby tives represmaofthis city to enter upon the SBI9 P -
'abov honed pilot for inspection ptrawas r PLRMI'TI CE
(We)agree to save,lades ly and keep harmless the C ty ur capelion ag oro ELECTRIC
ohil ie. judgme t nets and expenses which may in wit,,uhhou.,aiest said City pISER OR ADO TO MECH, `
in consequence ofthe granting ofthis permit. e ' PLUMBIN /FRH -
APPLICANTUNDB NDS WILL PLY WIT 1LI,NONPOINTAIRHANDLINGUND(TO (L"CPM) MECHANICAL PEC
SOURCE REGULA 0 .'.
AIk IIANDLINO 11NH'(OVER 10,000 CFM)
.r
1.
' !, CONSTRU ION TAX
natureof 'cant/ & actor Da EXHAUST HOOD(WHUCT) a,
,'-HAZA DWS MATERIALS DISCLOS F _ ` HOUSING MIT TION HE
xst. Will the o It future buildingoccupantmori
store or handle hazardous aal HEATING UNIT(0100,000 BTU)
. gas defined by the Cupertino
Municipal Codc.Chapter 9.12,and the Health and Safety
Code,Section 25592(.)7 . HEATING UNIT 100,00013 U). - ,
❑Yes .DN VENT ILATION FAN(SINGLE RESID) PAID - a '
Will the appHdram future building p' t isse equipareal,or devices*which I
u•emit h b I ,.M
out s dod by therea Bay AA Quality ManagmnenBOILER-COMP(3HP OR W,OW 6TU)
t ._ 1 n
Dm'm' "r' ',
❑Yes ON BOILER-COMP(OVER 100,000 BTU)p �+
t S _ .. _
MRC ONDITIONER
I h rve'read the h zadous materials req remems under Ch pt 6.95 of mit Cul _ _ _ SS CE ATH
forme Health @ Safety Coda Sections 25505 25533 and 25534 1 ndensond ohvt of the Q.
NEW RESIDENTIAL MECH, SQ FT ;a,
building doe.nut cunentlyh t Beni Kant my n:Ia s'b'4.1t Yfythe occurs unt' -
anusfaCeruf t f0 mpancy. ' '•
of the re9u rene na wh ch sob eeipdo t '.. - �,. ,a '
Owner or au I -Date _
- authorized em - - Date' e TOTAL: I%
€ � ' iSSUGU BY: