28962 (2) APPLiCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMIT NO, ^� ,••,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICALa • L y
' BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATL
" 2 3� R E G lit A leT p D Gu PSR r/N o
OWNER'SNA 13: - 1'll(N" q. CONTRACIOR'SNAMIi, LIC NO.
TSN MR" �1A16 gLE � OwivewoolzS CVA15r_;Irl ��/qq 9g " N/C ONyROI.q
\(CHITEU NOINEER: L 'NO ADDRESS: I k�,41 res IT-1-0 ❑ .
Ne '334.sTATe srgvlm /cle—
CONTACT pper�, - - Is )NE
�f ..v-�r21 BUILDING PERMIT INFO
g�,gZ��{D U j� �./SJ t�41—" ❑ Consultant Fees N d by Applicant(Initial) BLDG ' ELECT - PLUMB MECH
0L-I V aW Do 1-*:k coNS'T- co: . ;K1 e31< 1t
LICI?NSEDCQNTRACIT)R:SDECI,AltATION QTY ELECTRIC PERMIT FEE
1 nereny snits mat L a h.naea nnaer prav;,iavn,lir chapter 9 mbmmcia,. JOB DESCRIPTION
�Qty WZ Ib Seclom 70(glpd Divism.3ofhe Bminessand Profession,Code,and my license is
FI- nu full farce and a PERMIT ISSUANCE
�UU(JLicense Class Lic.p 414498 �''' FDWh ❑KITCHEN REMODEL
F ul Face and
t Alli'LIANCIiS-ItIiSIDI?N'I'IAI, CIADDHION ❑PI,UMHING BE PIPE
pN„py ARCIIITIiCI'S DECLARATION I IPANELS ❑MUI.TFUNIT OSTRUCTURAL
Z O tE2 1 uWemand my Ian shall be used as public Tawas MODIFICATION
OZ— QIA)/J - IIP 10200 AMPS .,<`1
O -(T�IMPiOVE E:1 CHIMNEY REPAIR
N,� .W] Liannal Prrfcssirnml 201-IINIIIAMPS IMPROVEMENTggg
...4I O.,I if,Iexempt It rn the oomal OVER 1000AMP5 0 BATH REMODIZUREPAIR ❑DEMOLITION
63aU6 I hereby.(tire,tnat 1 1. exempt from the Cssions o License law far the A
whichingreapeeaiavn 7erebr Business and Professions Code:Any city mcounty SIGNS ELECTRICAL �]'6'1'HER 9CO Ba'r1'I /AI
which require,,unry It cerebral II sap . den tI firepsflonysnucmre
w o� E X I ST'i N l f=001-1 .
pram I .. c I, 4 d i6 tt mm it In fl .h dt¢Nan -
t�m SPECIAL CIRCIII IIMISC
NWW p. (tato t belovedwith
s7 0 s fdmC u t 1' (Chet r9
(cane exempt
nbor ]IXnd fD"' or of the alleged (orf y o.Ction of ]EMP ME TER Ok POLE INSf COMM A d
tl y m Iy that i t. 1.5 b a of d th bas f metthe exemption,Any tai a( .� ❑NF.W ELDO/ADUO'E$N®0 DEMOLITION
c') Section]0315 by any applicantI spermit,uhjeds the upplsantroacivil pcnaltynr POWERDEVICLS ❑,TENANP ❑I'OOD SERVICI:
y actor no than live I I IAtllav($5001. r •' tt
❑Las owner of�epropeny;ni my employ.,with wagesa,,h ,a.Je cnciamstion. SWIMMING MB)L ELELTRI 'IMP"/'Ip.ch
geN�T/��
wlld to k endtne t ct ' t t adederaffestaff I (Sec 7O ,B mess 0OT11P.R`u
4'3m aad Professions fe CIM Th C I as . License Law docs n t apply t n owner of �' OUTI CTS-SWITCHES-FI% \ �'
property who bnd. ,irmamar,th h it.,mah workl n.elf ath ouSn -
his own employees.provided that such improvements a sat'intended or offered for NEW RLSIDEN'I IAUELEC'llt V UI- L -
sale If.hnuever.The balding or improvement isore xithan one year ofcompletion,the SQ.FT.FLOORAR.A &SQ,FT.
ownerhuilder.ill have me burden of proving mm he did not huild or improve for poo
If of woe.). Z 7✓- Z
co I,me owner of ct property,inn exclusively and cnnaaaing wife licensed cntmi t. -
onnmetmepnpem(Sea.7M4,Itdsiness and Profrssirnx Code:)The Cnnwdors Li. .
nae law caviare,applymms ownerof proven,ubo build,or imp rove,tnerem,snd QTY. PLUMBING PERMIT FEE
who eaniract,for,uch proj.t with a comrecmr(,)IicenxJ pursue.to the Co......'a
License laws PERMIT ISSUANCE
❑ tont exempt under Sea ,13&PCfor mie reason - - '
Owner hate - ALTER-DRAIN&VENT=WATP.R(P.A) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �-
I hereby attain under Iknalty of perjury one of the fallowing declamiians Soo
nwinlaina Cctlil lane of Cnnxenuo xdGin.aure for Workcr',Compem Z DRAINS-FIAOR,ROOF,AREA.COND, ) •i
,.tion,us prnvidd for by Section 3710 or the Labor Code,for the peitimamer of the STORIES "TYPE CONSTT R UCTION
work for which dds permit is jawed, FIXTURES-PER TRAP
❑I have and will nminmin Worker's Compensation Insurance,as required by Section -
37OOoftha Labor Code;ror tcperrmmancoof he work Car whichtispenrn is ismed AAS-EA.SYSTEM_-I INC.4011TI.ETS ' ,- OCC.GROUI' ' AIN
My Wnr rs Cmnp�n,aiinn lnsu ale carrier and Policy�Wll�p q '
Cartier. CO Policy No.: GAS-EA.SYSTHM.OVER 4 I FA)
% dl FM L( 1 ON FROM T✓'tj Z GEE NDUSTRL WASTE INTERCEPTOR
COMI'F.NSATION INSURANC: BUILDING DIVISION FEES
es.1(Thls,utin faced not heannplaed if mi
the pert i,Intone lmudrald,,Harr($aga GHBASETRAP
or l
PLANCI{IiCK PEE'
' Icenify that in the performance of the work ror which this permit is issued,lshall SL'WIiR-SANITARY-STORM EA.2011 Ff.
not employ any person in any nmnnerso smg c 'c11CteWotkers'Compete ENERGY FEE
,� ,moon Lows of ColJ�oryt@Uum C
O O spin"
La Cut
✓'�- - - - WATIik HEATH It WNENTMLECTR -
z C) pp eR.�u.I I GRADING FEE '
to NOIICHTO�IACANT:IIaficr making this Cenificam lir semptiavn,you should a WATIik SYS7EMI1'REATING? become subject to the Wmi Compcnsaoon provisions of the Lahr Code,you must - SOILS FEE
forthwith comply with such provision,m-do,permit shall hedeeraed revoked WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY.'; NEW RESIDEN'I'JAL PLMB. SQ,FT. NPAIDU Oyrsecosmconenngagencyonepermnancnof ceipt4 lis Fme work fur xhichthis pemdt is issued(Sec.3097,Civ.C.) -ULender's Name - TOTAL:Address04 1 certify Ihrt 1 M1ave read this,application and state tat the move inkannurn is correct.l agree to comply with all city and county ordinances and state law,relatngto QTY. MECHANICAL PERMIT PEE
Zbuilding constuition,and hereby aumance representatives of this city to enterupon the above-mentioned property for inspection paHxaeaPERMIT ISSUANCE(We)agree et save,indeinlry.and keep honnictA dm City FCuimnin.against'liabilide,judgments.cost,endexpenses.lach mayininy sayaceme.tuirvi,mil City ALTER OR ADD TO MECH.is e m i,marceofthe granting of tis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.gq CFMI
SOURCE REGULATIONS. MECHANICAL 3I'
AIR HANDLING UNIT(OVER 10,000CFNE CONSTRUCrio TAX
Signature of Applicant/Connaaor - - Date EXHAUST H60D(W/DUCT) HOUSINGMITIGA NIEE t
HAZARDOUS MATERIALS DISCLOSURE// DEi--q,s�a
Will th,.pplimmom future huiltngoccupant store lir handle hr.,Wnus mat,2 HEATING UNI'L(To lob,W,]ITE)
as defined by the Cupertino Municipal Core,Chapter 9.12.and to Health and Safety
Code,Section 25532O] HEATING UNIT(OVER 100,000 BTIO ,
" 0Ye, V<
- VENTILATION PAN(SINGLE RI3SID) PAID Date N
WIII the applicant or fun are Jim Wing occupant use vain pn ere or davices which BOILI?k-COMP(3HPOR IfN1,IXt0 BTU)
mit hozmdoas it emast idranl,as defined by the Bay Area Air Quality'Management )
istrin'I❑ op
Yes a ( BOILER-COME(OVER I krflO BTU) -
I have mad the lmzuNme
nus materials requlrenu under Chapter 695 al he CA- AIN CONDITIONHIL IS$UANCB DATE
fomes Health&Safety Curie,Sections 25505.25533 and 25534.1 understand tat if to NEW RESIDENI'IAI.MECH. SQ.FT.
building does not commonly have a tenant,tart' my respom ility to notify to accupont
irfal req rcn ouch ntp�l' t u lice lift 'cnificam or Occupancy.
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Owner ore onsculagcnt { - Uma - Tt �
hS,SUEDBY
OFFICE
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