28538 CITY OF CUPERTINO BUILDING-ELECTRICAL PERMII'No 28538 a.v e.v
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBING-MECHANICAL 285 3 18
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDAT
3—"I'll jfgyralek 11c:1. 7 5S'- W +3 �S,Q
OWNER'S NAME: 1 PHONE?: CONTRACTOR'S NAME: LIC NO: `
IN 41 er's IC Dts,f,v OIL{ 4.
NIC CONTROLN
RCHIMCtXNGTNEER: LIC NO: ADDRESS: ❑
coNTAcr: rILDNE: BUILDWO PERMIT INFO
❑ Consultant Fes Paid by Appliwnt(Initial) BLDG ECT LUM MEC L
Lom that EUCONTRACTU, no,himaof hap QTY ELECTRIC PERMIT FEB �
ON
I herthy aRnn that I am IlcenaeJ uNcr pmvltlOm n!Chapter 91«mtneneing DOB DESCRIPTION
�Z the«lion 7lXllq nfDivixinnlof the BusinennN Pmmwinns Code,sod mylicenso In RESIDENTIAL•
00 wr PERMIT ISSUANCE
W n ..va full meeod,Red. bl y ❑SFDWI. ❑KITCHEN REMODFI.
V((❑❑�� License Claes s��Lic.N
���•'%� Camra� + m av' s.. API`LIANCES-RESIDENTIAL ❑ADDDION El PLUMBING RF.-PIPE.
Z5a ARCIBTEC'S DECLARA'T'ION PAN17IA ❑MULTLUNIT ❑STRUCTURAL
dull W uwd ae public record, MODIFICATION
OZ� 1 utbernewl my ph nn UPTO 200 AMPS I [I INTERIOR 71 CHIMNEY REPAIR
;M11 Licensed Professional 20I.100DAMPS IMPROVEMENT
kg OWNER-BUILDCR DECLARATION OVER 1000 AMPS
❑BATH RF. CI AIR DEMOLITIO
a V 1 hereby affiw that I am exempt from the Cnmrectorx License law for the []OTHER
follnwinp rearm.(Seninn 7011.5.Bminesx and I`ndcaians Cods:Any oily or MumY SIGNS ELECTRICAL
gas-
!ho which requires a pc ntil to conomer.altar,Improve,demolish,Or repair any structures
Prim to its iavmme.also requires the applicant for such Pewit to rile a signed outermost SPECIAL CIRCUIT/MISC.
that he ie licensed pursuant to the pmvi.vi om of the C.......i License Law(Chepm,9 11!T 16-4
or aCC
((commencing with Section 700a of Division l of the Business and Profnsimr Code)or TEMP.MEII?R OR POLE INS. COMMERCIAL• N
n IY the he it eaemry therefrom stat the breis for the e11egod es[mplMn.Any violation of ❑NEW BLDWADDITION ❑DEMOLITION
1� Section701L5 by any applicant Our a pewit luhkcls tlR applicant o a civil penally Of PI EWER DEVICES ❑TENANT ❑FOODSERVICE
Iml mme't m avt hundred dullare($Stp).O IMPROVEMENT 01.as owner nfihe propcny,or my employees with wenn a their sole compensation, SWIMMING POOL ELECTRIC
will do rhe work,end the gmclurt is not intended oroffered for sale(S«.7144,Umloess ❑OTHER
eld Protest...Cede:The Connennis Licence law d«,nor apply to an owner of OUTLETS-SWITCHES-FIXTURES
trumpery who builds or improve Ihemnn,and who does each work himself tar thnmgh
his nom employees,provided tura such Improvements are not intended Or offered for NEW RESIDENTIAL ELrCfO SQ FT.
rah.If.howeveatmWildingmlmprominent hawdd wMinoan year M coreplednn,0re SQ.IT.FLOOR AREA LS0.7T.
owner-hoW,will have the burden of proving that he did tat build or improve for pur-
pose of male).
❑1,as Owner of am pn,,n,.am eaclaivdy contracting with licensed aanmmnr,to
costume,rhe project(Sec.7M4,Business and OafeWmrs CNet)The Cana«tae's
cenw Law does nm apply man owner of pmpeny who build%or improves thereon.and QTY. PLUM91NO PERMIT ti'^!'` .• PPB%. t'
who contracts for such prof«'m with n conorcmrr)licensed paramount.am Comrncmr'x 1,
Licensc Law' PERMR ISSUANCE
(:JIemesempiunder Sec. ,Bit PCfarthi,rnson
torturous
ALTER-DRAINAVF.NT-WATER(EA) VA A
Owner Date 1�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herthy all,.under penalty of perjury one of the following rkchoutinns:
❑Ihemaod will meinuin aCenificam of Cnnanuorelf-insure for Worker's Compen- DRAINS-FLOOR.ROOF.AR NO STORIES I � PI?CONS'IRUCTIUN
— anon,n provided for by Semon 1701 of the Inhre Crde,for the perfnrnwnee M the V
work for which this pewit is issued. FIXTURES-PER TRAP
El I have am will maintain Workers Com,croa on Insurance,as required by Section
37M of rhe laWr Cede.for the perfomunce of the work for which Nix pe.it is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My WOrter's COmpem,.! Immnr"mru rand Policy mm�her are:
Cartier. f'�'brit 'til) Policy No.: GAS-EA.SYSTCM-OVER 4 GSA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASHIINDUSTRI.WASTE INTERCEPTOR
ftm
IThiss«Oon need not he completed VIM pewit is forms,humdreddollam 1111101 ni :. IIDI V ION
rule.,) GREAST:TRAP PLANE EE
I certify that in the performance of rhe work for which this permit is iwtod,I dull
nmemploy any pnorm in any manner so an to beccme object SEWER-
n the Workers SANI FARY-S'WaM EA.200 FT.
CNF.RG
Oz xatinn lawn of California.Dote WATER IIERTHR WIVGNTELECfR
y 0 Applicant GRA 91 f
([ry yy NOTICE TO APPLICANT IL after making this Ccrifcemof Eamrlinn.yoa should WATER SY..WPM/TREATING
[' become mbjeci m[be Worker'.Compensation Provisions of rhe(.We Cede.you must V162jko
G
forthwith comply wilhsuch provisions or tMs permit shall W kened revoked. WATER SERVICE.
az CUNEI R DICTION LENDI NO AGENCY NEW RESIDENT IAT.PLMIL SQ.PE PAID
V fob (hereby efforts th.Uhere is.eon,boakm lending.,amy for tiro Net,..,o te
11 Ire 01"
Dr!p":fr the work forwhich thi.a pewit 1,issued 1S«.3197,Civ.C.1
V [.oder',Name
{iJ Lart A idrnx
�}.rr g4 1 cenify that 1 have read this application and am,that the eW'c urtur mei'm in BUILDING FCC
FtA C.I.I agree m comply with ell city mil coutnymdina«es and sum laws sequin,to QTy, MECHANICAL PP-RMI EE8"
If NY7
V building conamelion,anti herehy.mhmim representative,of this city m Mar upon the SEISMIC FEE
abovomentioned property for ho soion mr,romx. PERMIT ISSUANCE ELECTRIC
two)agree m rove,indemnify end keep lunnlca the City Of CuPenito eg.inN
Iiabiline,.judgmenlx,rnrsendn,runc,which they in any way accrue aliumsesaid City ALTER OR ADD TO MECH. PLUMBING FE.
In consequence M the granting of this prnuit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRIIANDLING UNIT(TO I0.0OCFM) MECHANICALFEE SO�CE RECIII/1TIONg. /1
AIR IIANDLINO UNIT(OVER I0.000 CEM) CONSTRUCTION T'
Signammof A,ica lt,onaecmr net. EXHAUST HOOD(WB)UCT) HOUSING MIDG ON DER
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant or future building Occupant more Or hanJle Weadom material HEATING UNIT(TO I Off"BTU)
es defined by the Cupertino Municipal Code.Chapter 9.12,and the Ifaith and Safety
Cade,Stam.231120)7 HEWING UNIT(OVER I 0100 BTU)
(3 ye" ONO, VENTILATION FAN tSINGLE RESIDE PAID
Will thea applicant or furor[building 1 use r Or devices which Dem Receipt N
PP !bythen ea Air n BOILER-COMP(3HP OR I01,01p BTU)
emir hazardous air contaminants er derived by the Bay Area Air Quality Management TOTAL:
Hst n7
' ❑Yes C]No BOILER-COMP(OVER III0,00 BTU)
ewiasa
AIR CONDITIONER f�a/-- _,
I have rewd rhe h oaNmn tion2 material,requirements order .I Lural Q93 of the Cab- ISSUANCE D'R../
fmmie gdtvt A Safety tly ,Section,8303,izmy eN sibili L u ramify d that if the NEW RESIDENTIAL.MECH. SQ.FT.
lruilAing Jses na currently have a tenant,Dar It Is my rt,PMxihility tnnorify Ne oceupanl
n!Iht rryuiretnnu which mu4 he met priIX to iauence of a CMificale M fkcvpaney.
Owner IX mhreised often, ISSUED
aRY:
OFFICE