28774 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. /�/� �g A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA274
L 8 /
BUILDING PROJFC7f IDP.NTUCAT10N L V 1
9UILDINGADDRESS: SANITARY NO APPLICATION SUBMITTAL DTfE
1330 Floater et Cvr�ertl:�o 06
OWNER'S NAMEPHO�+E: ,�J CONTRACTORS NAME: LIC NO:
Kooros -5anJld•eh ���• owner N/C /NCONITROL#
\RCHITECHiNGINEER: LIC NO: ADDRESS: ❑ I`_II/ I
CONTACT: PHONE BUILDING PERMIT INFO
SQ"'Le ❑ Consultant Fes Paid by Applicant(Initial) PLUMB MECH
LICENSED CONX_ Et.E TRACTORS DFCLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 henhy ammt Ihm I ern Idetecd under provisions of Chaw
pter 9(euncoeing JOB DESCRIPTION
O0Z with Sstien]fl(ID)of asision 3 ofthe Busircm and Profemimu Cade.and my license it PERMIT ISSUANCE
00 in full face and eRat RESIDENTIAL
wuF ❑S WL ❑KITCHENREMODEL
QFUU I�crnm Clem IJaI
NQL Date—Cwlhactw APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING REPNE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z o t2 z l ardnw
etd my plans"I be used as public records PANELS
UP TO 10f1 AMPS MODIFICATION
O Z
G []INTERIOR [I CHIMNEY REPAIR
ggCW Lianscd l4ofcoiaml ]01-10W AMPS IMPROVEMGYT
ygyW OWNER-caton,ifr DECLARATION OVER I"AMPS ❑BATH REMODEIIREPAIR El DEMOLITION
KooCC a I Fertby nffrm Net I..exemia fan tM Contractor's Code:Aityc taw co do rcwpn
3 L U follnwinp renwv. eSemon con-rust.
Broil., candn" 's.de iom Any city or county SIGNS ELECTRICAL -n
41 V- whkh rt'noo a perttdt to cools tib, elttt.imfnovc,h ennit t ri e a lis any mm�are
�LLON pda to iu i.uunrlva vlw mluim tlr applkevl Gr•mh pennitmflcasiyrcd slatelrrnt SPECIAL CIRCUIT/MISC.
u�>k�d.o
slicen.id wrt'arutolhepr D,vs im Tube ennuewn Lkerue Law lChamer9
SOhe
exernts erefort andI of basismJ oft ade,ed essoplon,Anwm Codeof)ar TEMP.ML-fEROR POLE INET COMMERCIAL
4 6 e exevtp thmefrmn erd the basis for tie mleged caunptiw.Any violation of
x El NEW BLDG/ADDITION DEMOLITION
11J13 by any epplicam torn pmmit wbjens tib vptlieem toeclWl prndry of PoWER DEVICES LITENANT ❑FOODSERVICE
then five handed dollen(S5W).
Krof the progeny.or Try employ.with wogea n tlarir sole cumpemaion, SWIMMING POOL ELECTRIC IMPROVEMPM'
c worV:.eM the slmnure is not ineoded ornRertd for sale(Sec.]IH4.Btssbem ❑OTHER
6 sad Prof.ians Code,Tie Curs License Law does not apply to w owner M OUTLETS-SWITCHES-FIX'T)RFS
Iaolmny who builds or immoves theta.,end who doe such wah himself or through
his own cmpbycv,povidM in.such inn,owxntcvts.oro intended-.Hind far NEW RESIDENTIAL ELECTR - SQ FT
wlc.If.however,the haildingor improvement is wld wiffioo.year.reoropktion.Ur. SQ PT FLOORARPA SISQ.FT.
-buikb will have the When of Powing plat he did mN build err improveforpar-
❑L an owner of site rotert,70a.B exclusively Protncling with: Thlicensed mart los to
construct the projat(Sm.1UW.Bualress and Nofuvms Code:)The Caurama(s D-
cense law doesi not apply to an owrer of progeny win haikLs or .paves lherron,aril QTY, PLUMBING PERM IT FEE
who contracts for such projects with a wntrecta(s)licensed ponatmor to tine Contractors
Ltccnsc Law. PERMIT ISSUANCE
cacmq under Sec. ,B&PC oethis
• ALTER-DRAIN&VENT-Wp EA) VALUATION
ocr Dme
411 WORKER' TINT PENSATIONDECfARAHON BACK FLOW PROTECT.DE '��OO•
I hereby afnrm under PerultY of perjury are of the follawivg JecHntimn:
❑Iharc"will maimainaCenifware ofCunwnuosdf-inwmlm Wnrkela Compen- DRAINS-FLUOR.ROOF,LEA,CO STORIES TYPF,CONSTRUCIION
station,as povitlN for by Seaian 3W of tle labor Cade,for Ute Ierf.e of rte
ill 1 have
work for whichlhi.s panus is issued. FIXTURES-PER TRAP ns.. a //• }J
and wmaintain Worke/s Cwnpemmion Insemncr,o recanted by Section W2 K /f
37Wof the labor Cods.for din perftnvuncc of the,wed for which this Permit is luuel. GAS-EA.SYSTEM-I I14(1401
OCC.GROUP APN
MY Worker's Comirerumion Insurance wrier and Policy nnml+cr an,
Cartier. Paticy Na.: GAS-PA.SYSTEM-OVER 4 HLA)
CERIIFlCATE OP EXEMPTION FROM WORKERS'
COMPI:NSATIONINSURANCT GRFASEINDUSTRL 1
(This smiw recd rta be ctanpka5l ifmu pvmit i.for me hutdrul&sitars[g IW) BUILDING DIVISION IFPS
or lux) GRCSSETRAP PIANCHECK ITE ^
Icenify patinlhe anRmwrux of the beconfor wubjeciis Petrillo hWisiumd,IsMll SEWER-SANITARY-STORM EA.
wton Law any Pe*ean in any mower w o to heeavra wbjm to the Woheri Crmtpar ENERGY FL'C
Z atiwlaws of Celifstmia.DateQ WATER WATER W/VLNT/ELECHt
z Applicant GRAUING,F�
N NOTICE TO ed to int ANTWort IL efts raking this Certificate the
Eacraptiw,ysy should WATER SYSTCM/TRFATING
I-' baweaubjeettotk Wsvh'o "i's t,This pian mans of the Inbar Code.you mart Sons• : y
Wq foMwilhcump{y wits.wchproviiartamthispexntitshall ba Jccrtwl revukN. WATER SERVICE -Pv- `, 94
/I
7Z CONSTRUCTIONLEbIDINGAGENCY NEW RESIDENTIAL PLMB. SQ.Ff PAID UI''tI}/J/J
UO I Aaeby afino libel them is a const tiidn lending ageoey for teffomeoee of Due Receiptvw
D. I-' Jr.work for which this Peanut is imueJ(Sec.J097,Civ,C)
Q U LeMm's Name TOTAL:
Uj Tart ,Add. TOTAL:
04 1 em ify that 1 have reac!this amocati(n vrd.rtztc that Ne above infonwtiun is BUILDING FEE
V) a stmt.lagreatocomplywithtllchyardcwntyo nmeamd lawsmWingm QTy, MECHANICAL PERMIT FEE _
U building wn.suuction,and worthy aathorirc npmcnlatives ofthis city torntcf upon Ur. SEISMICF
above-renlioned pon catY for inspcmion pur,asa.
(We)agree amn
to ve,indemnify and kce,a haNns the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEC
liabilitigjudemmss,ants srd calenua which nay in any way cease against mid City
In co r"atnee or de grant,of this permtit. ALTER OR ADD TO MECH. PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TIC)10.0fa)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.00)CFM) CON, UCTIONTAX
Siy..o,of ApplicwUCsmtmctor Dae EXHAUST HOOD(WOUCUHOUSING1MRIGATTON FEE
HA]ARDOUS MATERIALS DISCLOSURE
Will the applicant oe future building occupant soon or heraEc harardoas Trust HEATING UNIT TO 10B."BTI,
as w-no cl by the Culenina Municipal Code,Chaper 9.13,W Ute Hcilth and Safety
Crile,Section 2591(e)1 HEATING UNIT(OVER IW.000 BTU) nam ..
❑Yo Cl No Jo
VENTILATION FAN(SINGLE RIESID) PAID
Will the applicant or future building occupant use e9uiMcnI w devices which Jr LU'' Hal Rcccip N
tort haaerdnus air coctamiwn¢a,dionscd by the Hay Ana AU Que6ty Mana,s. BOILER-COMP(3HP OR 100.00()BN)
SDistrict? ROLLER-COb1P TONER I W.OoO BTI, mcT
El Y. F1 No
I have rmd the lurecduus crossroads ATR CONDMONER ISSUANCE DATE
r5.1513tmss uMn Chsptm Wai ii Ur.Cat-
Health&Snfny Code.Scctirxts L that i.25533 and 25534.1 umkratard Uw if de NEW RESIDENTIAL MECH. SQ.R.
building dom w wrtmUY ba.a a tmmn�dtm it n rvy respwibJiry to rtaify rte..pout
Mthe rr9uircmrnv whichmna ha uta priorto issuance ofn Cr,rdcmc of Dccup y.
Owrcrorauthorirale in gra TOTAL ISSUED BY:
OFFICE