S 3819 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI,TN'OF CIIPERTINO BUILDING-ELECTRICAL I PERMIT NO J
BUILDING DIVISION APPIACATION/PERDIIT PLUMBING-MECHANICAL S 3819
BUILDING PROJECT IIIENTIF'ICATION
BUILDING ADDRESS SANITARY NO APPLICATION SUBMITTAL DATE
f5 o IiIq'1 on If5pIP-�� . C�,OP,✓ti✓w cal �Z �
IOW ER'S NAME. P-HONE CONTRACTOR'S NAME LIC NO t
Q h S K.-viii 1'1Q I,/K/1'YL 4 W g h N/C CONTROL p
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�lllIIIIIIIIIIMJERLCHI LIC NO. ADDRESS
r1 AV-0 1 MVYO ✓ C- q_ ❑
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INIACI': PHONJ`!& BUILDING PERMIT INFO
t / ❑ GonSWlanf Fees Paid by Applicant(Initial) I BLDG ELECT PLUMB MUCH
PJ(Mrira �'l�avrlhPrli✓�k. � � E�— -�-
LICENSED CONTRACTORS DECLARATION l QTY. ELECTRIC PERMIT FEE
I hereby affirm Nat I aro Lcea,ed under pmvrvons of Chapter 9(ona mu mng I JOB DESCRIPTION
WoZ wnh Section]OOO)ofUivtsmn3ofen,Bustnessand Pmfe,stons Code, deny M1cenu gF ID .NTIA
F,o In mu freeaad effect. pI I �� PcxnlIT lssunncE 35 .SZ I BS--F !_
lXu' Licenu Clas M Lm.n ❑SFDWL ❑KITCHEN REMODEL
yZ Date V Contractor APPLIANCES-RESIDENTIAL I (]ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANE S ❑MULTI UNIT L1 STRUCTURAL
I
OZF r=/t'�{ �. 1 understand �y plans sM1.rll be used a ub •rcco , I MODIFICATION
O1•.'pC1� , /_✓�!I W JCM UPT02MANIPS ❑INTERIOR ❑CHIMNEY REPAIR
F�F'w Lte�y`t� O 2014000AMPS
L/ OWNER-BUILDIR DECLARATION ��� IMPROVEMENT []SWIMMING POOLS
C4 T4 Q 1 hemhy altirm that I am e,umpt Inim the Comm ins,License Law for the OVER (AX)AMPS O BATH RF.MODEUREPAIR ❑DEMOLITION
Y sit y al Y SIGNS ELECTRICAL OOTHER I
W 3 LL F which rag remora neat n]031 S..1,trier.and oc.demolish Cr'lc,em T mural
t— which lmitt iou'rev.,lnre toes the applicant for such permit file a signed statement 'v
.] Pour 4 pp Icon. g $PF,CIAL CIRCUIT/MISC
that W,,licensed pursuanva he provision.aflM Cnmrannr's License have(Chnp¢r9
W 0 (cummencmg with Secuon 7001 Divmon yet be ltustness andliful,aom Cade). TEMP METER OR POLE INST Can COMMERCIAL:
L 5:,Z oC that he is nempl Therefrom and Ne bml,for the alleged exemption Any vtolauon of O NEW BLDG/ADDITION O DEMOLITION
a, N Section]0315 by any applicant for a pemuT wbjec't%The applicant To a civil penalty of POWER DEVICES
h-ZY T mom than five hundred dollars(S50i 4 ❑TENANT El FOOD SERVICE
❑Lmmvnerm Ne property.or my employees wnh wage as Nnr role compensation, SWIMMING POOL ELECTRIC ��1Is IMPROVEMENT
F- ullldolhewod.,and the structure is notintended muttered for sale ISec.R0ly,Business -�`!" /I ❑OTHER
3°m and Profnsmn,Code The Contractors License Law does gar apply m an owner of OUTLETS-SWITCHES-FI\'TURFS ���aaallllll
property who build,or improves thereon,trod who does such wort,himself at through
his own employee,.provided that rich Improvement,are not.mended or m ened ter NEW RESIDENTIAL ELECfR SQ FT.
sale.ti,however.the buildmgnnmpm'cmmeti„nW wnhinone year of completion,The . 1 SQ FL FLOOR AREA S/so FT
ee-budder will have the burden 9f pausing that he dui not hold or improve for put- D
awn ('ale) OL.Syr g 7
I'm owner m the propeny.am eacla,i.ely emnmetmg with Deemed conhaebi m j-67 x r o-7- /•—/ -/'A✓I- 3 U 3 — 2 8 7
eamtmn be peace,(See nut-.Business and Pmte„ism,Code)Me Contmcmr,I.i- Z D
c claw does not apply to an owner of pmpeny u ho Hon
builds or Improves ere .and (QTY. PLUMBINGPERMIT FEE
whocontm n'fonuchp,ectsunhacnnnactorrf aemWpucmr or the Commons / L , ';/'
L¢enu I.ow. �/ •B&P C for Nn reason
PERMIT ISSU 'CE s• S2 I �� ( S/ e� ' r/{a
Iamcac ,Tun w
ALTER-DRAIWVF.NT�ER(EA) VALUATION
act WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEC�"(rEVI \ 3 Q 2- . O Q
1 hereby affirm under penally of 11.1 one of the following declarm....
J L have and will maintain a CenificmeofConsenua,clf-tenure for Workers Compen- DRAINS-FLOOR,ROOF,AREA, D STORIES TYPE CONSTRUCTION
t, her,as pmvWed for by Semmn 37M of the Labor Cole,fns the performance m the `
nk for w hick this permit is %ueJ FIXTURES-PER TRAP - — \ 12,
❑ I have and wJl mamtam Wi,,jer'Cn I,r,munt Ise...... ......rnd hY lecuun
i]INlnl ihcl,nbnr CUJC.IorNt-,crfnrmunce9l ihawnrk lurxh¢hlhi,permiu,n'ueJ GAS-EA SYSTEM-I INC 4OUTLETS OC GROUP MIN
Afy WnrAcr''C'Impinoumn Immame canner and Polley nood of arc
4amee_ Policy N9 --I ”, A2�L—//— GAS-EA SYSTEM-OVER a(EA)
CER FI�YTIONFROMWORKERS' I 3 ovc
/_ COMPENSATION INSURANCE GREASEdNDUSTRL WASTE INTERCEPTOR B ILDING DMSIDN FEF_ti
Gbrs.,am need not h completed dthc pcnmu,fnrane hundred dollars 1$t W) OR BASE TRAP
or lescl iPLANCIIE �E
Loy any that ur any ormaacerd the work
v.orewhich lhnPermit
icke",Co %hall (SEWER-SANITARY-STORM E, 200 FT T I ` /� �/s
not employ any person m any manner so.s To become,ub)at T9 The NbrAers'Compen- ENEffy��G;;YMEE z 7 6
zZ Appheaw,of Cahfumm.D.e
APPhcant WATER HEATER wNENT/ELF.ITR DI FEE
N NOTICE.TO APPLICANT If,after making this Cereficate of Eaempuon,you should WATER SYSTEM?BEATING
FKi ; become subject to The Worker's Compensation provisinm of the Labor Cade,you mint 50 S E
�r k illwuh comply with such prrsetntonsnr This perrinhdll be Jecmedrevnked. WATER SERVICE i
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLNHI. SQ FT PAID
L) I hereby affirm that there n a construction lending agency fmine performance", _ Dam Rec tY
U. ,w�-N��fhe work for which this permit is owed(See MN],Cie,C)
{fFS�]y Linder',Naim• �/ _
1<nder's Addre•• TOl'A Oy,1.� t _ T �i
F^ S 1 comfy Nat 1 ha,e read Nrc.,,hemma Ind'tate that the above mfsmauon Is t - / BUILDING FEE 5z
ft, correct.I agree to comply with all city and county ordinance,and suit-taus relating To QTY. MECHANICAL PERMIT FEE
Uz building construction.and hereby auNurre tepreuntatives of this city To enter upon the I (SEISMIC FEE �' V•�
.Mve-men..ned pmpeny formspoome puryn,es T ISSUANCE I I fj_
(We)agree To save.indemnify and keep bamdcss me City of Cupemno agmmr PERMIT ELECTRIC HE IJS I z�
li.h ldies.pulgmems.costs and expenses u hich may in any way accrue........aid City
t ALTER OR ADD TO MECH. �',t.7
onuyuence of Ne gunung of This pcnmT PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,000CFM)
SOURCE REGULATIONS I MECHANICAL FEE }Yy^t Z)
AIR HANDLING UNIT(OVF.R W,00I CUM) CONS TRUCTION TAX
Signal Altplic.e Cant actor 1 / //ODLte (EXHAUST HOOD OW/DUCT, HOUSING MITIGATION FEE ��C 6',
H DIIUS MATERIALS DISCLOSURE ..7
WilltrritTl ,orte,furore buJJinglacupantamre or handle bavandi material HEATING UNIT(TO 100,000 BTU) 1
its defined by the Cupertino Municipal Cure,Chapter 9 12.and the Health and Safety 1
Care.Section
Ye`25532(.)9 l3'9 HEAPING UNIT(OVER 100.000 BTU)
VENTILATION FAN(SINGLE RESID) I PAID �Z�O•
\
Will the applicant or future Wilding Date Receipt a
pp g o:cueaBayAe.An Management (BOILER-COMP(3HP OR 100,000 BTU) j
ten hvaNOYi air conmmmanrc a,de teed lily the Ray Arca An Quality hfanagemenl
nano? ! TOTAL
❑Yes ONO (BOILER-COMP(OVER 100.tXM]BTU) 11 -y �� -
I have read The Weathe,ma¢nul,reymmntem'under Chapter 6 y5 of The Call- AIR CONDI9'IONER ISSUANCE E
1 fnnua Ileallh M Surety C.Ide.Seniuns]5505,25536 and 2553) I under, vi Nat tithe NEW RESIDENTIAL AIECH SQ.FT �•
Folding Jlas nut currcn0y have a¢nant.thw it rainy rcgnnabibtymnnhfy the recu,.mt /O
nl the r guaenrcn s which must be,amt pour m t"mume ul a Cenificate of Occupancy.
_ —�
Oxncr�rlrihunzed ag m� Dine TOTAL �),
_ ISSUED BY
OFFICE U /Wd
Inspection Query for a Specfic Permit 1/8/02
PERMIT# SITUS ST(SITUS STREET-Co-t# INSUtSCRIPT InsTyp ATEDESIRE ateDone lnspecto UnitsIPass/Fail! Code
S3819 22650 IALCALDE 101/FOUNDATION 8/8/001 8/8/OOJDS 21P
S3819 22650 1ALCALDE PIERS I 8/8/00 8/8/0 DS 1!P
M/-0-
/8
S3819 22650 ALCALDE _ UFER /00 8/8/00 DS 11P
S3819 22650 ALCALDE _— PAD SETBK CERTIF 8/9/00'. 8/9/00 TO i 2 P _
— -- -- — ---- --------- --- —
S3819 22650 ALCALDE SLAB ON GRADE 8/14/00; 8/14/00 DS !
53819 22650 ALCALDE _ UNDFLRINSUL 9/6/00 i 9/6100 TO 2;F
S3819 22650 ALCALDE UNDFLR PLBG 9/1/00 9/l/00IAD 2P
S3819 - 22650 ALCALDE _ UNDFLR MECH 9/1/00 9/1/GOAD _ 2P
S3819 22650 ALCALDE UNUFLR FRAME 9/1/00 9/1/001AD 2 P
S3819 22650 ALCALDE INSULATION 9/6/00 9/6/00!TO 2P
S3819 22650 ALCALDE ROOF NAIL 11/20/00 11/20/00 DS 2P
S3819 22650 ALCALDE — ELECT-R ) 12/26/00 12/26/OO�JB 2! 1N
53819_ 22650 iALCALDE INS_UL 307 11/28/00 11/28/00 TO 2,P
N
S3819 22650 ALCALDE SHEAR NAIL 11/20/00 11/20/00 DS 2
S3819 22650 !ALCALDE PLBG-R 12/26/00 12/26/OO�JB 2 F
S3819 22650 !ALCALDE MECH_R 12/26/00' 12/26/00!JB 2P_
_. -
S3819 22650 ALCALDE FRAME 12/26/0 1 2/26/00 JB 21 IN
S3819 22650 ALCALDE INT SHEAR 12/27/00 12/27/00 JB 4�P
S3819 22650 ALCALDE PLBG-R 12/27/00 12/27/00!J13 3 P
S3819 - 22650 ALCALDE ELECT-R 12/27/00 12/27/00 JB 4P
S3819 22650 ALCALDE _ FRAME 1/30/01 1/30/01 AD ! 21P
S3819 22650 ALCALDE STUCCO LATH 1/30/01: 21F
S3819 22650 ALCALDE TUB & SHOWER PAN 1/30/01F 1/30/01JAD 2P
S3819 22650 ALCALDE INSULATION !„ 2/1/011 AD lip
S3819 22650 ALCALDE _ GAS TEST __ 2/6/01 2/6/01 JB 4I IN
§3819 22650 ALCALDE _ SHTRK _ _ 2/6/01 2/6/01IJB _ 21P
S3819 22650 (ALCALDE LATH 2/6/01 2/6/01!JB 21F
S3819 22650 `,ALCALDE ELECT RELEASE ! 11/20/01, 11/20/011AD 21P �—
S3819 22650 !ALCALDE _FENCE PROBLEM ! 1/10/02!_
P 1