99090197 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY aI -`4 Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
PUIIAING PROJECT IDFSTIFICATION
BUILDINGADURESS: SANITARY NO. APPLICAI ION SUBMITTAL DATE
2 plill6i jC G-r � - 30 qtr
OWNIUll PIIUNI!: NAMFy�QG I LIC
li b /V.` NIC CONTROL If
A CHII'ECI'IENGIN i1M: LIC NO: IDrT7a hes0h Lo las
CONTACT PHONE: BUILDING PERMIT IMO
❑ Consultant Fees Paid by AIIIIU nt(Initial) BLDG EW PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 thereby affirm mu I am lia,beJ ewer provision of Chepmr 9(mmmcming JOB DESCRIPTION
�p'z with Section 7000)MDiviaim 3 little,ee.iness and Prnfmaion C ndnty license is RESIDENTIAL
F W , nfull lame land elfecyk..�� p'I5 PI7RMIT ISSUANCIi
aF.VF Littrve CDs, U Lica D � ❑SFDWL ❑KRCHIiN REMODEL
NQL Dem Contract �.G APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
F AHCHI'NETS DECLARATION PANELS ❑MULTI-UNfr ❑STRUCTURAL
Z OI undcnurd my plan,shl be usnl u public records MODIFICATION
OZ-= 1 UP TO 200 AMPS El INTERIOR [D CHIMNEY REPAIR
E-�(=W Liccnnd l'nfictownnl 201-10(MAMPS IMPROVEMENT
C]SWIMMING POOLS
UWNEm exclopt from
m his, RATION Cann
i�(C w Q 1 hereby affirm char 1 am Hemp from chic Cnmrannr'a Lkerrce taw f«Jse OVER IOf18 AMPS ❑BATH RENqp ELl EPAIR ❑DENyp F la�
W 3 6 U
following reason (Section 9031.5,Husiress and Profc doom GNI:Any Illy m nm^tY SIGNS HLECfR1CAl, v ❑OTHER .f 140 A;tn/� ' /'ri
4Fl`O�<' which respites a Rrmil to rnry
nslcl,alltt,imm
lrtove,J. dish,or rep it aNret
any sure
hJ Prime to au iavursec,also required dseapplicem for such permit to file a siereal sutrntrnl SPECIAL CIRCUUUMISC. C
that he is liceedpeuem to the p .mn
ruvaoftltem
Ctmclors loow
se la (CliepnrY
�aOO (mmmracing nswith S.atin.NX00)ofDlvnxn 3 oftfse Heanc'sand NokrsiansCWclor TL'MP.MEI'F.R OR POLE INSf. COMMERCIAL
d thin he is caenga thertfmm aid the hers fm the ilkged cacmption.My violation M ❑NEN'BLDGIADDTTION ❑DEMOLITION
Section,01313 hy.,asplicam Gov pcmiil.ub acs ih eppbcame.civil pertaltyof POWER DEVICES
ern ❑TENANT [:1 FOOD SERVICE
FZi' not mom than rive hundred Nutters(S5(X)).
SQ SFW Luawasof die purmyemployee withwagesask,ompenwian SWIMMING POOL ELECTRIC IMPROVEMENT
will dor thwast arL lhesurcclurt amtirrnded«oRccd far vale
(Sea.)fW,Buairmu OTHER
Wlam Pnsfelandi Gdc:TM Comracmh I.ica.w law doe,not apply m an mvmr of OUT LETS-SwFICHES-
10X'1'URCS
popeny who builds or improves thvmra aril is ho Jaen much wart himmor or through
W,awn oal,crrea,pualfirJ that...M1 e.ol it void s ve int inlrndcd v ofTcrtd fm NEW RFSIUE�TIAL ELECTR SQ 4T.
.ole.if.Mwn'cr.tM M1mlJing arimpnowmm�ue.wd within n.c Y,ar nfmntpinliu,the SQ,FT FLOOR AREA SISQ.Ief.
neo-btific will have the buNrn of proving that he did ria build a impmvc for
pore or rak.l.
❑Lan nwn,r of the IrtvhcnY.ant exduGvdy eimructing with lirenved canner o
c.nstrun the protect(Sec.71N4,Busirsess arW Profaaions Code U lire Connector'
sc Lew mea rxn apply to an owne of papery win band..,imprnvm dsncon.ad QTY. PLUMBING PERMI
who cmmamx forwch pnijan with a c^nuccmrca licco�purwanrto the Contractor's
1Jccnw law. 185 A
❑Tam eaemp uivb Sao ,B&I'Cfu thio.
VALUATION
�wner Hone
WORKER'S COMPENSATION DECLARATION
I hereby affirmurdcrperen,of rerjury one ii folEnvine dcclerm
I] Iher.and willmammmaCenfi,,bof Cn oem ,,vell-inwrt for Worker's Cu A - R STORIES L
PE CONSTRUCTION
,door,u fac ideJ fm by Section 3'100 of the labor Cole,for Ese perfonrunce the
work for whichthis lscrmit is to". FlX"NRES- ftTRA
❑ I have awl will mnlntni^W.Arre C(mpe.wron Iroolon, ,as mgeirtd by Section
37Wof Jon LebarCale.far0 pefom ofdseworkfawitichthispnrtitisns . GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC-GROUP � /
My wmkcr's Compnwion lrisumrds certicroli Policy number art: GAS-EA,SYSTEM-OVER4 EA) J
Cmncr. Policy Nii FROM
CT:HTIFlCO OE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRGSF/INDUSTRL WASTE,INTERCEPTOR
(lTis section need n i be completed if he pmmit I.Gtr one hundred dollars;(5100) BUILDING DIVISION FEES
or le,;') OHIASBTRAP pLANCHECK FBI
I employ
may that in din any mnunee a1'ihc xtak for which tMs pemdr is Isstsed.l die8
.mem G SEWER-SANITARY-STOHSI EA.200 FT
p ry any pmnn in any mannas.av m M1ecome w�`eµie}vivke 'C prn ENERGY IH!E
1,Z satin.laws of I' Dae_ / l VV
Z O A,1icent � //�r— - WATER HEATER WNEYI'/ELECfR GRADING F£E
pJ NOTICE TOAPI.CAMP,9,after mekm8 this Cc (cmc ofMl WATER SYSTEM/TREATIN(I S FELL
Wba.me whpI In the Worker's Cmttpemalin^provninm ofthe IuborCde,you mast SOU
{ll� fonhwth comply with such pmrii.ia uthie permit shill be disclosed revoked. WATER SERVICE
Q
tau- z CONSIRUCI'ION LENDING AGENCY NEW RESIDENTIAL.PCMB. SQ.4T. PAID
V I forwhichthi that thcrt iseavuSectim tong aeeayfry the lzrfmrtanec of Date Rettipta
the work for which this permit is issocd(Sao X197,Civ.C.)
0 U lender's Name
IendcJa AJJms TOTAU
Fr^ y 1 ttair,that I have read thin apf icviun soil state that the above inf rm ion u BUILDING FEE
l)1 c xrm,I agree In comply with all city aril county udinvca u.l.mte laws relining to QTY MECHANICAL PERMIT FEE
U Z herdtngcrosirucoor.and hereby amMmee npraenwtivn of thio cirym eine,alarm the SEISMIC FEB
above-ractm l lxgmy fir inspection purptsea. PERMIT ISSUANCE(We)agree m save,indemnify end is
keep hurm ,the City of Cupnim eg.inv ELF,CIRIC FFP
IlaM1ilitiea,j W gmenly,emU cont mpen.ra which nay in any way accrue agaiml said Ca,
ALTER OR ADD TOMECH. PLUMBING FEE
Aeanseq NT ante,cru AN of INu perm it.
APPLICANT UNDERSTAN DWELL 1PLY WITH ALL NON-POINT AIRHANDLINGUNII'T010,000CFFD MECHANICAL Fl?E
Sf3U E CATIONS
X AIR HANDLING UNIT(OVER 10,000 CENT)
yyi CONSTRUCTION TA%
.)illibutrellcantractor Dale EXHAUST HOOD(WIDUCq HOUSING MrTIGATION FFP
RDOUS MATERIALS DISCLOSURE
Will theapplicent de future building occupant love or hondle baaardnds mxtrnal HEATING UNIT(TO 100,000 BTU)
as refinW by the Cupen'mo Meni,igJ Cil Chapter 9.12,and the Health and Solely
Ci.k.Scrim 25532(x)^ HEATING UNIT(OVER 100,000 BTU)
0Ya ❑No VENTILATION PAN SINGLE RESID) PAID Date Receipt X
WIII the applicant w Lune bundled h,the B use ea Airr Qu on i Mica ween, BOILER-COMP DHP OR IM."BTU)
mor hessrJmus air Ionamin".,..u refined by Jse Bay Area Air QuelitY Mumgrmcnt .
District:'
❑Va 7N BOILER-Q)MP(DVER 100.1000B'1'U) TOTAL' o
1 have real the hevarJw mmenals n ended Ch. 695 of Ilse Cali- AIR CONDITIONER
rtyuimrcn per ISSUANCE DATE
Emie Health&SW'ery Cod, 43".'553 .125534.I urdcnmrd that it the NEW RESIDEN TIAL MECH. SQ.EENiMEng sidesn0y , yrtspmdbilirymrtaify ase orcupara U 7
dth b.10 oce.fa CsrtlEcaemOccupercy.
dim, m Dem TOTAL:
ISSUED BY:
OFFICE