99080180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL ER. IT NO
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MEC11An'ICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADQRfiS: �O � D�
Oµ SANITARY NO. APPLICATION SUBMITTAL DALE
'MR'S NALMM/E/%� CONTRACTOR'S NA F �y� 1 NO:
sr�xl„ 6 � "71�vL�`. / No CONRULN
CHI'TECl/ENCINEER: LIC NO'. ADURErS_SG'. rC',.e/`lw_1 �1 cii 1W qC �I'/
❑
CONTACT: PHONE JJZZ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG Il FCf PLUMB MECH
ID �? E:1 ❑
LICENSED CONTRACIOR'SDECIARATION iELECTRIC PERMIT FEE
1 larch,a1r io that 1 an,hernswd alder pnwmnen orehaler a my11c ,is JOB DESCRIPTION
DMZ with11rage and el Division Jaf Je Bwires,end Pmf Ylicrn.sc is
�O O `� PERMIT ISSUANCE RESIDENTIAL:
F�u m full forte ardforte el '7 V rn 0 SIUWL 0 KITCHEN REMODEL
QF-U�j liamc Cl IicN '7 V APPLIANCES-NFSID[NTIAL ❑ADDO'ION ❑PLUMBING RE-PIPE
N G wa Dale Conlracta
f-Oh nRCI11T[CPSDEC ION P 0MULT1-UNff ❑STRUCTURAL
Z I utdenurd my plans shell he caul ax public records MODIFICATION
O Z- UP TO 200 AMR
F'^F'0DebasedProlevional ❑INTERIOR ❑CHIMNEY REPAIR
OWNER BUILD ER DECLARATION 201-IIXX)AMPS IMPROVEMENT OSWIMMWG POOLS
C C LLQ I hereby affimt that 1 an racial bran IM1c Contractors License Law Ger the OVER IOW AMPS ❑BATH REMODIr EPAIR 0 DESIOLITION
x O n U fountain,realm.(Sanwa 7031.5,Bari and Pm(ectims Code:Any Or,or comedy SIGNS ITEC iCA1,
1+13 4 h which rtquirts a pemdl to acramcl,si improve dennlLsh,or repair any swnurt
F�OQ Prior tons assurance,elsortquimx IM1c applicwl forwchpttmit tofile a signed!statement SPECIAL CIRCUIT/MISC. 'f
End kr,licensed Irnuum(aipavisimsoflheConvacla',Licrnsel,aw(Chapta9
W{YDQ fcmvnennng with Station 701af Division Sof Wr 6uxineG.wd Profinsions r)Gaor TEMP.MEI'ER OR POLE INST, COMMERCIAL
1 a e y Iha he is exempt therefrom and We hams for the,dkged exemlim.Any violmion of 0 NEW BLDG/ADDITION ❑DEMOLITION
�N Section 9031.5 by may appliavm roe a permit mhjecls the apparent on civil pmvlq of POWER DEVICES 0TENANT [_1 LOGO SERVICE
F_Z_Y nor mac than fns hundrd dolbrs($500).
❑ Lasaweerr theloiorr my conne,m with wages we their sde compensation. SWIMMING POOL ELECTRIC IMPROVFAIENT
S will dothewrxk,.ndlhcari mea rmendedrfoffvined fawlc r.Scc.IIMJ.Baarcix ❑OTHER
andH
tryst rr my whore Cute:The arcs he-s License o do doe,nor„ply m lf name M OUTLETS-SWITCHES-FIXTURES
63- his-a mplhoilde u imlovca thymin,and who dors a wuf himself.,m or through
his awn emlo)x+,pmsidN dw wch improvements sec raN intended or oRercd for NEW RESIDENTIAL EfFCfR SQ FD.
sale.If.fir-c-r,the holdingalmpnrvemcm it sold army e,yearafromplabon,the S AREA "Q.ET.
rnvncr-huildcr will have the burden of loving I Wt hs did not build oximpboe for par-
ofuk.).
I,es owner of the piam caduaivdy umtmaing with licensed cmaracum u, TUFAL:
0
amgrat the project(Sec.9(00,Business eM professions Code:)'fbe Connxtor's Li-
,Lawaplywunownsrofprapcnywloo Wildsorimpmv therttq.anti QTY, PLUMBING PERMIT FEE
wM mmr ace for such projens with a eomrena(s)Iicemed punuam bill Commmor's
Lmcnse Iuw. PERMff ISSUANCE
0 lemeaemlunder See.net ,Bk PCtur tics rt:.snn
Umc ALTER-DRAIN k VENT-WATER(G) VALUATION
WORKERS COMPENSATION DECLARATION PACK II,OW PROTECT DEVICE
I herebyanion ceder penally of perjuryme of i rollowbng Jeristab m:
O l have and will mam.in aCmificdtc ofConwnno.mlFinwre fa Wrrker'.Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPECORSTRUCIION
avian,as provided fa by Section 37W of the Labor Ca e.for the verforri of the
work for which This permir is issued. FIXTURES-PER TRAP
0 1 have arld will maintain Worker's Cornperremim Insurmec,as required by Sce ion
311(lafthe LabaCei forthe perfica c of Je work lot which thi,pear ishesuM. GAS-E.A.SYSTEM-I INC.a OUTLETS OCC.GROUPI�APN� �
C Wa nln.s trcc rant Posey No / res GAS- SYSTE14.0 RJ1 //
Ca c M� IA.
IRTI KATE Op
COMPFASATION INSURANCE
NSURAMCFCHEERS' b
GRGSPIINDUSIRL WASTE INTCRCEITOft
BUILDING DIVISION DFES
(Ittivaw
rahnecJnot be ncompleted the Lenart is fwmehmlrtd vdollars(g1 W) GREASE TRAP
or Icsx.) PLANCHECK FEE
Toy any Jut inin pcJaenmccvfthe�`}y kforsfiic hie permit uissucompern SEWER-SANITARY-STORM EA.200 FT
not employ any pen npl rlrZy))�♦�nnlhc watrry ComPrnENERGY FEE
OZ
.b.""a"
C.7WgI'ER IIEAfER WNENT/ELIiCTIi GRADING FEE
z O Applicant / l
fA NOTICE TO PPLICANT:If,atcr Inking is Ccnifica¢of Exemption,you sMwld WATER SYS'1'LWfREATING
a ; bccmte a. l m 0e Workers Compensation provisions of the Irhar Code.rose new. SOILS FEE
fonhwith comply with wch pnrvummnr this permit andl he Armed revrAul. WADER SERVICE
a �
oz CONSTRUCTION
action GAGIWCY NEW'RCSIDGMIALPLMH. SQ.PT. PAID
I he,which ria Jutmit is .emewc0on.Us..grnryfw the perfnnnence of Ie ReccipaY
U� U IM1c rworkyes far which this pCnail is i.suW(Sec.JOY],Civ.C.1
p F' lsulels Name TOTAL:
U tenets AdWrcxs TOTAL:
Fi I army that I have read Thi..application and state that tle adrvc'mfomvuon is BUILDING E
h caeca.Iagme merabi%ithal city am eawryd.dinencesenduaelew.rdaunJw QTY. MECHANICAL PERMIT FEE U ,Z M1wlding cansemmion,and hereby authodac nptcsenutivmafthu city w en¢rupm Je SEISMIC
F
above-mentioted lupcny for im buion purposes.
(Wal)aIn ease,inm
kafy and keep harmJae less Cay not CupmingaimPERMIT ISSUANCC o e
a ELEM'1
liahilitics.lodgnenax,cape andesimrsra which navy in any way acme agairv,.wdCin ALTER OR ADD TOMECH.
fthc ling dims I PLUMBING FF.
n cmsegaxe a gran pemu.
APPLICANT UNUE TANIM AND WILL COMPLY W A/l.NON- DINT AIR IIANINJNG UNIT(TO 10.00i MECHANICAL WE
SWRCY T r ��
AIR HANDLING UNIT(OVER 10,0IXICFM) CONSTRUCTION TAX
Si um of Aplicam/Cwunctor f I Dille PXHAUSTHOOD(W/OUC)
HA/ARDOUS MAI E W ALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or finance huidinga'Npanl stat or hurdle 1wasNou.mamlial HIEODNG UNIT CFO 100.00r)BTU)
as dcfned by IM1c Cupcnioo Mwicipa Cue.Civil Y.12,std the Hrnhh and Safely
Cole Secrim 11532a)". H13AIING UNIT(OVER W,IMBTU)
O Ye, ❑No VENI'ILA I'[ON FAN(SINGLE RESID) PAID
One Receipt g
Hiliahc.pplicam aar.a Fuficam by ag�u
Bursea Air caor dcviccs which BOIIJJt-COMP(3HP OR 100.000 BTU)
_.of bar't seri canlanlin.Vlla u dcfirrd M1y Jac Bay Area Air t�a,lity Mvugurcnl TOTAL
DislrinE HOILF.R-COMP(OVER 100,000 BTU)
El yes ON.
1 have recd Ih hvnNou,soul I, n boder AIR CONrDMONEN
e rtdNimrtrn Ctaptrfh95 fthcC �S ISSUAjJCE UA'fE.
Rmia Ikullh 6 'oft C l ]5505,255JJ std 25534.I u Jia i NEW RFSIDPNIIAL MECH. SQ.FD. FU( Y/
buiad ekes y msihilttyJ�] y I
of Nem h aCm�cN
Owner au 'red. t re TOTAL: ISSUED BY
OFFICE