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CITY OF CUPERTINO BUILDING, - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PING PRODPING —MECHANICAL7u)ENTuuCSOkNI
BUILDING PRIIJECT IOFMIPICA'1lON
/ iRF1IT N
11UILDIINNG ADDRP_SS:
SANITARY NO.
APPLICATION SURMI'I'lAl,DDATE
OWNER'S NAME: PHONIi•
HQ .-2(r5_-939S
-ON TRACI ORS
"� NAgqMB: LIC NO:
W 1
NIC
❑
GDNTRGI.«
CHITECUFNGINEER. LIC NO:
ADDRESS:
Gly
CON'1'ACP PIIONG
BUILDING PERMIT INFO
LCAGdoB s66
Rb Yld o 2-s'�8
EI Cranna rat Fiat Pad b)' Applicax[(Inlllal)
UR 1
BLDG fill PLUMB NUR`
❑ 2` ❑ ❑
LICENSED CONTRACTORS DECLARATIONQ'Fy
IT,eneby alr IM1m 1.ram littrd antler p,nviaann. or Chaplcr9(rnmmaning
ELECTRIC PF•RMIT FEE
JOB DESCRIPTION
I'F.RMITISSUANCE
y with Sction]I)0111M Oivhbn 3ortk xusiry vnrd Pmfessiom Cd.lc, and myliccmcis
ut
in full fora,ddre".
RESIDENTIAL:
❑SFT)WL ❑ KITCHEN RHMODPI.
APPLIANCI!S-RESIDENTIAL
- Clint;s
'J Licene Lic,0
Do.—ion
[I ADDITION ❑PLUMBING RE -PIPE
STRUCTURA
❑MULTI -UNIT ❑ L.
MODIFICATION
El INTERIOR ❑CHIMNEYREPAIR
IMPROVEb1ELT SWIMMING TOOTS
ARCI H ECFSDFCIARATION
Z IUManumd my Than, shall Mu.vd as puhlic records
y Lianad Prufisicnnl
PANELS
UP TO M)0AMPS
Zoll -1000 MIYS
OWNERBUILDERDECLARATION
Q I hereby affirm thanI inexempt fur the Caolr¢alrs Licence Lan. fm TIC
-) following rtv,wn. 1Smtion 703", nuninesa and Pndeesinne Gdc: Any any or county
IEPAIR ❑DFh1GLITIGN
C] HATH kFh10DElR
❑ OTHER
OVER xIg1AMPS
SIGNS ELPLTRICAL
j1 which rear a Trait to farutnun, atter, improse, demolish, or nepai, arty —a —
SPECIALCIRCUTGMISC
ponmars lomat al.w«quuca the aWficanl for wch Wmam to fide a started oae,aerd
in. heis I kmld pllRlanl to tM To,,imo,dthe Contorron"["a— Lw(Clu'ptefu
L (comrmcirdg with Sl:<rian]000)n(IJivivmJof the fllunCss scrod Prfcasiau Cde)or
Y 'hat he is exempt IMrelmm and the hasp fn the axegd cxemptioa Any vioWlion of
TEMP. METIER OR POLE. INST.
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
a Seenon I'(D] 5 by vnr applicant for a fermil suhjoets tM u,daconl loo civil pcmdly of
Gn Ml nnoe plan flue hurdrtd doles IS5009.
❑ L us owner of the Mpeny.or my employee+ win walls as Ilei, sok mrnpenxotien.
%ill Jo the ark, and the structure a not inlrndd or ofR`rtd for sale (See. 707 1. Business
POWER DEVICE
TENANT ❑ FOOD SERVICE
IMPROVEMLNT
❑ OTHER
SWIMMING POOL FE EC1RIC
OOTLIT''S-SW[TCUPS-FIXTURES
and Nrofessaons Core, T e Contractor's License Iww docs am apply to an . of
Propmy wbm buildso, improve.' llmcrmrl and who dors such w«k himrclfar omogh
his dwn m,loyeas, provided] thrt such imprm'cmcmn am not late ded a oxmd in
bing or vcmml is wW%'ilhin one yeir ofcomplcden. the
sale.If, hwever, flat, building impto
NF. RESIDIMIAL EL(iCfli SG 1'1'.
iO IT. FLOOR AREA
EISQ. FT
dwn+-buildar will Mvc the hurcen of pmmrg not he did. build m improve for p e -
pa
r of circ ryop excluaiv contracting Tian 1 coati to
TOTAL
nd Cott]
xletN[I TIC prnja'I (G:c. ]llfa. Bueinus ud Prtltavaiunn Clak::)'I1C Convrc91r's li-
7( . B
whobudJsmane,te Commi.or"
cemeLawmatnlapPlrlcco
QTY. PLUMBING PERMIT FEE
inerofpmlCny
wtro cootracu fa slrh project+ W iN a mnlracu.(sl li¢nseJ pmauant to the Conwclm's
PERMIT ISSUANCE
lifere- Ww.
I am cacmpl nnla Se". . B & P C for this reason
M IE
ALTER -DRAIN&VI-WATER A)
VALUATION
w,. . ID IQ
BACK FLOW PROTECT. DEVICE
WORKERS WFIPFNSATION DECLARATION
I hcrehy affirm under penally of perjury are of the following deeluations:
STORIES
TYPE CON,SRUCTON
I Mvc amid will mandminn Ccnifi<ucnfC... eal lexelf alme for Worker n CnmPen-
.on, as provided fa by Section 3M of the 1abIC Coda, fa the peen—ore M the
-1 ur which this perm➢kmud.
UkAINS– FLOOR, ROOF. AREA. CON U.
FIXTURES - PER TRAP
(D I Iwve and will mainlnin Woracr's Cornpenamaon IEa Ince. as rewired! by Section
37M d the Lail Cad, for thepsrff a.flhe wwk for which this permit is issud.
My Worker's Cnr,ona ion Inmrauc cafriar aa! Pokcy numd, are!
Carrico Policy No.:
GAS- EA. SYSTSF I INC. i OUTLETS
OCC. GROUT'
�',
Ile/
GAS - EA. SYS7ENM 0VERV(lA)
UNP-ASFJINUUSTRL WASIF.IMIiRCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
WILLING DIVISION FEES
(fhisxtttt+ion rceJ nut be nNllptcld if lM1e permit ie fmrmcM1udrd dollar -(31(X11
rc less.)
GREASL'"BAP
PI.ANCHF.CK Foil?
SEWFiR- SANITARY -STORM PA. 300 Fr.
ENERGY IEE
I eedifytlwl loth, effoo ene.fihe work for which this Pero, stad.I ,had
bjeal It, Wn
Ivo employ any prawn in any canner so %s m become wo th dndl Cnpcn-
WATER HEATER WN ENTMICCDt
GRADING FEII
Z saticia Lar, of Cdifnerm, Date
Applicant 1
NOTICE TO APPLICANT: IL after noting this Cenif m of F era mn, you shardd
Coprman pruam hC of JC 1aCadet, you vu
oe subject to the Workch mtiosisi
Rm
frthwiftnmply w ah uehpnnuim, orbit panni a hull M1e deemed mv,gdd.
CONSTRUCT ION LENDING AGENCY
IhcmhY VRnn thm thacinaam,arvdinn larWmy u6cmY fnnbc )wNommwc of
the work fC which Thi. permit u loud (Sec. 3091. Civ. C.)
JLcmkrs N..TOTAL:
WATER SYSI'EMTR1!ATEND
WATER SERVICE '
SOILS1
� ,
PAID" ��
nT I)vtc Rwcip
NI2W' R69DENTIAL PLMEL SQ. IT. U
V 1 V 199 1 1i
BUILDING Flili
IrndcrAdWrcu
W I
6. anify the] 1 hove read this Mgliawion aryl stale WI IM1c olmore infmmutlon is
nmal.l agree malnmply with ell tlty ad roomy,xdinuCeaad..,,e Iowa mWingm
Z building cdm-mction. and hereby ammome tepvicemmie, ofink city In cmernpm the
( p
QTY. MECHANICAL PERMIT FBEOy-
S&ShB ITE
PERM IT I.lSUANCH
aboverrcmioned referny fm inspe"ddv tori
(We) ugmc m eevc, Moriarty and keep hamlees Ilr City of Cupcnino agaiml
ELECTRIC FEE
PLUMPING FEE
Imbi,,as.judgl.,. mus a e,.penseswhiah any in any wuy ucnuc against wad Gty
in rnn. quenc of OC granting of this permit.
ALTER OR ADDTO MECIL
Al R HANDLING UNIT(TO 10.000 CFM)
MGCfL\NICAI. Flili
APPLICANT UNDERSTANDS AND WILL COMPLY WI'I'If ALL NON -POINT
SOURCE/tEGUTA'j�ONS.
AIR HANDLING UNIT(OVER 10,01)0CFND
CONSI'RUC 1ON'TAX
,I / T 4 Q /'r•I q�
SignmumL-ollf�Aj,d1cacm�omnsSY Dale
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST' II0ODfW/DUCn
HOUSINGMITIGATION FFE
HEATING UNIT TO l00.0008'1'U)
Will the applicamnnfnare building dacupmn uaenMille has rdoux material
as d,l by Be Cupnliro Municipal Code, Chaplcr 9.12 and IM Health and Safety
Cola. Seetion 255320C
HEATING UNIT (OVER 100,000 BTU)
Vcs No
\'IMITATOR FAN (SINGLE REST))
PAID
[)We Raei
fl011-IiR-COMPf3HP(lH l()0IKKI BTU)
Will be applicant or future building necuplmnl use eyuipmen m devices Which
mnhDoonhms air cnmmnunls ors defined by the Bay Ami Air Quality Munelunenl
T( !.
BOILER -COMP (OVER H)0.000 B'TO)
Disam1
❑Ycc MIS.
CONDITIONER
rtyu 533 a d 155 . I and rr tte of do C.E.Cala.
I Mvc and the haan tae, merfamdsR
forma Iteslas & Scam C'de, l,.dlwma 255113.21533 end 3534. I understated! J,s if dC
/ ISSUANCE LATE:
D — �•� Y 9
NEW RLSIUEMIAI, MECH. SQ. FF
Wilding dY.n ^'It cumnlly Mvc a Icranl. IMI it is my M1 �Imtlslh'I Illy In rXMi(y the IaY`npNl
O
of the remena Which mlutMmar p,iu to iwanec dka Cenilirle n((kcuparcy.
A�/v.a dam— /n -l-99
ISSUED BY:
TOTAL:
r—, 1).
7dn T
OFFICE