99100056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY y too Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION)'PERMIT PLUMBING-MECHANICAL
PUIWIfNG PROJECT IDENTIFICATION 50001
BUILDING ADDR 5S'. SANITARY NO. APPLICATION SUBMITTAL DATF.
7 51 K 0 2 /0-
iR:S NAME: PHONE: CUM'RAC OH'S NAME: IJC NO:
p L a ,770-7 1
NIC CONTROL
A-CHIT:CI'/I?NGINEI[R: LIC NO: ADDRESS: ❑
CONTACT �7 PHONE j�/T-� BUILDING PERMIT INFO
„I j� n 6 SOZ ❑ Consultant Fees Paid by Applicant(Initial) tlIJ)G ELIiCr PLUM Cu
/ ❑
LICENSID CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 Wcrchy.iron that I ata herald once, M Clwplcr 9(conm,eoeing JOB DESCRIPTION
OWZ mSmicn]IXI(BofDiviaiml3Mdc llusirraaand Plvfcs.iuu Gdc.and mylatereel, RFSIDENTIAL:
�O O sal PERMIT ISSUANCE
�- In lull forte and cRm. 2"7 ❑SFDWL (3 KITCHEN REMODEL
QUV Lwenw Claa Lic.N APPLIANCES-RF_SID=- AL []ADDITION ❑PLUMBING RE-PIPE
v 6 i 1}a c Commnix
(I----S�DN AROIIIECTSIlGC1ARATION PANELS MULTI UNIT ❑STRUCTURAL
Zpv�Z I unJelwM my,gam dull he osM as public rmnLe MODIFICATION
OZ-D UPT0300AMPS ❑eATIJ
❑CHIMNEY REPAIR
F FR Llcenad l'roft,,awal 3(11-1100AMPS VHMIiM' 0SWIMMING POOIX
Xy l OWNER-BUILDER DECLARATION OVER 1000AMPS EMODE[AFFAIR [3 DEMOLITION
C Q I hereby oRrm that I am exempt front the GmBenolc License Law for the
X O i U following town.(Smi^n 7031.5.Hurinea end improve.
denwk or Anyr an a etaunrY SIGNS ELIiCfRICAI.
❑
W 3 a{- which,tt,'eu a permit ot nmvtrva,aIle,.inpruve,den man a«rgnir ed svuemm'
Ft2'} prim,nit.iesuantt,alw rtyuim the applicant fur sash man at fJceeignW mvcmm�ti SPECIAL CIRCUII'IMISC.
fy�Y m.,he is limed lvnuen In dr ptnvi,ions a(the Carder s Linnse Law(Chapn 91
(conamc-Ing wish Sce.7M0)of DiYi.3 the Bushes,std PAN.i^ns Cak)o, TEMP,SIFTER OR POLE(NST. COMMERCIAL'
a%o y that he A comp,lhcrtfmm.nd the bmic far the alleged e.empioa Any Yii lvim of l ❑NEW HLDG/ADDII'ION ❑DEMOLI'LION
u] a
Section 7031.5 by any npplicwl for u permit whpu,.IM applic to la a civil pemilly of POWER DEVICES 0 TENANT ❑FOOD SCRvicF
y} not mart man five hundred 6u11am(S500). IMPROVEMENT
t�6 Q I,as owrcr N lir plgmY•am my maplaywith wager NS,Mir sole emaNcra eat. SWIMMING POOL FIF,LTRICsot
D will e work, samearels not inlndmm l eRerd tar We ❑OTHER
do th
W and Poafvions Code:plc Cuorac,ur'n Li¢ac law does no,apply,o an owner of OU'ITIi I'S-SW I'ICI IES-FIK'IURIS
4' .. InTenY w1,o Molds no m,roe,ncn on,and who due,such work hin,elf or mmugh
his mm employees,p,widd deaf slash iar em ma arc not intended ew offend for NEW RESIDEINMAL ELECTR SQ
We.IL hoverer.me huiMling or impmremeN is sold withinaryem of compMiaam lWe S IT.Id.00R ARBA Fr.
r-Wilcer will New TIN buado ofpmOCT
ving that he did sax M1UEJ¢impmre to po- � 11 199
hrcof sale.).
FI I,as ownee of the Ixopnty oe e.aclusively emaracbng with licensed1c
c,imm, rs it) TOTAL:
euonael the M*t(Sec.70 1.B.m.ss and Nofcuirns Code:)Th Ctmincon's Li-
aeLa.Juesnxapplylo an.weer of l rocri,wlu Wildslx improves llerNn,ad Y. PLUMBING PERMIT EE
who enlrMls fu soh pt, ia wilbncartmcux(s)Ilccn.ipumum w,M Conlrxmr'v
I-ieTnae law. ERMI'f ISSUANCE
Age71m^evemp under Sec. ,B&P C fm this reavm
A VALU6TIUN
�r HIO - 3
W'ORKER'S COh1PFNSATION DECLARATIONLj / //
I thereby alTrm,Wer p.Ity M perJu y ore of R,following declanlinas: IN
nIhaveandwill mainlninaCmificmenl Comennoalf-iraaae for W'orker's Cmryem DAIN$-FL .RWF,AR COND. S-T(IRI '1'YI'E WNS
.lion,a p,,id,J for by Seri,3]%,e,hc La N,r Gide,for the performame or the
work❑c and
thispnnn is ortacr, ES
❑ I tire mil will Cod,,
he pert Cmrynin ion I wine,fico ac,ea rtyuim, i Smith
J)W of the lobe Cole,for the perRmunce ofthe f«which this pn.mtix iu¢d. S S OCC CROUP APN
My Worker's Cornper, ion lnwrnme carrier and Palley number are:
Cam,. Poiicy No: 'O P /fir
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPIi SAI'ION INSURANCE' 1e L BUILUIN (V ISION IF
S
IThiraulion rnvl nw M1econlpldW if,hc perMtufarwr hurdmlJolluc 00) G .ASE
PIANCHECK FEE
u I¢s.l
1¢nifY that in lhepetfaaowrce of the sank Ran whits thio peanut is iswctLlshall SEWER-SAN -STOR .300 FT. e
not toy any pno^^in any,runrt� lea bj:cx mlhc Wuecn'Compn. I:NI:HCYIH:E
O z ,�rac.�nGin}^ }]y /O%N w WATER HI:A - w .:LEC R
z pp,eam IY a GRADING IFI:
NOrICIi TO APPLICA :IL after nmking this Cenirrn¢of Pscmpdun,yap should WATER SYS ',.VFLIAI'INC
F" Name,object to me Webers Coma,mcvion proviii.of the tabu Code,
muN SOILS IFI:
Rieloodl comply with such pmvixwu or thio permit 4M1ailnd deemed mold. WATER SERVICE
a CONSTRUCTION LENDING AGENCY NEW H151UGTIAL 1'LMB. S 14. PAID
= z I henby aR,m deal mcrc ua aanrutf n lcmling Xgco,y fa the PerRxmmecof Darr, Rcrcipp
U 0 thea wore for which mi,permit is meed(Sec.3UP.cm c.)
QU Lerxles Nuns TOTAL: TOTAL:
W IrndKs Addis BUILDING IEE
1 certify mL 1 have rruJ Nix appli ation and m
ananc than e abut ove iafnonaue
.�'. Val correct.,agree to comply within city.nd.may oNinarm end save law:relying to QTY, MECHANICAL PERMIT FEE
U Z building msad cmolnion. llemWyamhonm repc,nn.,es.f,hiu city to em,,.,.Ile SEISSIIC FIE
,W,e mentioned pm(eny for im ec m p e,e,. PERMIT ISSUANCE
(We)neer to save,inokmnify and le keep Namea the City M Cupnino against ELECTRIC IiE
IiabilRie�julgrnenu.code and capers.winch may in any way acceue against and City ALTER OR AILD TU MECI I.
couryucrl¢of IhC'—fir,of this pmdt. PLUMHING FEE( '—APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING US I'(TO 10.000CFM)
FEE
SOURCERTG TUU' /� CONSTRUCTION
NT
� AIR HANDLING UNIT(OVER III,IXXI ) CONSTI1UCIlONTAK
Sigvlum of Appl iavnl/C�LLonl///ru'Inr Il li%HAUSf HI%)D(W/DUCD HOUSING h11TIGA'fIONI'IiF,
HAZARDOUS MAD(TAI X DISO-OSUR17
W
BO
thc^ptalicanl¢ful.¢WuilJiog¢cupant slue mhandlchamNous rrm¢nal IIFATING UNIT(To 100. TU)
as def V by the Cupenirn Municipal Cute.Chapter 9.13,and lir Health ad Safety
AftNc.Section 25533(a)'r IIEA'IING UNI'1'(OV IW.gO H'N) ��
❑Ycs Fl No PAID
VEMILATION N(SINGLE RES ID) a RcceipM
lOwn"?
W Jl the applicant u future Wilding neeupam as Nutmacru or Mico which
mit harardom air conlmni rlann a&lied the Bay Arca Air Quulit M d MOILER- SIP(JHI'OR IIXLfXO RN)
by y amgcnr 'I(YD\:.TFIE
BOIL -COMP(OVER 100.000 BTU)
❑Yes ❑No
I haver id the h rmdtes materials r�uirenreelA under Chapter695 of the Cali- CONDITIONER ISSUANCE DATE
Form,
Hcalm&Safety Cuk.Slcutrov Z5A1.5,3593 sad 25500.I.ndemM1ad mw if,nd NEW RESIDENTIAL.MECH. SQ.FT
bUlldl e,sax ovnerely have a teminl.IhN it v my agpxlsibdlty to notify the uivpum
f ,MVI.said u We met pnu to uNNNA,ofa Cenir¢te of Oce.,Fmi
n ( /
Uw�i mia1NMda m Diane TOTAL: ISSUED BY:
OFFICE