30161 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-F.LECTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT P1,UMBING-MECIIAN'ICAL 30161
BUILDING PROjFC1'1DENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE. CONTRACTOR'S NAME LIC NO: I
An r-[�_ T NtC CONIROLN
ARCHITECT/INGINEER: - LIC NO: ADDRESS: ❑
CONTACT. PHONE: 9 BUILDING PERMIT INFO
❑ Consultant Feu Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
El El IDLICENSED CONIRACT(1R'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Wal 1 am Iicros 1 under provisions of Cm,aar 9(rnnmrncm, JOB DESCRIPTION
� with Sectinn]fMMlln(DivixiunJuDM1e Businevr aril 140fcasinnaCMe,tM mylicctu'c is
��xZ in full Bxnee arW aft PERMIT ISSUANCE RESIDFNTIAL
FZULkLich ®SFDWL KITCHEN REMODEL
<Vreo
N6u Dom I ' Conine! APPLIANCES-RESIDEMJAL []ADDITION [I PLUMBING RE-PIPB
4' ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z Z N z I uoderuwd my plans shill W read as public rccda
UP TO MN1 AMPS MODIFICATION
P.P' ❑INT
.tt��r Liarnxal PmfcviaW ERIOR ❑CHIMNEY REPAIR
2f11-Iog1AMPS IMPROVEMENT
gyx, OWNER-BUNTER DECLARATION
y,W, I hereby affirm that I am exempt from the Comracors License law for the OVER I"AMPS ❑BATH REMODEIIRPPAIR ❑DEMOLITION
x 3 LL U following mason.(Section 7031.5,Huxi.and Pmfevian Cole:An,city or court, SIGNS ELECTRICAL
El OTHER
LL7 which rtyuirts a permit In cwmnim
t ,that, prove.Jemolirh or repair any vmcturt
0 priminiD iuuaree also rtyuires the applicant fmcuth permitmBlcaaignW memnent SPECIALCIRCUlUMI,SC.
tUa isliwn.cdpunuunlnot peavisinnxofl Cmtmanr's Lion law(0hyner9
OCp0q (cvmnrrcingwiWsslion7II00)of DEisino3W'the Hwxittux tail Pmfaaima Codelm TEMP.MINER OR POLE INST. COMMERCIAL
a a e LL Thar k is exempt therefrom east the Buis for the aIfe,W exemption.Any viola aim of ❑NEW BLDG/ADDITION ❑DFSIOLITION
e rn Section 11315 by my uppliunt fn.pe on,nuhjecis lha,applkant to u civil penally of PO`VER DEVICES ❑T&NANT [I FOOD SERVICE
F Z Y ^o mac uta rive hundred!dollars($500).
�
1,art nwtterofihe psxedKor my empkgc with watts as ImirsWecompmwtim. SWIMMINGPOOLELECfRIC IMPROVEMENT
will do Ihework,and the some unc is an,offended!m uftered hr rale(Sec.Vtbd,lousiness ❑OTHER
And Pmfcaxiats Coda:The,Canaacmrs Lcam.a law dao not apply m son owner of OUTLETS-SWITCHES-FIXTURES
IeWeny who,Wilds on itnpmvn Wcrean.and who Jxes such work himself or thmo h
his own cnnpley¢r,provided thin such impmvooetns ore non amended in nRcned for NTH'RESIDENTIAL ELECTR SQ ET
xale.If.however,IM Widingorimpovement is sold within osayearofcompknim,the SQ.FT.FLOOR AREA S/NQ.ET.
wrcr-thiWef will lova the W rd,o of proving fast ha did not build!ter Improve for prr-
Pase us tivot.
p a I, owe of et ped 7G4,,B concis and contracting with )The,d contnclma m IOTA
cone lot Law
ees a,,, (Sec.7314,.net of andrty who ons Cock::)The Caurauur, O-
sslaw don nm vpplywon nwenf pnTe,nY who Wideaimpnnc lhaeon,aril QTY. PLUMBING PERMIT FE `- C
who contro s fu such Projects wild o cmurcta(s)Ikensed pur situ to the Cmtmxlera
tieerrse VP' PERMIT ISSUANCE
❑I am exempt a tilt Sae. ,B&P C for this rmmn JUL 15 1996
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Owe Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CTI Y OF U'UNtHI INN
I beneby a01nn umkr penatyofperjury oro of the following decloom ,:
1-1 I have and will mantain•CanificateatCmvu!rind(-insure mrwmterx Cntmrn DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sauce,As provided far by Section 37M of th labor Cade,for the perGmtarrce m the
work for which this pa nit is issued. FIXTURES-PER TRAP
❑I love and will marrom Wmkar s Camprtuarier Itnurvct,m retained by Section
37M the"floor Cole,fmtW perfmmunc nt the wnk fm which this perform is ixvaaT GAS-EA.SYSTEM-I INC.J OUTLETS
OCC,GROUP APN
My Worker's Cotnpensutiot Inwmee ceerier and Policy numhn arc:
firriec Policy Na: GAS-E4.SYSTEM-OVER 4(FA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF,ASHtI NDU,STRI.WASTE;INTERCEPTOR BUILDING DIVISION FEES
(Thuseetionnmltlex herntmgnul ifthe fantim ahwnrlmldolWsIS 100) GREASE TRAP
a less.! PLANCHECK ILA
I crnify that in lhcperfommrce ofmc work for which thispvmit kLsuec,h1rall $li\VER-SANH'ARY-STORM EA.2W FT.Iwr ami any psnmim any mmnr. Ia sribjcnm the Worker'Comprn ENERGY FEE
O Z satlan Iowa of C aria.Date WATER HEATER WNENT/ELECIR
O Applicant T GRADING TLE
V1 NOTICE TO APPLICANT:If,artlimilking this CcAirican,of taempiun,you should WATER SYSTEM/TREATINO
1^ — h ext subject to the Woak,fs Ccon troatiun proxisians of the Taber Cod,,you mus SOILS rl'E
4aS1 fu withcnmplYwiih.wchprm'isitnsor Wispermilshallh&cm mvok 1. WATER SERVICE
d A
CONSTRUCTION is
ION LI'NDING AGENCY NEIN RESIDENTIAL PLMR. SQ.PT. PAID
() O IherewYaffrm that WronI,is osaxJ tntxrian lending ngmey fathc.peefmmatta of Date RaeiprN
the wok for which this penal!B ivucd(Sea,3091,Civ.C.)
O F' Leramr,Nun TOTAL
V Leaders Address TOTAL,
19 y
1 tinnily that I!rave nem this ii'lle.1iw vol xtanc Ilial the ahovc iofamtuion a BUILDING FEE
0`1 nonce ]2a tocmtlplywiWallcitymldewnlymdima sandwtelawsmlatingm QTY, MECHANICAL PERMIT FEE
UZ buJdingeaawletian,rdh,reby euthxize reprexemuivn Mthixcoym etvnnpm the SEISMIC FEE
.hove-mcmimW pro,soy lint itaspnnion furyoxex.
(We,)Artie,to save itakntnify and keep hvmlexs she City of Cupertirw artist PERMIT ISSUANCE Ft FLTRIC FEE
Iialahmex,jwdgm,ots,costs and expemn which may in any way tame against said City ALTER OR ADD TO MECII.
in vnacyusnee of the granting of this Permit. PLUMBING F/17.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-PO AIR HANDLING UNIT(TO IO,o00CEM)
SOURCE REGULATIONS. MECHANI ALIEE
AIR HANDLING UNIT(OVER I O,Ot10 CFAD CONSTR :CIONTAX
Sigtututeof Appli,anlCwrana EXHAUST HOOD(W/DUCD HODS HTGATIONIFE
HAEARDOUS MATUTA1S DIS CI,OSUR
Wllltheapplicanlnrfutuee Wildingwcu,mistae alum lelutrnrdouamntuul LWATINGUNIT00100d"BTU)
in definedi by the Cupertino Manicifal Code.Clo wnr 9.12 and Be Haalth and Safely
Cade,Section 25512(a17 Ifl!ATTNG UNIT(OVER 100,HW BTU)
❑Ya (D No
VENTILATION PAN(SINGLE RFSID) PAID
Will the applicant or fulun,Wilding awpant u.se,tuipoent or 1xviec,whits Date ,near.
onto harnflons air corcuomarra as deftrad by the Bay Area Ala Quality Maaagenem BAILER-COMP(JHP OR 1001000 BTU)
District! TOTAL
E]Y. [I No BOILER-COMP(OVER I00,000BTU)
Ihave read the ltvmdoui maderials titulrvtnents uNn Chapter 6.95 of the Cali- AIRCONDIT70NER ISSUANCE DATE
forma Health&Safety Coda,Sections 25505.25533 and 25541.I undentntd that if the NEW RCSIDENTIAI,MECII. SQ.,addingck—mer aunandy hast uamtm,that II is to napnsibility to noity olencetiprnt
M We"uinanents which mut be met frim to isstune do Cenifeue a thrukvocy.
eTwe a uuthorved agent One 1 ISSUED BY:
OFFICE