30664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO' 106.64
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: / SANITARYNO. AP PLICATION SUBMHTAL DAD
88 /T / hRAIdZ_—
QWNER'SNAMII: , _/ PHONL CO ACIUR'S NAME: LIC NO:
L's Illl a$3-/ S e Nn CONTROL
RCHITECTfENGINEER: LIC NO: ADDR ❑
_ONTAC .. k PHONE:J/ U
BILDING PERMIT INFO
]]JD
w I k f � ❑ CorlwltarH FceS Paid by Applicant(Initial) BLDG ELECT PLUMB Mre�C1x/
❑ ❑ ❑ ly
LICENSED COMRACn under
pm,DECLARATIONChap QTY ELECTRIC PERMIT FEE
1 ior,70 Nm,nw 1.m liarud uvdcr proviciau M Chapter 9(crcrmercNg JOB DESCRIPTION
"OoZ wiN S«tiw]g0)ofDi,ision3ol the Buainas uuf Profea,iom Code,amt mYlittnx i,
in full farce and effect. PERMIT ISSUANCE
jut: Liccnu Clw O' `3� T.icit �ra 0 KITCHEN REMODEL
``tail Dme�'�-`I �l-Canllaclnr • 4 APPLIANCES-OISIDENI'IAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATI N
ZOt�Z IuMnw.M my plan,Hull le l,�ePublic,acrdr PANELS 0MULTFUNIT ❑STRUCTURAL
UPTO300AMPS MODIFICATIONOZF-� LeenseJ Profu it.ml - ❑INTER TOR 0CHIMNEY REPAIR
3111-10X0 AMPS IMPROVEMENT'
1' OWNER-BUILDER DECLARATION
y C W 6 1 hereby affirm Nd 1.m exempt from the Cour.ctnrs Licenu".fill Ne OVER IOOOAMPS BATH REMODEL.REPAIR 0 DEMOLITION
x 6 u following reason.(.Section 0031.5.Busieeu and Profe,v.n Culk,Any city m cwnty I OTHER
Vi LL O which cequires a ppmil to canurvcl.alley.improve.drnuflid,m SIGNS ELECTRICAL rtpair any umcwrt
m.] privxmils issaaac,ulxn rcquirn the npplicwlfur such permit to Ekut,grcdttmntunt ', SPIiCIALCIRCUFUMISC.
�QF Nuheialittnacdpunuanlm Nepuviticm,oflhc Cmil l 'sl.icens Uw(Cl r9
ul of feommmcnng wiN Seedon]tKq)Df Divuknluf lle Biniress and Rofes,ioma Cadc)a , TENP.METER OR POLE INST.
L a o p�C
that he is exempt Ncrtfmm and the Nora fa be al exemption,Any violnian of 0 NEW BLDGIADDITION 0 DEMOLITION
�m
Section 7031.5 by any applicant fie a Pemnil al Oeappliomp to a civil penally rd ` POWER DEVICES ❑TENANT OItpOD SERVICE
Bill nom Non five mall dollar,(5500.
zC, 01,u owler M Nc IMPROVEMENT
Ill tut mycngbyecawiNwages a,Noir sok arc nisUm. SWIMMING POOL ELECTRIC
will Bothe work,ands: umcturtisrtarin Laker.mao,d frwdel5ec.TD W,Bluirras ❑OTHER
a,� and Pinert,vOau Crile:The nv l flrtr Littn,e , such
fila apply na en owner M OIITLFIS-SWRCH&S-FlXNRES
pmpmy who builJr m impnvu Hewn,end wMr Jna wch work himmlf m Wwgh
hi,own employee,,pmvi lcJ that,well irrymrvcnwnu art tax intended fir oBereci fur r NEW NESIDFIAL CI'It SQ FT
tele.If.however,be but[&,or improvemem is Vdwllbinotm Yemofccmpktioa,the SQ.FT.FLOOR AREA LSQ.FT.
owlla-builderwill have the ducts ofpm'i^i Not h<JW cul biMmimpove fer .pur. P A f D
pose of sale,.
I,av owner of the popany,Bill eselmively c xnraming"Iicel c olmctom e, I TOTAL:
eonYNp Ne p jc l(Sa.71H6,B.,iMs upl Vilrfes,imu Cade,The Conl,actor's Li- DEC 1 3 19 6
sense Law does rug apply to u owner a Property wM haa improves dawn,and QTY PLUMBING PE FEE
v,haa.nteu fa such pojeu wiN a mar.cu,r(s)liamcd pm,oant m Oe Cooueprys
license Law.
O loin exempt on BR,Sec. ,B&PC Bod"raven PERMIT ISSUANCE
CITY Ur I.;urrrtu U
O`vrc Date ALT2R-DRAIN&VF1T- R(EA7 VALUATION
WORKER'S COMPENSATION DECLARATION
y, BACK FLOW PROTECT.DEVICE
e I hereby affirm onokr penalty ofppjury oce ofthc following dmlaminms:
I havered will m-butoo aCemfB1.eutCwwnt mulFimane far Worker's Compcn- DRAINS-FLOOR.ROOP,AREA,COND.
Iiia,.,u poviJpl for by Satioa 3700 of Be Isle Cute fa the i foxmance of the STORIES 'rYPECONSTRUCTLON
wink fu which this pcmdt is iwunl. MICNRES-PER TRAP
I have"will maintam W'orter"Corrgensatiom Iowa¢,m nryllved by Salon
3700 olthclsbor Code I—be perGamaneeuftle work fa worth Nil .it,is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS,
OCC.GROUP AYN
My W. r',Cor9Pcr.a.lmy. runt P,I, wed %
Cartier�Q�(/pA�1_/ arM Policy No.: Y6r.•IO - I 1 GAS-EA.SYSTEM.OVER 4(EA)
CE TIFTCATE OF EKEMFTION FROM WORKERS
COMPENSATION INSURANCE Ii GRPASE/INDU.STRL WASTE INTERCEPTOR
Qbis 1161.drmn he cn,nPktN it Loc permil i,firm hundrp1 dr11un IS 100) BUILDING DIVISION FEES
m I..) GRIASE TRAP PLANCHIICK FEE
1 century that in the pMoemnrex of 0e work fm wbichthis permit is issued,I than
mat employ any perunl in any man mhce bjmb lbs W cilli Compm- 1 SEWER-SANITARY-STORM EA.3o0 FT. ENERGY FIM
z tatmn La " f�C lifomia.Date 2
0 Applicant /UL!liwl m L WATER HEATER WNENTM-ECTR
/♦ GRADING ITE
h
NOTICE TO AP-It,20er makirrg Thi,Crnifxwe a Esempion,yw shwM/1
ld WATER SYSTE '1tEATING
h' ^' became m the e Wcel Coxrywtiw amvisinm of dde.
e Tsbor Coyou must SODS FEE
fcnhwiN rnmply viN..rh pnvi,ims or this Fe l vhal M deemed revoked. WATER SERVICE
� z CONS[RUCTION UNDINGAGIT'CY NEW RESTDENf1Ai.PLMB. SQ.ET, PAID
C.70 I hereby all that there in acornnuctiom krll all fords prfrxnuott a Dete RcccipY
� -+ Ne wxk Tec which Nu permit i,i...V.n ISs 3091.Civ.C) ,
0 U lender"Name TOTAL:
Icndels AdNecr TOTAL:
y I certify clot 1 bove rectal this appiauiun and swe Ln Ore ahove informal is BUILDING TLE
h comer.lagreerocomplywiNWlcityvdmumyadiwrarerduv wsmlfi to QTry• MECHANICAL PERMIT FEE
C„J Z Willing mmlrysurd d hamulb
by aorix rcpacruatives d this city,.enter B,l thatSHISMICFEP.
oFuve-mentiwN property far inepatim purpnc. PERMIT ISSUANCE
W/d, gree lo.wve,iM....mfy mJ kap laude.the City of Cuprnilm egvinnl ♦ ELECTRIC IEE
Iiebilitic.lutlBrcne.conn sal cxpemas which may in any•my eaves agaimi mid City ALTER OR ADD TO MECH, n
wscgacar of lbs gronung of dti,pemtr. I.• PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO N."CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IF."CTNU CONSTRUCTION TAX
Signwrt cf Applicant/Cwtrai Due EXHAUST HOOD DGDUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WII de.1licvnt affumn:Wattlingavpwt uotmmluNle lurudwx meurial / HEATING UNIT(TO 100,000 BTU) 66 Ill
ear okficed by the Cupertino Munlcipvl Gvic,Chopin 9.13,and the Healed and Safety
Cask.Sectim 255331.)? (HEATING UNIT(OVER IIIO.(Io0 BTU)
-' ❑Yes D(jfo VENTILATION FAN(SEJGLE RESID) PAID
Will Ne Bppli...I or future hui Wing,..,,um sew ryoi,ocan or devices which Date Receipt Y
I'h.mNaus air contaminants as defiled by the Hay Arta Air Quality htmwgemenl BOILER-COMPQHPOR I00.000BTU)
w+uinT TOTAL:
❑Yes H/Nu BOILER-COFIP LOVER 100.000 BTU)
' \ / I have nh1 Ile huuudo''i'''olln:uadW, AIR CONDITIONER ISSUANCE DATE
mylllmiwms uNrr Cluper M1 YS of the Cali
fmnia Hath&Safety Cade Satimn25505,25533 and U53e.I urdpmnM Nu if de NEW RFSIDFI.'UAL MECH. SQ.FT
baddingdoct na wnendy have a tenon,but,it u my ncgmsiiility na oily IIB oRvP•u
ofthe R,phre repU wy�n rnW511e final pniamitWNCe Of.e[rtirK1C OfOalmanrey.
Ovoo," d oicid.'e. / I�ie/ TOTAL: ISSUED BY:
OFFICE