25691 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO 15U I APPLICATION/PERMIT PLD,u"INU-MF:C IKCA PERMIT NO
L
BUILDING DIVISION BUILDING PROJF.LT IDE.NTIFTCATION 25691
BUILDING ADDRESS: 1 1 SANITARY NO. APPLICATION SU MITRAL DATE
LJC Vt- UNIT x LOT ���-�l3
W SfJA,\1� PHOYECOCIOR' NAME LIC NO - CONTROL. l
JrAL HF
•\RrilffECT/IiIJG 'ER; LIC NO: AD _ `_
El
CONTACT: PHONE:
. 6�• tPCIRIC PERhITC rrr •u'FEB' •• BUB.DINGPERNUTiNFO
BLDG ELECT PLUMB SRCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECORATION ❑ ❑ ❑
I herehyaRrm Jul l am licertmxla dCM1a 9(commtettcin with APPLIANCES-RESIDENTIAL JOB DESCRIPTION
CaZ poPskru per yi
''-CC Section]OOOI ui Division Ju(tk Buaircaaad Profession;Calc.and my licave is its pgNELS
y=1F-- full force urd effm /c• _^ X�- _ /�
I'(ZJ D.t. e%?_]ti. Lic.x ( (r — UP tO XM1AMPS Ir-f`�)1/"\r.\��„}I- S'�.'_-_
yc, Dum ARCNf1ECTT DECLARATION NII-1000 AMPS SQ.FT.FLOOR AREA STQ.FT.
OVER TWO AMPS
cZy,E lundvatad mY Plmu>hyl be uadapublic rtvoadf.
P: SIGNS ELECTRICAL
< `<J Lieemem Pla(eLpoll
s Yy.Y¢ OWNER-BUILDER DECLARATION SPECIAL CIRNR/hIISC.
jCi=V 1 hereby affirm Mel l am exempt from the Cmunor'a Licelue law ft the
.+130n lollowiny teuum.(Sectiun]031,3,B-meas and!Pmfeuitde:lf CoAny city of cwnry TFAff.METER OR POLE MST.
i' which(egmres•permit to crm 1.almt,improve,dentdifh,or repay any swctme
`e 1.!7>- pliur to nu vfunx.alto requires this sppiimllfawch penlut to fde•ilgnd f,m,mil POWER DEVICES
j Y that he if liccmd pusumu m Itr p,si o Of the Catch',U.law(ChWer
aa_x y(cunimcrcingwith Sccllon]OW)nf Division3oflk Bust.,d Ptrfi.ru Cade) SWIMMING POOL ELECITtIC VALUATION
o lha ha is uc therefrom aha the b.•^ft Isis yvi
� y mp elkgcd uempJomM olasw of
-Z< Sali thsa.Sby lemam licalI.(S50mdt fobjaothe appliant m•eivB petulty of olnlETs-SWRNFS-Fl%'1-TIRES
nm mte IM1nn Live hundM ddluv(55001. NEW RESIDE.TIAL FT PM SQ.FT.
tCG_ ❑ I.auwncr ofli thea -t.is at menywwiNwapaulsfe(w romprnsiness SfORI' TYPEC STR ON
-til Jolhewak,code: hu,Cole isnot Lioctdt Law
dfor deliee]Oan,wrrsecof
tortpm ed,who
Cole:The Courxlar'a Dame Vw wls m apply to st owp is
.rt who builds of improves Ih idr n,er esms dmca coach work himselfa farsad t If,
cmploym.irlordthuyensmpmvemrnuinons, eddtoffeed(male.r- ROUP RFS.UNITS
bmldc call thaw the,burden
of pro mmu inor be within bviki M malt on-Ihaowm-
buiWkrwill have th blvden of proving Ihv he did Ila W iN a uoprave ft ptrpme of TOTAL
vle.1. �"':"'1 PLUMBING PERMIT:-42'`y, j4:'FEE"'Q;:; FL DZONE
❑ Luuwneroflbe progeny.art exclovvely cmanctiolg with licuoN contress,t Y'- .:.,; .v..c. APN
cmnpum the Project(See.71 f .Busircu and Flafautu Cafe:)The Co.,
Licemelawdoesnot apply to enowmofpopny wbobuiNf timpmva lMcm.ad PER.MR ISSUANCE . .
wh,eme,Leev fmfuebpojeeuwilhe<onurn(f)lieemedpunualttolhe ColllrYlora ALTER-DRAIN&VEST-WATER(EA) FEE SUMMARY:'-_
Licrn.w .law. _
❑ l an eaemp wder Sec. B&P C fm thio r..«. BACK FLOW PROTECT,DEVICE
OUTSIDE FEES
SANrtARY Y N
Owner Dam DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMANLA
COMPENSATION DECRATION SCHOOLTAX YN
•❑: Ihemby aft thalhavc ecmilae a(mumtmsclf-i^•,;temtiB�of FIXTIItFS-PER TRAP RECE�I'x
w,akeni Grempnnwm lru..or.�id copy dvmf(S 381 lab C.)which PARK FEE Y N
ca�mall employeC.s uMer�lu pemljt5..7 RECEIPT'X
Policy# W —( 1'�DSS LL GAS-EA.SYSILM- WCA L _ BUILDING DIVISION FEES
Cumtreat Y / (7m� GAS-EA.SYSTEM �(F�.) C' CHECK FEE
❑ CeninN m,,is hereby fumbabod.
fpm CatifM ropy if fled with the city inspection division. GREASFIINDUSfRL WASTE MTERCEITOR TNG FTE
CERTIFICATE OF E�ON FROM WORKERS GREASETRAP DATE SOILS FEE
COMPENSATION INSURANCE
(Thio.1ian rim be cwnpleld ifthe petal u fer one htdteE dollms(SI00) SEWER-SANRAAY-STORM EA.)DOPY. ENEROYFEE
t leas.)
I certify lha in the perfmrw.ee of de,wale for which this smart is iamcd,l shill WATER HEATER WVENTlEAECIR
rot empty sny ptaan in any matolt fo as to become fubjest w th Workers' PAID
Z Compem]ulonlawaof C&fid u. Date WATER SYSTEM/IRI:ATING Dace R..,N
Appliwtt
z O NOTICE TO APPLICANT:Ifafter mskilµthis Ceruftae of Ecatplim,you ahould NEW RFSIrsl PUMPS. SQ.PC - TOTAL
V) become,mbject tO the Wsters Cmnprmdw provisions;oflhe last Code,you mous;
> form-th comply with such paviumtf t this pormj,mail be deemed mvokd. BUILDING FEE
y Q CONSTRUCTION TENDING AGENCY SEISMIC FEE
D Z 1 beseby affirm wt Jet as wumelian kdkg VaeY or Ile prrfonmee,of
U O he wo for which thisprnni,if issud(Se 3097,Civ.C.) I TOTAL ELECTRIC FEE
LI..
IxdIt ci:.wers Name
.".. .v
O Lodcr'a Addw Q7Y.N wfy�ayMECHANI SAL PERMIT'i-E''�'•Lj ^a::�ig PLUMBING FEE
1 certify Lha I have read dlu applict im mud awe IhL Ik above iNmnfum u 'tet.h l+•fa'l;
comet I.g to complyw'ith illmty ad mmly ombrances ad awe laws relsom,b, / PFRNIT ISSUANCE �� MECILN'ICAL
I"' y buH,inSc,mstruchm,td hereby aulhariu leQe,omo se,oflhucity toenta upon this CONSIIIUCfION TAX
C..) Z above mrnliald pmprry ft inapecdon pvpma. ALTER OR ADD TO MECEL
(we)apcc to save,idatmay ad keep harrsdm de Cry of Cupatiuo agaulu
Iiahllltio,judgmcmu.cow and caper#,which may inany wey amucogsinsamid City AIR HANDLING UNIT ITO 10.000 CFM)
inL of the gtvi'ngottf petro
, M
1\ e AIR HANDLMG UNI-T(OVER IO,000 CFM)
sigw Iu9i7e A� pll6at Itaclor DICT / rs(HAUST HOOD(w/purn
PAID
HAZARDOUS MATERLsM DISCLOSURE HEATING UNIT(TO I00.000 BTU) Date Receip x
Will the applicant orfum,building occupenl mare t handle,haadous matemid IIEATNC UNIT(OVER 100.000BN) TOTAL:
as Jetlmd by the Cupertino Mmici pal Cdc,Chapel9.l2 aha the Nealm ad Safety
Code.Seemn+553](y:' VENTILATION FAN(SINGLE RESID) �_
E)Yes farm
Will the c,�ranttfw uo ilding o,e do, Bay equipment tdevlmwhiche.nia }
BOILER-COMP(HIP OR IoLos0BN) ISSUANCE DATE
M1 erJ laminwu a dcliled by Lha Bay Area Am Quarry Mwgc i BOILER-COMP(OVER 10).000 BTU) r A 9 y
rNlriny s m an ff��T
1 L NEW RESIDENTIAL MECH. SQ.FT.
1 have rcv Ile hvadwu mate^"s rtquiretmu under Cluspw 6.95 of be OCT 2 8 1993
CdimmialldoesM ty Codc.5ec1iom35U5,35531 ad353a, ityto oaad lhac
if the building thea rml ms,,m t ly have a,l h,t that it is my mpaLsibillry to rolify,the
vmpwt of Inc nynireneno which nlaal ne,m grit m ruaamce of a c�einirlQeve of � �I Y VC GUt'CFri I IIVU/�
rk. ancy. �c�-2J�C C17 �Yl'
Owl¢r o aulhoizvJ agcm Date ISSUED BY:
OFFICE