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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELEC7OUCAL •I - y PERMIT NO,
J
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - AIicHANIC,U, (i A 7
BUILDING PROJECT IDENTIFICATION �F 1
A
BUILDING DDRESS: SANITARY NO. APPLICATION SUBMITTAL UATI
�CONTACT :�a PHONE /LQ<r
�l O
�dJG1JSs6 f�,c5
❑ Consulted[ Fees Paid by Appli"ill Hnitlal)
LICENSED CONMACIORIS DECI.ARAI'[ON
y v o thatam l lico
I herebor odor Iler provisions of Chapter 9 fcommei
vng
z with Se,liun]Iplof Divi.dsm3 oflhe HusinnSvM Profeuiom Cude-ond my liana is
O in full force and effect. /
F 6S3 stir
" U� Xa.h�. $.�f'ViA�i Jp7
Ill�L ARCHITECTS DECLARATION
1 mukrvand ntr Manm.nau bu oust.. prinre rtel,rdm
QTY ELECTRIC PERMIT
PERMITISSUANCE F
APPLIANCCS-RESIDENTIAL24
PANELS
CCHIMNEYREPAIR
UPTO 200 AMPS
Licensed Pmfevimsl
DECLARATION ConarON
Q 1 hareby vR the I con uempr form the Caslrt,lor.
Hot, I.H U.rx for. law for the
201-IIKXIAMIS
OVER10DDAMPS
SIGNS PIJ:CFRIG
: Any c
U fidlowhich iaguia a Pennell t concr , dl Well i onJ IrMc.ioli CUJr: Any city or courtly
which require � pemdt to corrurvcA Hier, improve olrnlalisn, or mTmir trey sbuwurt
pnor m iuissuance, also rryuioc. he appliwnl frrsuchp.it led 0k n6tiold slalCmcnt
that he is licxnsed pun ,.,,. Io the pmsuions of Inc Contr.n<r', Ream. U. (Cheper 9
00 (commencing with Sewion'/W0)af Divmoln3oflhe Burin. cost Profexmioll, CodeLr
SPECIAL CI ITMISc. 4.
TGAIP MEIT. O 1 tINS
e' Inv he is exemp therefrom ort the Simi. for Inc alleged ncmpriarl Any violation of
1y SmMscr 703" by.ay aWiconl for x emit whjecls do applicant to. civil rn ly of
POWER DEVICES
more drool five hundred ddlerx ($5(p).
SWIMMING POOL ELECTRIC
Qor,
Ql,ul,wnrr oflhc propcnY•cemYemploYceswimwgeudo'vwlccoxryonunon,
will do m<work, W do struclum ie nB inleoded ornB<Ied fon sale (Sea. THLI, 1luslorm
and Profeorscs Code: The forted. tm's Licercc Ilw Mn not apply to en of
OUTLETS -SWITCHES-FDCfURFS
property who build. ur improve.s thereon. end who der such work bimxlf m Imhof
hix owo employee, provice! dol such impmsernenu . not intemini w afrool for
NEW RESIDENTIAL ELECTR SQ FT.
ole. IL however, the Witch, minstor. ma<I is wld within oroycvof wmAci, o, the
owner-buBJer will hava th b.odo of po,ving Pico he dill not build ar intprvve for so,
Isom, of ole.).
EI 1, m owner W the luo cro , nm cadu.ivcly contracting with licensed! contmclunv w
cunufucl the projecl (Sec. TDkg, Bu.inese.rrt Pn,femiw Code:) The Co nnomloos U.
cern. Law dues e,x.'lylo an owner of pmpeny who builds or mpmvn lhReun, arst
QTY. PLUMBING PERMIT
will, co.1,00l, I., vU[h projects W Ith Y e1MIrMIIM(t) ficon e I pWaUYnt In IIo Ccolmclo(i
PERMIT ISSUANCE
Tic. Law.
(]lam exemp) ondc, , H & 1' C for this rwmn
ALTER - DRAIN & VENT- WATER (EA)
Owrla Dale
WORKER'S COMPENSATION DECLARATION
HACK FLOW PROTECT. DEVICE
1 hereby aMi m ulvlcr peruhy of perjury mo W Ire fallowing dxlar.doma:
DRAINS- FLIX)R, ROOP. AREA, COND.
has<onJ will mnimaina Ccrttiwlc of Cunumlo xlf-inuuc for WnheL Compel,-
Ssa u provided! fm by Section l]Oo of Ito L.hx Code. far the perfmrwtt of Ile
wot for which This peamit iv Swed,
pl%TURES -PLR TRAP 110*1
C 1 hice will ms.rryulrM Section
Worker'. Cwnpwsare
.fthe a v ric for
J]Igl of the Labor Code, for lM perSmmn
ode, for wok for which Nis pemdt is i.esuN.
h , i
GAS - PA. SYSTFI.1-I INC. COVREIS
or lorl
My Wokkm�e en ,Insurgy ogler ural Policy
Cartirr. - Palley No.:
GAS - EA. SYSTEM -OVER 4(EA)
CEUHFICATH(IF EXHMIMON FROM WORKERS'
COMPENSATION INSURANCE
GREsl5MNDUSTRL WASTE INTERCEPTOR
(ISIS teclion heed rid be eomplemd if the pcmlit i., for,. hundred Dull. (51(1(1)
w I..)GREASE
TRAP
I certify met th the pefunrtence of lto work for which this Permit i, oersed.!.hall
rlol<mpinr troy Pc. in any manna.so. inbmmse subject to lee Worker; Cornpen-
L vie. laws of C.liful Doc
Applicanl
SEWER-SANITARY-$TQRM EA. 21X1IT.
WATER HEATER WNENT/ELECFR
NOTICE TO APPLICANT: IL after mokioi, this Ce.tiheve of Laerrption, you drould
btu rte subject In de, W,r . Compcnvicn prnsi ull of the tabor Code. you moo
TaMwilh comply withsuch pmvtdoe, - do, ennit blah no dorms! resulted.
WATER SYSTEM?REATING
WATER SERVICE
NEW RFSIUEN'IAL PLMB. SQ. FF.
L CONSTRUCTION LENDING AGIliCY
Ther which rm tw tart it. co (Soo. ion lcndi, C.) cy for the perfomwceof
the work for which this permit is imsueJ fga. 3(19], civ. C.1
jerdhName
LurrdelI Address
ymat !nave reirdl wm phemi< mull . are Inv the have IN« wenn is
O mrsu'Llalpa to wmply with all city cod mmry ardiwntt. cert wtc low. rdetingm
briding comaracliml, and Mrthy uudortiss mprtsentubvcs of mix city to order upon do
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
.hove-mmtiaresl property for impaliml ",pumv.
(We) agree m save, indemnify W k,p hamd<ss tlo City of Crpcninu ogalnl
ALTER OR ADD TO MECH.
IiWilitin,jltdgmems,rnmts aml espcmcw which may in enywayvsrtoaldrou.aid City
in eve W uentm of the grarinng of Ohm pens!.
AIR HANDLING UNIT(TO I MD CIM)
A .ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
U EGULATIQ .
AIR HANDLING UNIT(OVER ID,Un CFM)'
D-
wIumofAppliwnoCondaclm/ Date
1
EXHAUST HOOD(W/DUCI'1 V
U"`ZARIXNSMATF.RIATSDL WSURE
HEATING UNIT G70 100. I(1 BTU)
Will dle.pplicant a future building locvp.nt .lose or handleSuardtlu materi.)
as dsGmsl by Ih<Cupertlnn Munlclpd Cads. Chapter 9.12, and be Heallh end Sufery
Clyde. Smion 25532(.01
HEATING UNIT (OVER 100.000 BTU)
❑Yl, ED No
VENUILAT)ON FAN (SINGLE RESID)
Will line, applicant a future building Nerpam ua cyuipncnl w deices which
air corowniwnis m Jefml by the Bay A. Air Quality MVlagemeel
BOILER- COMP QHP OR IW." BTUr
lerihhtraenluos
Wurk59
Ye. E] No
BOILER - COMP (OVER HX)LE 0 HTU)
AIR CONDITIONER
I have read the hvvdous naurial aryttfi95 oftbu Coli-
tcyuircmcme undtt Ch
NEW RESIDUsi MECH. SQ. ET.
flmw Hcdth & lithely Cole, Smiau 25505, 25533 and 2551E 1 lardcrsuod l if Eft
69iylirrg Jnar ml csmendY h4 e v Irnva, dm it is my rnyansihililThay m ndfy fe uccr utr
OFFICE
FEE
7
RFSIDENTIAI ____//
CSEUWL )91'UCHEN REMODEL
CADDITION
❑PLUMBING RE -PIPE,
C MULTI -UNIT
STRUCTURAL
MODIFICATION
❑INTERIOR
CCHIMNEYREPAIR
IMPROVEMENT
C BATH RFMODEUREPAIR C DEMOLITION
C OTHER
COMMERCIAL_
CNEWBLDG/ADDITION CDEMOLCUON
C TENANT [I FOOD SERVICE
IMPROVENHE T
❑ OTt TER
SQ. FT FLOOR AREA 5/SQ. FT
J
PAIR]
FF:E SAN 17 1996
Ohl`vII)li t
''v �nnoN
hP
V BUILDING DIVISI Lig
PLAN C FEE
3%kDINI FEE
SOILS FIE
PAID
Gone
Receiln N
TOTAL
BUIL TNG FEE
SETS. IC PER,
EI.Ii RIC FEE
PWM ING ME
MECHA ICALFEE
CONSTRUCTION
HOUSING MITIGATION Ft
PAID
Delo Rcccipt N
TOTAL:
ISSUANCE SSUU\NCE DATE
ISSUED BY: �._
N N�
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