99090064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL. RMTfN
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. (�
BUILDING PROJECT IDENTIFICATION J
BUILDING ADDRESS: SANITARY NO. APPLICA ION SUBM111'IIAL DATE
W J'e-1 GIV ED
Lia rioru ila-- .3- 57 3 C ACN NA E X76 7401/
NIC CONIROLX
. RCfIITELT/PNGINEER: -4 U{"��'fI/� AI . _ ❑
3U ✓`3/ C/�,-, �l44 oil �in �lnbs. G+.
CONI'ACII PHONE: BUILDING PERMIT INTO
���O G,/�. ❑ CnnDUliam:Feet Paid by Applitanf(Initial) BLDG ELECT PLUMB MI:CH
iilai)/ E o'rJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECIARATLON QTY ELECTRIC PERMIT FEE
I hermy er dam 1 an Hceracd toner pow.lion,of Chaper 9(commencing JOB DESCRIPTION
CCO with Section 7000)of Division Softhe BuaircasW pmfessimet Code,and my liceut,is PERMIT ISSUANCE m0 R SIS
QU{_' 'n l�Il fora Att Le.X �0_ ❑SFl El KITCHEN REMODEL
FF , APNJANCES-RESIDENIAL ❑ADDITION ❑PLUMBING RFPIPE
<UE Due Conhact«
F ARCITECTS DECLARATION PANELS ❑MULTUUNIT C]STRUCTURAL
ZOnZ etrarWmyplana del as puyJic res, % MODIFICATION
OZ—C UP TO 21XIAMPS/ gcR d [_1 INTERIOR [I CHIMNEY REPAIR
a�F-m Umnsd l'ndcaiotn ? PTI-11X0AMPS IMPROVEMENT �SWI.MMING POOLS
Y OWNER-BUILDER DECLARATION OVER "AMPS ❑BATH RE.MODPLREPAIR L1 DEMOLITION
C I hcrcM1y vhrnn that I sm externo frohe Cnmmcta's License Law for the
7xa�55,�
00, GOM1wing mwm.(Section 1031.5.Busincxs and Pruf iaru'Cour:Any city or county SIGNS ELECTRICAL. ❑OTHER
which rtylurta u prrmil to cnnatfuct,alter.ini,ove,demuhrh,or repair am strvcmt<
FSO JJd i m era is.,,dm tcquira the appliam t«ouch permit to lilolii,ad surrntrnt
SI'ECIAI.CIftCUITIMISC.
Sly �� sew tc in licensed putvuntto the provisions of the Comosomes License fuss(CMptt9
W TYCO (commencing with Seetion](ro)of Division 3.Uhs,But.vast Pmfessims Cor lor TEMP METER OR POLE INST.
0.C Bear M u exempt derefmm sort We bads for the d ogerl exemption.Any viduim of ❑NEW BLDGIADDITION ❑DEMOLITION
Sustion 1031.5 by any.,]it.f«a permit subjects Etc epplicmt ro a civil panty of POWER DEVICES
to []TENANT ❑FOOD SERVICE
F.Z}
not m«e etas five incurred dollars(SS W). IMPROVEMENT
❑ I.uowrtcr of the propeny.«my crnploryecs with wages ns drirsdc cmnpersuian. SWIhLMING P0f3L EI.ECIRIC
well Bothe work.andthe he Co eranot s Licend«co,clues
tele(See.o oro owner of
[I OTHER
W3 eroerty who
Cod e:TM1<C«u tbereu LiaveIondocsnot applytolf awns of OII'11.IT5-SWITCHES-Fl%NRI:S
1r,..o whooyee, m,i&d,b,stmt, nwho Mensuch e,nr no cled.,or through
his own euseve,Do ptnvidcd Nm mr, oncia,ctoanu ort ml intended or,loom,The NEW RESIDENTIAL ELECB WIT,
wIc.ICM1nwevcrill iu, hog«run of,ty is.rold,Itw,thin oneild-,.Me,hon,the SO FT.FLOORAREA 5/SQ.IT,
cof Weft will M1nve the WrM:n u(pnwing IMt lu JiA nut mild«wpnrw T«pur-
pxcniwl<J.
I,m rrwoar of ctK progeny,ant isms.vdy eonhneting wits:)The Camwerrn m '1(YI'AL.
ome Lo thee,. ply
.our Busi of enc u,who
hose Gste:)The ..thecmr'•Li-
meLrwd for suchply tom owra custax c�y wlcensuid+«inttothe ltcmn.uts stroll QTY. PLUMBING PERMIT FEE
who mntracu
for such pnjecu with a mnvact«(a)lic<nsN pursuant to the Convect«s
License law. PERMITISSUANCE
Ison exempt«d«Sex. ,B&P C for this ransom
®Over, Dmc ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DF.CLA RATION BACK FLOW PROTECT DEVICE
1 hereM1y thrum under pet of perjury on,of the IN lowing declvations: L/
❑(have emlwill mainuina Ceni0cem MCwsenno.¢If-imurt for w'orker's Compem DRAINS-FLOOR,ROOBAREA.COND. S"IUR1E5 TYPE CONSTRUCTION
anion,as povlecd for by Saban 3]W of the(nun Cone,fur the perfomunce of Ile
v0rh l - h,his p<mot is iss ti. FIXTURES-PERTRAP
vc lust will nwiomin workers Contpnwfmn Inwmuce,as rryulred byscion
3700 or hie Lder Cnc,fw the perfnmmrce ofthe wool,fon wh'nh this tit in inwcd. (AS-FA.SYSTEM-I INCAOU7I.01S ()CC.GROUP APN
My Woo tet t c hon Ion nc < brand Policy num ) �y s"ry''_ //�3/��t-�/
Cwtier.�Infer No.: r L GAS-FA.SYSTE.M-OVER4(EA) J�Ofr ` 00 I
CERI'IFICA F,OF EXEMPTION PRIM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
(This smian recd ant be rnmplcuJ if rte permit in f«ane huruhed dollnoa(510!11 BUILDING DIVISION FEES
or loo") GREASETRAP PIANCHECK FEE
lcenifythat inthc perf«merec hfthe w«k f«whichthispeumitisiswal,I"I so SF,WER-
8 cm lnY troy Portion in any nlvlrla u to become w t to the Wml rs'C SANITARY-STORM FA.2(10 FT.
rZ resatvm laws of California.Due tryec atopen- ENERGY FEE
Q WATER HEATER WNENT/ELECIR
z O Applicun GRADIN
N NOTICE TO APPLICANT:If,after making this Ccnilicne M Exemption,yon should WATER SYSTEM(RtFATING
I'^ herborl wb}cct to the W«hexa Camp or this pmvinims of the I.otwr code.you mase 1
ranhwi55<trrrply who such proviainns m unix pemmh atoll he d«mw rt.�ok<d. woos sl:RvlCE r.
d � P ID h
."O. Z CONSTRUCTION Li-:ion ENO AGENCY NICW RESIDENTIAL PhMB. SQ. 8
U 15ere5y etfiw that there lseutnstmdion lcmling agency fa the perfmmrne til u _ U �Anfttl5CO i RaeipM
66F' thevul,for whichthis pe.,,isissuN09
(Sce.31.Civ.C) I S I I
I< e<r's Nume V TOTAL:
U n
fencor's Address TOT
F y I hfY that 1 out,«ad this application amstate thea stathat th<above ird«roeuon is S
mBUILDING FEE
y cortat lepra to romply withw city aM mumy sxdinance wvl suit,lewsrtWinB to QTy, MECHANICAL PERM IT _FE .�.
U Z Wi4Eng c«awctioo,eM hcrcbY awh«iu rtprtsenurisa of this city to arca upon the �_��—SFJSMICFF.E
above momiorcd ptarprny for inspection puryoaea. PERMIT ISSUANCE
(We)torte to use,iMermtify and keep Lwmll the City MCupertino egahut ELECTRICHE s
Iiabililles.jodgmentsamts mrd expense,which may in any way serve egaim,uhl City ALTFA OR ADD TO MECH.
in umse9ucme of the granting of this pcmdt. PLUMBING FIE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR UANDIJNT UNIT TO I0,NX)CFI1)
SOURCE REGULATIONS MECHANICAL FEF.
TTer--44�v At��9 / &� AIR HANDLING UNIT(OVER Ih,(XUCI'M) CONS RU TI(lN'fA%
oig.mwm of�jrpl"or ovnr f/ De¢/ PXHAUSTHOOD(WIDUCf)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIOA3ION FEE
Will thcapplicmt«future oucor handle M1".+^.sus meterid HEATING UNIT(TO 100,000 BTU)
v e<Enee by the Cupenirto Municipal Code.Cbaper 9.12.and the Health std Surety
Code.Satvm 25532(x)? / HEATING UNIT(OVER 100.000 BTU)
UYo Cif—j No
VENTILATION FAN(SINGLE RESID) PAID
Will rhea othetw a fnurt WiWinB«tvlurtt me coryipmcnt a Miac whicM1 Date Receipt X
iorn, ardws air comounituns its e<Brrcd by Use Bey Ara Air Quality ADrogcrocnt BOILER-COMP THE OR 100.001)BTU)
TOTAL:
Uwra:'
❑Yes BOILER-COMP(OVER 100.(00 BTU)
I ve tM1c M1ereN;mm
s ulcti9Ls rryemla Cr
uirtnn ume95
ptcr 6. 0f the CWAIR CONDITIONER i- ISSUANCE DATE
Lnniv Mreal"I &Safety Coda Smiomn 21505.8593 and 15134 1 unolerueml dont if the NI?W RESIDENTIAL M11L'CII. SQ.P.
5tiding ter safety Cy MSC ,1505 i.2553 and 151341 tanto yl tPrpae, aCq LY.
ofllr<�w1hpc us5n pr« ,,cuocc(otuCctllfaal O gy
Owrra rumlwrimd 0gc lA C5J I Dent!Y TOTAL:
IssueD BY,
OFFICE