29139 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-HLECTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING.-bIRCHAMCA- /�•(] •F (]
DILDINCPROJP.CTIDFNTIt'ICATION L J 1 J
BUILDI,NGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SNAME: PHONE: CONTRACTOR'S NAME
N/C CONTROL#
4RCHLHECT/ENGINEER: LIC N6 ADDRESS: - ❑ qottt,
OONTACf: PHONE, - BUILDING PERMIT INFO
❑ Consultant Foes Paid by AppHwnt(Irl r{LDG PLUMB MECH
LICENSED CONTRACTOR'S DECLARA'HON QTy ELECTRIC PERMIT FEE
I beteny affirm lira I am liceriacd Iver pnvisienw or Clo en 9(�rnmencing JOB DESCRIPTION.
XXWoo wiih Salion]IXp)orUivisiomJnftW Rusime.0 nsW Pmfcssimms Cidc.and myl'iccnw is RFSIDENTIAU
F in full fence wind effect. PERMIT ISSUANCE
❑SFDWL - El KITCHEN REMODEL
F<UU Li<rna Class IJc.N
NQL Date Couctme, APPLIANCES-RESIDENTIAL ❑ADDMON ❑PLUMBING REPIPE
ARCHITECTS DECIARATION UUH-UNIT ❑STRUCIVRAL
F D'n- PANELS.
X pN 7J. 1 umlrimmmd my plan.J"I be wad w public rtconk MODIFICATION
O X Np UPTO XIo AMPS
Licensed Pofes,ioml - _ []INTERIOR [I CHIMNEY REPAIR
OWNER Efr
....]1 301-1000AMP5 IMPROVEMENT
DE CI.ARATION n +'
C� { 1 hereby affirm thatexciaN
I am esemp from the Cuntractur's License Lnw fur the OVER 1000 AMPS 11 BATH REMODEUItEPAIR-E]DEMOLITION
X3�V folElowine mason)Sectio]UJIS,tlus'ves aoO Pmfeulotm Code:Any city or SIGNS ELECTRICAL - ` ❑OTHER .. ,
4411 cntcquim a permit to aTnNet.timet imp4vic demdian,«repair maty rWflWe la
��•� pri«to its .cvurues
c.wsorewrtKc aWlawro for such permit to file a signarr.�r
l cmcnl SPECIAL CIRCUMMISC. V y
xnt4 Na he is licenralpmauw to lk peowesicttof the Cotrectocs License law(Chnper9
W OCpO (eonmmncvng withselicas700pof lasovm 3 eftlul Bao.and Pmessim,Code)« WAR METHR OR POLE INST. COMMERCIALi
a d that Ie u exempt tbcrtfmm and Nc bai,fen the alleged exemption.Any violation e! ❑NF.W IiLDO/ADDITION:rIDEMOLITION
SeCi«t]H31S by any ap,4cwu In,apemiil subject,me eppliinnt to w civil pmwty of 1'OWI:R DHVICI_S
ul^ret El TENANT ❑FOODSERVICE
p+Z_Y noltmrelharifivchmulrtdddlun($500). _
< 1,es owns#the pmp:ny,«my employ«t wiN wagesw their sok amprnvtiem. SWIMMING POOL.ELECTRIC IMPROVEMENT
will ib die went,and lite strucnm is nut intends,«ofewd lm sale(Sec.]OM1.Business ❑OTHER
3 wet Profit..Code:The Contrxtafs License law does int apply to in irwmer or OUrLErS-SWITCHES-Fll(T11RES .
property who builds«improves thereon,nM who door such work nhiixlf or dtrnugn
his owo t,mpby..pes,k wt the such imprvverrcnH are ret iott,tdrd«offered for NEW RESIDENTIAL ELECIR SQ FT.
swe.If,huwevcr.Ile beiWingmimprrvennent is sold within avec yew ofcampnionnhc SQ.IT FLOOR AREA $tiQ.FT.
rer-0uillly will hast,the W Nen of poving diet he did two build«Impose fee pw-
pNow).
1.a,
1111,as owrcr of one
ee •um xclusi vdy cammswith licnrnst,d crowd'm
ceastnsn te pmjm(Se.7UL Bushs M .Code:)The CoG-
Lew kcsout ymanownsfpntpen,,he bWEdar imposes.t1mmmn.ad
QTY. PLUMBING PERMIT -
FEE
wIwfssect, wpursuit atithe
ConvonWs
Ucrna law. PERMH'1SSUAN'E
❑ Iwmeaemp uMwSec. ,B&PCTs Nurtnso _
De . ALTP.H-DRAIN& WATER(HA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK ILOW PROTECT.
I hereby af0rm ander penalty of perjury one of Ile following dwm
lalinra: CIO
/,—
•y I Nve wed will neemoussa Cenifcwe of Consent n self-iruure for Worleh Compos, DRAINS-FLOOR.RODE AR ND STORIES TYPE CONSTRUCTION
tion,u"w6c,l f«by Section 3]1X1 of the labor Code.Ir IW permimmne<of Inc
work for which lbiw permit u iawed, m IIXIl1RF5-PER TRAP
Fl I lure wed will meinWn Wnrkdt Compenawiim lmanece.m too meed by Smiort
371X)urthv labor Code.lir be pedenmwce fthewM lar which Nix pemlil uiewni GAS-EA,SYSTEM-I INC, TS OCC.GROUP APN
My W'ork<{s Compensation lttswv carre,aw P.licY number we:
Cwdu: Policy No.: GAS-IA.SYSILM OVER 4(HA
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE GREASEM'DUSTRLWASfE INTEROP R
(Ihu.mion mieed trot he completed if the permit is f«enia huntlml When(5100) BUILDING DIVISION FEES
«les.) GRFASETRAP PLANCHECK FEE
I anifylhw in Ne prafi.oeoflhe worl:fu wMch Nis eemit,,is d,lshdl
o«cey—
mpby any Peis.i.wi,.waw to Nneome wbjmm lie W«kcn'Compcn- SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE -
O O Atippi Litws MCelifomia.Date _ WATER HEATER WNENDELEC1'R GRADING FEE
7
a V3 NOTICE TO APPLICANT.If,eller making this Crnifiewe of I:xcmpiin,yea ahmtld WATER SYSTEly! f TING
I^ become wbjat to the Wenkcr'a Coiryemwio provisions of the Labor CMe,you poet SONS FFELr
{a fmNwiN comply with such poo itiana«bit permit snail be deemed rmrvvniTd, r WATER SERVICE
c. Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID,
WU.F. IhrrthYalEtmthel inert i.saedi(Sce. Ten ding ngrncy for llc pNommwce or Dwc RmipY
0 F Ls wok for Fluce ch Nupermit is i,..-n(Sm.JD9],civ.C.) - - •
U I<Mers Name TOIAL
f< cr'sdlro'
As r
F yM1 cenify diel I have rod Nit application and M
awe mt Ne above infomnttiun it BUILDING FIR'.
- r
Z? coons.I agree to comply with wl cdy,and comy ordinances and mate laws elating in Q'rY. MECHANICAL PERMIT FEE
LIZ building cnraa«tloi.vid by bYwbon rtp mai eofNiacirytornn ups its, SEISMIC FEE
eMve-rrcntiomied p.yeny fen inxpstion purp«cn.
(We)egre<Iosave.indemnify and kap bemdeu the City of Cupeunsageina• PI:RMITISSUANCE ELECTRIC FTE
liabilitie,judgmrnts,con and cspm.at which they in any way awnw n,..said City
in cense wrocc of die gsame,of Nis pemul. ALTER Oft ADD TO MECII. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(X)0 CFM)
SOURCE REGULATIONS. - MECHANICAL FEE
AIR HANDLING"a(OVER 10,000 CFM) CONSTRUCTION IA%
Sigmturt of Applinnl/Crswrwnen D. EXHAUST HOOD(WMUCD
HAZARDOUS MATERIALS DISCLOSUR13 HOUSING MITIGATION FEE
Will lne wp,hevu or Emrt buildieg«c,sout meneor barWle barardoas rnpd al HEATING UNIT(TO 100.(V0 BTU)
w defined by the Cupitirtos Municipal Code,CMper 9.12,and the HnIN end Safety
Cusee,Section 8S32(e)e HEATING UNIT(OVER 101"BTU)
❑Yet ❑No VENTILATION PAN(SINGLE RISID) PAID
Will th Vp4icww er fuawe buildingt use - m«devices which Date Rtteipt N
by do,
An.
BOILER-COMP(3HP OR 100."BTU)
iIFmit Wmdowu air conmWvnta es defried by die 11ay Arra Air paliry Menngrnirnt TOTA .
sWcrY - BOILER-COMP(OVER 100.1#10 BTU)
LWi�lidi�
Te ❑No
ere and the bvamluts mrutnials menu m#kr AIR CONDITIONER rtcuirt Ou,,r6, S M Ifo CWi- ISSUANCE DATE
lth&Safety Code Sections 15N)5,8533 and 25511.I uMers.mod Nn if 0,,-
'
W NEW RFSIDIiNf1AL MECl1.
ict rot•oureWly heve a entities.dW it is my msandibiliry n eodfy We esermt
'vcmvvs which rwa he met Iriorm pwamee ofw CcniOsvteautlwnewlti' t Esee TO AI. • SO DB
OFFICE
Inspection Query for a Specfic Permit 9/15/97
PERMIT#;SITUSISTis SITUS',STR_EET Lot# 1 INSDESCRIP,T Ios,T -6 DATEDESIREA Dk6D6We
29139 20647 IFORGE BDG FLOOR NAIL 8/2/96
9139 2064 FORGE BDG IL PLATE NAIL 8/2/96 8/2/96
9139 20 47 FORGE BD 9 TOP T 9/27/ 9/27/96
9139 20647 FORGE BD 9 RGH MECH 9/27/96 9/27/96
91 20647 FORGE BD 9 FRAME 9/30/96
9139 20647 FORGE BD 9 R C CHANNEL 10/1/96
9139 20647 FORGE BD 91NSUL 10/1/96
9139 2064 FORGE BD 91NSUL 10/1/96 10/2196
29139 20647 FORGE BD 9 ELECT REL 12/9/96 12/9/96
9139 20647 FORGE BD 9 ELEC SERV PANEL 2/3/97
9139 20647 FORGE BID 9GAS-F 2/13/97 2/13/97
9139 20647 FORGE BD 9 BLD -F 2/13/97 2/13/97
9139 2 647 FORGE BD 9 BLDG ENERGY FINAL 2/13/97 2/13/97
9139 20647 FORGE BD 9 ELECT=F 2/13/97 2/13/ 7
139 20647 R E BD 9 PLBG=F 2/13/97 2/13/97
9139 20647 FORGE BD 9 MECH-F 2/13/97 2/13/97
•
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Inspection Query for a Specfic Permit 9/15/97
ns ato Unit"s'Pass/Fail,Code,=
B 12P
B 8P
J P
J 8P
S 6P
J 4F
J 4F
J 4P
S 2 N
S 2P
S 2P
S 2P X
S 2P
S 2P
S 2P
Sl 2P
•
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