99090122 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRIGL PERK
BUILDING DIVISION APPLICATIONMERMIT PLmiHING-NIECHANTCAL
BUILDING PROl IDENTIFICATION
BUILDING AD DRESS �+� CU�E/�/ �NO C� 9� v SANITARY NO. LI TTAI.DA
TE
2004? 6AC0En/ �yAr6 P . � -Zo -4
OW 'S NAME: '/ / PHO `c CONTRAROR'S NAME LIC NO.
CON'IROLN
O Y R 1•' fT ,4 Xl V O —01 NIC
-ARCIUDECDENGINEEPL LIC NO: ADDRESS: ❑ 1.
CONTAGf: PHONE,. BUILDING PERMIT INFO
Sof Il I A Conwltant Fc®Paid by Applkanl(Initial) BLDG LECT PLUMB MECH
❑ ❑
LICTNSED CONTRACTOR'S DECIARA70N QTY ELECTRIC PERMIT FEE
I lemny alrrm doom I.tn Baena.nnea prow.imt,of Cb.pa 9la,mmen=ine JOB DESCRIPTION
O0c, with S,ol,m7(XX)pd D.1kmt13.fa1llasineuand Pmfc:loon,Cic,na!my 1111.1 is RESIDENTIAL
Y00 ! I'ERMI'f ISSUANCIi
Ul, on force and affect, ❑ADWL ❑KITCHEN REMODEL
F(,W Dolle Class Commata APPLIANCES-RFSIOFNIIAL []ADDITION ❑Isf.UAfBEJG RE PIPE.
ttFnn GZGZ=1y ARCHITECTS DECLARATION PANUS ❑hfULTTUNIT [I STRUCTURAL
OZV+Z I undarsmrd my Mara shall be orcd as pubBe recalls MODIFICATION
UPTO2 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Fa
'InC Iy Leaued Ptofassiam.l 201-IMM)AMPS IMPROVEMENT SAT LING POOL S
Z�CJ OWNER-BUILDER DECLARATION
LL pVHR I1XM1AMF5 ❑BATH RI'MODEI/REPAIR ( Lff10N
Y
C Q 1 hcrchy a0imt Ihthat1 am cwmpt Tamm Inc Cnntmcnx'a License I,nw 0v the
k 3 U lolkwinp rm�nn.(Section]0]IS.Bu.ulla.wd Pmlcvimu Cuk:AnY city is ewn7 SIGN'S ELECTRICAL DOTTER
L1 wh"calnires,Peon i,to construct.elnr.irlwvosc demolish.of ra,sur.......te
(ria to its kimarce,alaregomewihe.,fictet for such pacmith,0k•signed uv.I SMECIALCIRCUIT/MISC.
F;!�Y had lr is licensd pal .,a the Pm,i.smm M lite Comrclof.licenu L.w(Cluper9
m aS. COMMERCIAL
�O (mmmame�np worn Sctian]000)of lTvixiwiof the Busineu aM Nofessinns Codela TINP,METER OR POLE INST
Ct. a of Ihel M:is cmmpt Incrcfrmt old tM1c lusix fa Ila nllcecd ucmpenn.AnY vinlotiw o[ ❑NEW BLDGIADDITION 0 DEMOLMON
It Se tion 9031.5 by wy applicant Gx o pconit.whjeets Ila alrpleam In a clvil pnully of (OWER DEVICES ❑TENANT FOOD SERVICE
rid most,man rise hwdrN do1Wn y cra,l.
F=6 U L.sowrceof lir lxopeny.amyaoplovm wilnwred fac Fevsdec .Buvion. SWIMMING POOL ELECTRIC DOTTER i G will do de vsorL artd theatncturtutmtivcoded aoRerW fa Wel5ec.70L1.Busircu ❑OTHPR
F
a3 °rid Pmfeho Cafe:The Ceslocoir Ties.tawdosto applytoan lff proof OUD.EIS-SwRCHES-Fl]sT1RFS __�--- --1
Ink own wholaid,ortortoisesHerta, ,orwinmdoes ms work himself of mdfon
Ink own amever.m provided that such impms sold w art rix intended m offered Gr NEW RESIDENTIAL ELIiCTR SQ PT.
,ale.If.hmwevcn lite M1ulDingmlumpuvenaent is sola witM1ln one yearofcomplelnn,the — !!\\SQ.IrI',-X1,rK)R AREA II LSQP
. I'.
k
hr w ill haw Me burdenof pn,,in,tat he did no,Wild a impova fa lar- If'If
k , U 199II,
o is
r,ner of the paprny,un exclusively<wr.ednQ its,licensed]marxlaa m TGT
Drawn Ina project(See.7011,Husiteaa.M Pme,woms Code:)Tbo Cotard.!,Li- (�
cane Law,tkestut.,I,to nn.Wrerof popes,who Wild,m improve therms,arta QTY, PLUMBING PERMIT FEE u1
who wnvacu for xuch prujaa with a comracim s)licensed poo,uwt to w Com mnnrs
Lieenm Lnw. PI?RMIT ISSUANCE
❑Isent cxcmptu rSee .B&PC for do.r. w�
(Amer Ove ALTEiR-DRAIN&VENT-WATER( -[� VALUATION
�-' - iAKILK1RSCCi6&SATIONDEaARVDON BACK FLOW PROTEGE DEVICE ODU.
IIheod,v.Rtm iid ,,caalty ofpeoury ole of the following dechruioriv M
❑Iave.nd will maimvn.CeniOrnmMGtasamnn sdGimum f«Wm4mm's Compen- DRAINS-FLOCILRODEAREA.COND. STORIES TYPECONSTRUCfION
..tion,to pm,sled fir by Seclitm 371X1 of the Labor Code,for the performance of the
wap for which his panni,Ix IcauN, FIX'I'U R By-PER TRAP
F 1 have and will maintain Walker's Compamatiw In%moome,as rtgaimi by Section
37M a Inc Lahv C.1,for de perf.of Inc work fm which lou pecom,os oesuce. GAS-EA.SYSTEM-I INC.a OUTLETS OCC.GROUP � "N
My Warker's Coor crisuion Insurance car tend Policy numb.arc:
Cardec Policy No.: GAS-P.S.SYS1Ls60VER J(EA)
CERD FICATE OF E%EJv1 MON ITtOM WORKERS' d
COMPI'NS'ADON INSURANCE GREASUINDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FRES "
(Ilik-6...loavl not Mewtplaed 11 the permit lx tm ons,h.ondmd 1,41—(Sl(ID) GREASETRAP
nr ksa) PLANC)iL'CK FEE
I eenify thatin the pMamarea M the woA far which Thi,permit is usual,I,Full
rer employ any Pe�ntoany nl.mer sit u to brceme.wbjalm the Wal:eri Comprn SHWI:R-SANITARY-STORM EA. I'I'. ENERGY FEE
Z ,.tion lawn of C.lifomi..Dee N'ATIJt HEATER WNENT E.LECIR
Z Q A,h,aw GRADING FEE
N N"TICIE TO APPLICANT If,after making this Cenifievte of Exemption,you should WATER SYSTEIvvTREATING SOILS ISE
I'a hcome subject m the Wi kdsComnpcn.wtion pmvisione of the laMr CWc,yoanma
forthwith comply win each pvykinmor this pcmia,dall ha dacmad rtvoked. WATER SERVICE
aQ
= Z C.abate UCITONLENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FT PAID Due Ravi .
1 trr which nn tat mit i is.co (Sce.3n leldis,a8cmy fa the ps4mm.nce of p
U _O the weak ra whirs this pewit i.i.anea ISa.3097,cat.c.)
� U Larder's Ac TOTAL:
U I<Itdcr's Addrtns TOTAL
} 1 I,miry that I have mud Nix"Aicmion and singe tam the atone InOrmatinn Ie BUILDING F:H
�-oN correct.l vyracm comply with all city and ewny otdinattee and vac laws rtDvine to QTY, MECHANICAL PERMIT FEE
U Z Wildon,wmmaction,and hareby authonac reprasanmtivaa of mitis city to anter upon the SEISMIC FEE
above°r^tiw°E pcocny for invpedon:sum,s a PF.RNUT ISSUANCE.
(We).pee to rave,iMaimid,andep keharmless the City of Cupertino.pini ELECTRIC FEE
lian0itia.jWgmenu,coag and exptue which may in.ny way acme against aid City ALTER OR ADD TO MEiCH,
in mnscqucac of E,,Btami,of Ihis pans 1. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO III)(0 CEM) MECHANICAL.FIT.
SOURCE REGULATIONS
� ! A � . AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Sib ale of pplicwVContrcta Date EKIIAUSTHOODIWNUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will tMapplicwtafmumbm1dimgoccupans sbancclwndle M1eoa,iou%materiel HEATING UNRT`O 100.00 BTID
uv defined!by the Cupcnino Municipal Colla Chapter 9J2,and the Health and Safety
Code,Saclion 25532(.)! HUAI'ING UNIT(OVER IN),"BTU)
❑Yea F-1 No VENTILATION FAN(SINGLE RESIDE PAID
RTII dlc yrylinm a fumrc Wikline wwpad use equipmctu a devices WTiah Dare Race
.mihaatedoua.i,contamirwta ea defrical by the Hay Arn Ail Qoady Management BOILER-COMP UHT OR 100.000 BTLH
Dnlria? L
❑Yc, 0N BOILER-COM P(OVER I(101M)O BTU)
I have trod the hall material,ryuirta under Chastal 695 of the Coli AIR CONDITIONER ISSUANCE DATE
ronin Health&Sufuy Code,Seervu 25N)5.25533 vol 25531.1 uvdcrsreM dw if Ile NEW RESIDENTIAL MECIi. S0.FT.
huJdmB doe mg aaramtly havealrnan.thv loran,respanbilitymwdfY de acupau �� Z � .- '/"
ol ryw crus wh Phe pita w' nf•Cau ear Occupumcy.
O n rawnu r iagant Dale TOTAL: ISSUED BY'.
OFFICE