S 3976APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERNIIT
BUILDING - ELECTRICAL
PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
S 3976
BUILUINOa DDDR ILS.S:
'ft4s Lai
�NC'�i ' ^ e
61 as
1
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNT•R'S NA P_'
CO
CTO N E: LIC NO:
NIC
CONTRGLN
ARCHO'ECTiTNGINEER: Lit N
DRESS'
. U.
❑
CONTACT: PHONE'
BUILDING PERMIT IN FO
/n�
F_(4`n� Y
❑
Cauvl ant Fos Paid by Appll ant (lNHa)
B❑x EO uMB iro❑x
/
'• '911T
❑�
LICENSED CONTRACTOR'S DECLARATION
I hereby amen float am 11mnrN si c prorLbas orchal9 (I.ecing
QTY
ELECTRIC PERMIT
FEE
JOB DFSCRIPTION
with Seetion 700,1 of Dirivan 3 of the Bwnan e,W Pmfasims Code, and my liceme is
in full forte atd cIT
Gmnsc Clan Tic. N
DateCn,or
—PANELS
PERMIT ISSUANCE
RR FSIDENTIAy
❑ SFIDWL ❑ KITCHEN REMODEL
❑ADDITION XLUMBING RE -PIPE
APPLIANCES - RESIDENTIAL
THEM
I ,mdera,ud ney plans, shall be used a Bomic records
❑MULT-UNITC❑ STRUCTURAL
MODIFICATION
UPI 02- AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT (]SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
OTHER
Lice.—I Pn Is...]
OWNER -BUILDER UEC, Contr ON
1 lercby ¢(Sero Chet 1 n.5 exempt fnm the Cnn,rtttor's Any,c law forco the
0dlrwing.i.. (Batton 7031.5. Nurinas lob Pmfasiotn C't Any my x cdtnty
201-IIWAMPS
OVER I"AMPS
SIGNS ELECTRICAL
which n permit ,c cdu,rvn, eltcr, improre. y s,mcturt
SPECIALCIRCUIT/MISC.
hittilensefi-S
its i n permin n a>Late memrn,
prior m'nsissueneanlsn«91i
provotIcn—fineuch
slut be is littn.H Wntunmt proviaiomn(thc Ent 'n Licc law hap¢rY
Lice
TEMP. METER OR POLE INS(.
COMMERCIAL:
(rommmeingwith Scdien7 q)dlNvisienrlthe Busi sCNOor
,het he is acmpl 111crc(10 a,d tM1c M{is for the M c violation al
❑DEMOLITION
❑TEN
POWER DEVICES
M eve7ol LSve hu u cantforaprnnit 'cuntn ocivil penaltyM
tort,wsc Jeno five c dollws(S30t
El Las uwscrt,f Ue pr ny. nr my , ryes it gcx a, their role cm,pcnvtim.
wd1 Ju U,ewurt, end the tin oRertd fm sWclSs.)DW. Busina'a
ccnrr's
NDCJAOUITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
a,td Rofasiom Cale: The Co 1 w tba tot apply ,o an Dover of
Ol1TIFT5-SWITCHES-Il%'IURIS
pnrycny Opt Ml,dr. car iminov and wl,o diver each work h,or Eor Orvsgh
nimlwvorcnu
his o+n empkryas, povidN uc rot imenkJ m offend for
NEW RESIDENTIAL ELEM SQ FT.
a
BBQ. FT.
snk.ILhmx.enthe be.ldingmim ,cmm,ie roll wiUtin arc year of am,pleliun. thl
rcr-huildcr will huso the burden n proving that he did rim Wild or improm for par-
pose of vk.).
❑ 1, its owner of the pmler,y ern escludwly comracting with GcrnrN ccinlrocrou bt
D
TOTAL:
aol al the Project (,S.c. 91114, Bwinna aN Profession, Co.., The Cmo-x,m6....
taw law docs,a apply,o an owner of progeny who buiWsor i,opmva ,Mem.aN
QTY,
PLUMBING BERNET
FEE
JUN 1 6 1999
whomntrvc,for wch projc,e with acnnlrenm(» liccnvd punua,I nIheC,naO1v
PERMIT ISSUANCE
Liver. law.
❑ I am Bump, url Ser. ,B& PCfar Ibis realm
ALTER - DRAIN & VENT - WATER (EA)
Owner [)are
By VALUATION
WORKERS COMPENSATIONen DECLARATION
BACK FLOW PRtJRiCf. DEVICE
1 thereby oW
eny amt nr 1cnry nr ��gory nD encol he fnu;twing du.Jwadma:
DRAINS- El ROOF. AREA. COND.
❑Ihave aunt will maintaio. Ccnifctic d'CuhTnto self-imurt for Wmketa Coapen-
morm or Calc for the of the
on, as pvidN lim1E for by Sec37of the labe Ierfm,u,u'
STORIES
TYPE CONSTRUCTION
,.A On which Nis Per 11 is iarucd,
FIX'I USES- PER'HIAP
❑ 1 hate eN will mwnudn Workc(a Compclvation I... u rtqudN by Section
37M M the Labor Coda, for ,he feafOmurceof the wort for which this pmnit is miner.
GAS -PA.SYSTEM-I INC.4 OUTLETS
OCC. GROUP
AI'N
My wo"cke Cana"'. oe Imumnce cvner arJ Polity numher art:
Camey: Policy No.:
GAS - EA. SYSTEM OVER4 (EA)
CERTIEICATIi OF BXEtMPT10N FROM WORKERS'
COMPENSATION INSURANCE
GRF,ASEIINDUSTRI. WASTE INTF,RCEPIOR
BUILDING DIVISION FESS
(This sessfon,cd not be comPletN if1he, permit u for one hu,bredddW IS 100)
m las")
GREASF,TRAP
PIANCHECK FP,E
SEWIiR- SANITARY-STORM EA. 2(p FT.
I ccnity,h., In the peel Ni pc,mit is iswN.I ,boll
ndempbyanypma Y. eW sefybf.�N��the W.
ENERGY FEE
WATER HEATER WNEI.T/ELECTR
cation lax — /
AOGICE- �'�{
GRADING FEE
ri
NOTICET6 APPLICAYT7L niter-p-G9ri.n rCMt tat f oil,or Coo vowatmust
heconm mhjca m the WixkcCr Compensation Pnrvisian, afTabar Calc, yiw mutt
wpT1:R SYST?M/I'RFATINC
SOILS pZ'E
WATER SERVICE
fmhwi,h comply with wch pmvuiwu or,hu pcmdt rhell be dccned rtvotN.
NEN' RFSIDEM1TIAI, PI -MB , SQ, FT.
CONS'IRUCDUN LENDING AGENCY
I Lereby affirm Uw dere is a emwec,ion boiling egcrcY for ie perfmmarce of
PAID
ecerpt N
the work for which,hie permit is issued ISee. 11NO. Cls. CJ
TOTAL:
I<nJcr'e No.
I<,ak(.Addrtse
TOT
BUILDING ITS
1 cer,Ify That 1 huvc oeaJ,M1is o,hee,ion and one Iles, the wine infonnatlm is
'orrcl lagrzmcomply withal, my mJ roomy dJinuecsuN vert¢ laws rtW,ingm
er uMn,
buikling com,rue,iora aN lemhy aultxwizc repeaeewives of thio city to enter he
QTY.
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC TEP,
ahovonsntioocd pmpcny tin in,lec,ion pe,,,
(we) wee to nive. indemnify awl Leer, hwmles the City of Cuprniro apiw
ALTER OR ADD TO MECH.
PLUMBING FEE
Iiebili,ies,juJgrtewa. rnua arW caprnva which racy in unywayaccwcagninu said City
nocquence of the gmming of,hn Penni,.
AIR HANDLING UNIT (TO 10.0011 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCB REGULATIONS.
AIR HANDLING UNIT (OVER ILAY) CFM)
CONSTRUCTION TAX
of A,PricenUCmnrvcmr D E
fIAlARWUSh ATERL\IS DIS OSURE
EXHAUST HOOD IWMUCII
HOUSING MITIGATION FEE
HEATING UNIT(TO IW." BTU)
Will heapplicso, m future Wildieg eccvpen, mute le heearel matmi.l
us dednN by the Cupcnim Municipal Ode, Chuger 9.12, and the Ilmlth adl Safety
Cork. Saaim 25532(.)9
HEATING UNIT (OVER I WTO) BTU)
p Yt, ON.
will ,he applicant car fmurt Wilding occulnw use, or R ics, w'hicb
rympmrn
rnut hazaNma air contaminations as Jcf nal by ,bc Bey Area Air Quality hle,ugrment
District?
❑Ya ON.
PAID
Date Rcciq N
VENTILATION FAN (SINGLE REI
BOILER- COMP CLIP OR 100,0,0 BTU)
T AL:
BOILER- COME (OVER 100.0)0 BTU)
AIR CONDITIONER
have read Ise hvvUw, nutcrink,cquire,rcms udlm Clupttt 5.95d1M1C Cad i-
forr,e Hcehh & SsfnY Code. Scctidn 255(15. 23333 atal 25534. 1 u,tic,sum,M, if tk
building daes mn whiliry to naify theeoaynt
ort ,rclpdo na,�crtli bade of pvmy.
ISSUANCE DATE //ff
�/% �•
/ �-g� /
lr
NEW RESIDFMIAL MECH, SQ. Fr,
ISSUED BV:�
nmhnrirN ngmlI Its tws, US,
TOTAL:
OFFICE