30295 a.. APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL"' PEEMIT NO.
BUILDING DIVISION APPLICATIONIPE RMITPLUMBING-MECHANICAL 30295
9
BUILDING PROJECT IDENTFlCATON
BUILDINGADDRiSS: „ SANITARY NO. APPLICATION SUBMITTAL DATE
�.�IF Gillick w C'u r7no Ca 9So�� S11(i
OWN R:SNAMB
:
////eI'IIONB' CO ACTOR'S NAMT: LIC O:
`lI/I �V- �I3D �5�� NC CONROLa
ARCHI'IE /ENGINCER: ' LICNO: ADU SS:
LR LC�"E�INOC)G�iPd. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
/ n/ _`,D ❑ Consultant Fees Paid by Appllc nt QNNeI) BLDG ELECT PLUMB MECH
❑ ❑ ❑ 2<
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF,
XZ 1 hereby efrrm thou 1 ern IKenxd rode,pruvislvns of Chapter 9(nsrmreaing JOB DESCRIPTION
��yF00 fh Sanson 70oo)of Division 3 of the Bee one sed Professiorrs Cu«k,and my license i. RFCIUFN'!Tet�
FOO afull form earl f r �J �f PERMIT ISSUANCE
�FU�j li<rnsc �� I.iu.» `�^�-7s RSEDWI, ❑)(11CHENRF_MODE
NQd Ihte�Conamator AQ bLlhllh it APPLIANCES-RESIDENTIAL [I ADDITION C3 PLUMBING RE-PIPE.
F o, 1unJcrsunJm I H
ARCHITECTS DECLARATION PANELS ❑MULTLUNIT EI�UCCTURALN
OZ-Z- YPan. Mused m ' OIUP TO 310 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1-t3 F' IxmacJ preo,,,,mul - ' Sol-IUIO AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
4 K
w6 I hereby aftirn that I am excerpt from the Comroemr's Li«ruc Law for Nc OVER I(X)0AMPS ❑BATH REMOUF,I/REPAIR ❑D17MOLITION
x O a U following ream o.(Section 70313.Buaire,,ts sort Profession Cods:Any city«county 'SIGNS ELECTRICAL - COMER
til O w.bkh reynims a I mpit to emnruuct,'I"improv,dertwlish,«repose troy wu 1. rn(L( .
,� pros«fn iu issuance,dso rtyuires tM oppliam Re such psmtiuo flc u.agaJ uaemrnl SPECIALCIRCUUNISC.
�} fM1at he is,scour,quatuot to the povlsiora offhe CaumclNxl.icetx Law(CM1eper9
I+I�pO (aamancing with Satin]Oro)uf Diviswvlof the Busirtessard Professions Codc)« - TEMP.METER OR POLE IN.ST, COMMEROrA
a then be in uemp dlmfrom and the basis for the alleged exemption.Any violeion of Q NEW BLIX'i/ADDITION�1❑�DEMOLITION
Sedma7031.S by any Wplicemfor opani,suhjnec ole npplirantm,,so pa"tYof POWER DEVICES ,,,.�,W, + � RLCt�
rot m«c than five hundml J i.P$3110). ❑I�RryWyym,A4GSr1 RLIY D SERVICE
f0 ❑.I.mvmv Mfhe pmpeny.«my empbYees with wages es toed utle compenwion, SWIMMING POOL ELECTRIC ;
will do tha work,and Ncswamro is nut intenJCJ—ffered for aale(See.WHY;Busi"^s= OTHER
W- and Prefnai«n Cork:The Ccauateor'.,sans law don ra apply to so Dura of OU]],E'f5-,SM'fl'CHES-Fl%'NRES P11"I t- si40C111 iNU
13- prope�ay wln battles or imlrmves tht uW alba don wch won himself or fM1muBM1 �
his own employees,pmvs4d most such impovemcma sR not interrlerl«nRmral for NEW RISIDENDAI,FT FCfR I SQ fT.
stale,If.howc,,,.tic building«impovemcnt,,odd within one yes ofmmpletion.the SQ.F,FLUOR All ESQ.FT.
ar-builder will hues the buNsn of proving the be dm m build a ioRrme for par-
pm,of sok.).
❑ L us owner of the popery,unt exclusively arntracvng wiW liemm contratan m TO
earl tle ptojal(Sec.704,1.Busing s srad Preressians Code:)The Camacrors Li.
are law dose n«apply ,an oweneref popeny slay builds or impnvn thereon,and QTY, PLUMBING PERMIT
win commas f«xuch pmj-L,with a mann,loon Ilcmascd por giant br lle Conlawor's
License law. PERMIT ISSUANCE
❑I am eaemp under Sec. .B&P C fm dda,¢son -
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I Nearby dr.tonderpmaltY of perjury vac of the fNlowine dalamlirms:
Ihevs and will meinuin uCrniha¢ofComm�uv ad4insum fnr Workers Compere DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
motprovided for a provifm by Samem 3]0(1 of do loom Code,f«the perf.of de
sof,for which this penrtit is issued FIXTURES-PER TRAP
Chave and will maintain Worker's C«npcnsmwn Inrome,-rsvleirN by S of, `
al Labor Corte.far de pMamwrce of die wM for which Nu Permit is issual. GAS-FA.SYSTEM-I INC.J OUTLETS OCC GROUP APN
My W a C r� u Imuti a eerier amt policy rrWWnNsaarc' -
carrim�.NicyNo.: /.in'r�"�D?[oU GAS-EA.SYS AI.OVER Y(EA)
CERTIFICATE )F IiXENPTION FROM WORKERS'
COMPENSATIONINSURANCE r GREkSMNDUSTR,WASTE INTERCEPTOR
(thisTarim recd no,ba c«npknd ifthe permit is for oa hundml dollen(S 100) BUILDING DIVISION MEN
or I—) GREASE fRAP PLANCHECK FEE
I ramify tea,in The pafwrm ofIh won for which floor psel is ivuN.I shall
rot eaoPlvY any Psn^rlly humane, at vrp:�bpT term W�xku.'Cnmprn- SEWER-SANITARY-STORM EA.]00 FT. pj,h"GY ME
z urian law uf,7,m ri I � _fes
zO 'It., t��q �[ WATER HUATER WNENTNLECPR GRADING FEE
T% NOTICE TO APPUCANI:IL ar'cr making this Cenif tc M pfia,you stwukl WATER SYSTEM,TRII ING
a become•uhjal to the Workers Comrn
lmfion pmvici«u SOILS FEE
fnnhwifh comply with xuch provisions(it this permit shell he drama!revoked, WATER SERVICE
a �
= Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLKIB, SQ.FT PAID
Vim , l forcbyalErm Paermt is oconumefi097.Cingegency Rulhcperf«nunceof Door Raciln»
LL p: The wink furwhicM1 this permit klasuW(Sa.309],Civ.C.)
O U I.eodcfs Nus TOTAL
IrndaS Address TOTAL'. --
1 renify dist 1 neve real,Nis Wplicaion and cute that the abrwe mfonawtioo is BUILDING FEE '
y c«rett lagrtemmmply wiN ell city and c«mty«dower ab..,.4ws reeving fo QTY, MECHANICAL PERMIT FEE
V Z hviNingc atnctl aM hereby emhoaiureprt anNai...ofdrisciytorntnu,osma SEISMIC FEE
aNrve-msnlinad pmpcny f«inNcdioo Por,,a_ PERMIT ISSUANCE -
(We)agree to ease,Jde,wfy nerd k,,P hernk,do City of Cupadw against ELECTRIC FEE
InNlities,judgments,mss ud eapenscs:hich may in any way accrue nalnu sail City
in nnse9uce of The Sting of this emit. ALTER OR ADD TO MECH.
atunrmPLUMBING WE \
APPLI�ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FTE
SOURC GUTATIONS.
L Xj/s-9.7 • AIR HANDUNGUNIT(OVIIR 113,0(X1 CFM)
CJ CONSTRUCTION TAX
Sigoamrtof pplrandConttaf« Dem EXHAUST ROOD DYMUCD HOUSING MITIGATION EFF,
IIAlARWUg MAT:RIAfSD15 GSURE
Will meepeicum m future building occupy o or handle 1-ardour malarial I I IIiVRNG UNIT TT O I 00,0()(1 BTU) _
as de0ad by the Cupertiw Municipal Crile.Clapta 9.1;and the Ilealth and Safal
Cods,Savor 25533(.)? HEATING UNIT(OVER 100."BTU)
Yes FlNo ' VENTILATION EAN(SWGLE RESID) PAID -
Will the applicant m Tanana building am tore Jevicn which Data Rsmip g
pen ea ipnan« BOILER-COMP(IHP OR 10(1.afN1BTU)
Dinh havNsea air rnnumivnn as def art by fk Ilay Area Air Quality Mmmgcaanl
UiurinTO
[-I Yea 0 N BOILER-COMP fOVER 100.0100 BTU)
1 have rcali de harardax mecdals rtquitenenu,moor Chapter 6.95 of the Call- AIR CONDITIONER _ ISSUANCE DATE
Terms HeJth&S 111 Code.Saviors 25X5.33533 real 215 f I anakrved that if fk
hoisting does arm curteaTy base atmno,ae,it is mYrtspaeiNliry to roafy an,ampm NEW RESIDENTIAL MECH. SQ.FT
of the mquimnats shzb mus,M1c inn m,h.i.uuarce ora Cenifo ate of fkca,shho. - j
Owmmaufh«irsd agent Dec TOTAL: ISSUEDBY: /
OFFICE !I