99080047 APPLICANTTO FILL IN INFORMATION WffHIN RED LINES-USE BALL POINT PEN ONLY 'O 17 0
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMFF PLUMBING-MFCHANTCAL
BUILDING PROJISCTIDENTIFICATION
77C CNG ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
�_frr
+ :S NA MI^, I'l i(INI ) COTR CI'ON'.l'NAME'. 1.1 NO:
S N/C COMAOLN
#:RCHITECTUENGINUER: LIC NO: ADDRESS: ` �N ❑ V
1061K. �` C�
coN'L'ncr. PHONE: 'n BUILDING PERMIT INFO
U f—J Jy £� O J� ,.r 7�/ Z-- ❑
LI, N Coru'uBam Fees Paid by Applicant(Initial) B_I.Dp EO PLUMB MOx
` CENSED COkAMI)kS UECLARxn OOQTy - ELECTRIC PERMIT IEE \t cW�
hereby affirmthnt i am Berm i trader pmvisirs of Chapter 9(nntmeneing JOB DESCRIPTION
OC)Z with Seeich7"/uf Division Jif the Business"Pmfessimes Cole,earl mY Bccrtse ie
WOp in PEPUMUISSUANCE RESIDENTIAL
F full five and A rt./� LY
QF-VZ�j Liccnn<1%^ _.{__L_Lic.N a 3.s ❑SFDWL ❑KITCHEN REMODEL
NQW Date Cuntmctr APPLLANCFS-RISIUFITAL ❑ADDITION El PLUMBING RE-PIPE
F,7y ARCIIITF.CI'S DECLARATION PANELS ❑MULdTuNIT []STRUCTURAL
Z p H Z 1 undcuand my plan+shall M usM u pdHic mcrda MODIFICATION
OZ—Q UPTONOAMPS [I INTERIOR 6?[:HIMNEY REPAIR
N�F"ul Lkcnsd Profcaional 1(11-I IXNIAMPS IMMOVLMCNT [3 SWIMMING POOLS
C6 OWRIiH-BUILDER DECLARATION OVER 1000AMPS [I BATH REMODE EPAIR ❑DBMOLMON
Q 1 hereby milrm that 1 em uempt firm the Comrvcror's License Law for the _
ua�.3;i.V following realm,(Sec.10313.Business trialPmfitocanv Codco
e:Any city or umy SIGNS ELECTRICAL ❑OTHER
Q which requires•iarr it to construct that,improve,drnelish,r repair ar,sonde,
F�OJ frinnn its iss—re ,a lm requires the applicant Er such Perminu file a signed gammen) SPECIAh CIRCUITIMISC.
{vvtyy��h That h:"Urenaalpw.uan bntle pruvi.wm"do CumncnNs hiamsc Law lCM1apter9
CSO (commencing with Seetwn]OW)of Divisim Jufthe Hu.ircv and Nofesiom Crde)m TENIP.METER OR POLE INST. COMMERCIAL
a a e C that he u exempt theo from W the hsu fa the alRgcd exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLPHON
-H Section 1`031.5 by tiny applicant for aprnnit subjects the applicant to a civil(melty of POWER DEVICES ❑TENANT El FOOD SFRVICE
t than Ovc hurtlmd&]too($M)(o
� Q cot I.as carrier of the property, em I IMPROVEMENT
❑ Pc Y Y P"Ycxx with wugn an sole cmtpensxem. SWIMMING F(R)I.tiIELTRIC
Sec will alorhewrk.andtM1e svucture 1a,Life oruficrtdfn ii,pl,... 9rerof ❑GIBER
yf—vg eM Pmlcasim Cak:The Canvreras Ixense Iaw,doe rot apply m an wur of OIIILLTS-SWITCHES-FTXNRCS
pmpcny who INAMs or impmvcs therms,add who doe such work himself cr through
his own cmployres,provided that such improvements am n l inur nr offered for NEW RFSIOENTIAL ELECIR SQ
mk.It,havevu,the building or intmocmcet is sold within one year efcompletion,the IIS .FT.FLOOR AREA r'f YI'.
-natMar rill Tuve the buten of proving that he did net build or improve fm Wr-
pFoscneof sale.). D
❑1,ea othe of the property,,l oid ,vdy evnuseung worn licensed eomcon'y Ii T AL: III AUG
conumd the pnnjcct(.Seca]6f A,Rnan<ss and oyvU imo crh:)'Ihc ee loartme. nal - Lg �asrew
se In doenmupplymam with
pmpeny iev beilrlssw improves lhereon.vnd QTY. PLUMBING PERMIT F O S,tJ
who contr uRraucn projecuvirh acmuans.(a)IittnsW puvuot to the Cunr.cror's '
liccmc Ijw. PERMIT ISSUANCE
❑I am exempt under Sec. .R&P C for this reason Cv
AILER-DRAIN&VENT-WAIER(EA) 's' r EUAT�N���
lwrcr
[)at -
0
m -••
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /7
I hereby adBmt mode penalty of Pejmy me of the following decluvions: L
❑ Inaveend will nmimainaCenliica¢orf Comm�uo ulf-instrre for W'orker's Cumpen- DRAINS-FLOOR,ROOF,AREA,COND. Sf0 TYPE CONSTRUCTION
anion,w pmyrdled for by Section 37M of the Who Coale,for the perfrnadee of the
work for which Nis prmoit is i.c LL FIXTURES-PER TRAP
❑1 hove and will maintain Worker's Compensmion Ineurarce,has required by Section
37W ofde La�bor.yCCccoydW�e...ffiporp IN, of dcc of tM wok fnmurywhiniicchh rtchis permit is issund. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP �/`�➢Nf
Carrier:k i4fP'OLyf�e-and Pnlicy.A/MNT Z(J�g�1,- ( `' y�
Policy y Nn.. GAS-lin.SYSTEM OVER 4 UA)
CERTIIgCAIE OE EXEMPTION FROM W ORKEAS'
COMPENSATION INSURANCE; GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION IFPS
This ortim need.h,,completed iftfepemdt is fnare mandrel kell—lS 100)
r Ices) GREASETRAP F9ANCHLCK ME
certify ohm in tic perfumtmwe of tHr work hr wb'mh rhosµor In 000 d,I shill
M employ any pawn in any manner became as In M1ome subject to the Workeri Crnpem SEWER-SANITARY-STORM EA.2IXI FT. ENERGY FEE
oz uim Wwnc(Califomja D. WATER HEATER WIVENT/FdEM
Z O Applicam GRADING ME
h NOTICE!10 APPLICANT.If, it,,mitring this Ccnificatc of Evcmpt oro,you should WgTpq SVSTF,M/IRFATING
a ; become Sema r t,the Worker's Compenvahoo pm t,mr,;of the I.d r Crain.yen,const WATER
FEE
foMwith comply with such pravisionts or Otis Permit shall nd dcetrd revoked. WATER SERVICE
a �
� 2 CONSreisecIONLENDING AGENLY NEIS'RE51DEN11A1.PCMB. SQ.FT. PAID
UQ ihaebyofhnnthat=itrcisumnuructimn lending ugcmylarthe pMnnnarcc of Vele HKCIPIa
0UInework for which Ino.µit i.iawdlSec.3119],Civ.C.)
F-' Kande,',Name AL:
{U Lerh/s Adtlrtu TOTAL:
1 Certify that 1 have read this opplicntim and ante altar the above infommatioo is - BUILDING ME ri
failcorrect.I agree to comply wpm all city and comity ordinances and ante lawn relating to QTY_ MECHANICAL PERMIT F13E
UZ Iwildingcunsamcior.and nertnyaulhaiecrtpreaenrarivesn(rnisdryreenterupon the SEISMIC PER
above-corona t pmpmy for reinsertion purposes. PERMIT ISSUANCE.
(We)agree to ane,inhmanalp har
ndy akeemless de pc
City of Cuni.agilmu ELECTRIC ME
Iiedril'uien,milgrecnts,emus and expenses which may in any way aervc against sad City ALTER OR ADD TO MECTL
in twgrcnewdda rantinguftntsµit. PLUMBING ITE
APPLICAKT U .
STANDSPND ILL COMPLY L NON-POINT AIR HANDLING UNIT(TD 10.1100 CFM) MECHANICAL FEE
SOURCE RFfi CI'IONS. _
</ AIR HANDLING UNR(OVI?K 10,OQ1 CF.M7 CONSIRUCDON TAX
Si tire of cnnVContmmnr [)ate EXIIAUST HOLD(WIDUCID HOUSING MITIGATION FEE
MATERIALS SURE
ill Bic applicant or future Wilding ocupau urc in handk hazadods material HEATING UNIT(TO IM.000 BTU)
as defrrvt by Its,Cupatiro Municipal Code,Chapter 9.1;and the Health vol Safety
C de.Section 255Jp(a)9 HEATING UNIT(OVER I W."BTU)
❑Yes ❑Nn
VENTILATION FAN(SINGLE RESID) PAN
bill the applicant or future buildingecc Date Receipt N
he gain A Wuipmeurildy viceswhich BOIIFR-COMP OHP OR 100.(00 RTU)
emit harsNous air a�ntaminants as dcOrM by the Bay Arm Air thelity M1fawgrncm A
D dors?
❑Yes ❑Nn B(IILER-COMP(UVIA IW,IXXI RTU)
AIR CONDITIONER
Ihvve rand the baoudous nsunalsrrydinmdmu under Chapter 695 N the Cali- ISSUANCE DATE �T
Tania Hrolth& fay Code,S lions 3 505,]S5J3 vol 15534.1 mdowaxl Itw if ole NEW RESIDENTIAL MECH. ,F1'. y '
lommngmr mmOy Aavice arwn ms" Iles my rexfxna'
as which prix rerifytluoccii'm SQ
mua�m faC MO -
•gem Due TOTAL ISSUM BY:
OFFICE