99100044 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRR'PINO BUILDING-BLECI'RICAL PERM'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BIIILIHNO PROJFICr IDESI'I eicATIoN
BUILDING ADDRESS; SANITARY NO. APPLICATIONSUBMl ITA.DATE
w�lYNoaoi PP,R►sh PI . d - �-9
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1 1 11 1 ` NIC CON'1'H(11.M
ARCHIGE1'117 Mil Ip!it LIC NO. tiA) ItIiSS:
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CONTACT.. PHONE. BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BIDO ELECTPLUMB M17CH
❑ ❑ ❑ IV
LICENSED CONTRACTOR'S DI!CLARAGON QTY ELECTRIC PERMIT FEE JOIE DESCRIPTION
I hereby affirm that I am Iicenwil under muvisimns of Chapter 9(comnmmcing
�aZ whnS...iaa]0I10)afl)ivi.imfi lethe Busim,,mm! 'rofes.inm Comated my licence i� RESIDENTIAL:
LL]pp - I'IERA111'ISSIJANCI!
�V~ Lifull cenna'n'easldi I. � L11 A ❑tiFDWL ❑KI'ICHLEN ItIiMODIEI,
Q U APPLIANCES-RI!SIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
gzw Dale Coma I'll MULTI-UNIT ❑STRUCTURN.
F y ARCIII'IECT'SDECI. A'IION INNEIS
m Z 1 underswnd my plans shall nc u.wJ us puM1lic rttmJu MOOIIICATION
CZ-o UPTO2IHAMPS El INTERIOR ❑CHIMNEY REPAIR
F4t0 Licensed Prcdcxxional 201-uXXIAMI'S IMPROVEMENT E]SWIMMING POOLS
yQrY�j OWNERdtU1LDHR DECLARATIONOVER IIXXIAMIlS El BATH RfUODEI/REI' k DE El
C 1 hereby affirm that I um exempt from the Contractor's License Law for the
X6 p U follnwing m:uon.Notion]11)1.5.Business and 11 111..lonx C'odu:Any city m cnunly SIGNS 1!I EM RICAL ❑0'1'.IER
which I m construct.alter,ire demolish,on repair any Samsun
h mymrcs u pcnni ptoses
prior o its iswaacc also requires the applicant for such permit to rile a.ignedemmment SPECIAL CIRCU IT/M ISC.
malee,,I Jvmoant to11 1 I' ( I 'nl ILh:mler9 COMMERCIAL'
��oo (cote s 'ms ai ]aHl n)' e f In
6 tLa that h pt m of nJ Ih b f d + p e t' t et o_ ❑NIiW BLDGIADLUDON ❑DE OLHION
Scalon]031.3 by any upplwnl hrta Men bjsWnihu 4vlpsnelly ol4 PO R
VICES TENANT Ll FOOD SERVICE
FZY
no more thanf hundred J11 :($500). L 11' )VLM17N'1
=Q ❑ I of the p l�edY Y em III g:a r: Ic MI 1:1 TRIC
:IId d k' 311 1 1 ri' 1 t IT Itis S 413 n O'
~� o LOU 'EIA
-11 LIES
a3� dl r . Code: tire c 1 1 1 I J t 1yt
p openy ithold, improve,In In g
hN pluycc........ded Thal such ,it p 11 rl m' J dlcrd Inn NEW 'IA.ELLCTR SQ 14.
ode.Lhowevar,me building or impmven¢mizsuld within oncymr of completion,Ila: .IT.MOOR ARRA ESQPI'.
.
awnet builder will have the burden of proving that he did not build or improve for pur-
poscaf Indic.). 'TOTAL:
0 L as owner ut the property.ani exclusively mnlracting with Rezoned conlmctnn ei
construct the project(Sec.70L1.Busirmss and ProRssions Cove:)I Ow Conlmemr[LI-
wLewdoos nm apPlyne-o,net of mu,ny who neildsur improves mrr:ur.and QTY. PLUMBING PERMIT FEE
who contracts for m it P oieclswithacun1,;,c lxl Iiecnscdpursuant o,be Contracts,
Lwtrsw Law. PERMIT ISSUANCE
❑I an,exempt under Sec. ,B d:F C for lois Lemon
�
ALTER DRAIN&V I!N'I'-WAIT (HA) VALl1A1'ION
wner, Dam q
WORKERS uAl,oCOMPENSATION DECLARATION SACK PLOW PROTECT.DEVICE ��J• �O
1 homl w llLna mWct pcoahY of pI fClry one ul tau Iolum ng Worke,tiuns
❑move prov idll main by eQ•ni 3700 of"the I,auoCodc.sure ter Wmkcrscc of the
ERALN$-Fl9f)R,RWP.AkIiA.COND, S'TORi1' 'fYi'Ii CONS'18UC'1'[ON
cation,as pn,viJeJ for try Section 3]IXl of the IaMsr Qdc,for me performance of Inc
ata A f or wblob this P':nnit is isxlmA. PIX'IlJRHS-PIER TRAP
1 bmthand will ode.au Worker's ante inion rkfar mc,h i%Fro by Sssued.
3]1X1 of the l,aMa Cde.audit,performance of Lite work ran which this pemlil it issued, GAS-IiA.SYSTEM-I INC.i OCILISfS OCC.GROUT' AIN
MyWorks. hCoi mJnsnrnrecenrrter: If poliry.lY1}nhLl'/R)�Ib�s GAS-IiA.SYSI'ICM-OVI!Rd(IiA)
Carrico /Gel �� 'Put,Nn: (J4'
CERTI1gCAIL017EXEMI7I0NI'RObIWORKE;RS' GRHASEBNDUSTRL WASTE INTERCEPTOR
COMI'ENSX1 ION INSURANCE BUILDING DIVISION TEES
(Thissedionneulnol he completed it de,mial is Bonne hundred Jnllara($1(X) GREASE TRAP - -
PLANCHECK 11313
kgs.)
Iocalyoymn,that in the perf rmm�ccoi theoleO he,unncohork for jc Oofl mlil.ko,Con,
a1L SEWI!R-SANITARY-5'TORM F.A.200 17.
nnlcmplay any ponos In tnY scanner pu usm MtvmlcmM1juuuthc Warkeri CamMn, ENERGY ITE
Z smiort lawSof C.Idorm..Dae WADER IT EATER W/VLVT/ELECTR GRADING FEE
zApplicant
N N(H ICE'fO APPLICANT..It,efmn making Ili,C'cnilicme of 1�mtpnion,you ehouIII WAI'Bit SYS'L'ICM/TRIIA'IING SOILS FIJI
FMeame subject to the Workds compensation pmvi.dons of the WMn Code,you mato
a tordo,ire comply with Inch pnry%ions or this permit shall M1e deemed mvokcd. WATER SIikVICE
I'
NEW RESIDEN'I[At,I'LMB. SQ,ET P to
'U Z GGNSIRHCIIDN LENDING AGENCY
hereby affirm that tbem.is a consoccon lending agency for the performance of 'nl Da ^lam -Alttipx,��
Uthe work l or which tors peril ie' 1ned(Sec.3097.Civ.C,) jUl1 V_\\ �1'O'I'AI '
'VS U LoWers Name TO IAL:
LcndeJ.AJJress IBUILUWG'PEE ' �I
1 ceaity that I have rend .ane This apPllcan oll hnd oral Lite above information is C
Fe rn cotrcct.I agree to comply wits all city and county ordinances and ease laws relating to QTY. MIECHANICALPF,RMI'F FEE v jyy II 1�
IiISMIC IlE13
L)Z building construction,and hereby authorize wpecwnratives ofthis city to enterapnn the /
uhuvemenliunal property for inspection purpows PP.RMT ISSUANCE ELECTRIC FEE
(We)ogre ,,save.indermiry and koep hamless the City of Cupertino against o n
Iiabilinesjudgmenn,enSls and expenses which may in anywayaccmeagainm said City ALTER OR AUDIO MECH. MBIN
m con,,pon,eol The gumtie of Thin punnit
rPI'LICAN'r UNDIERS'TANES AND WILT.COMPLY WITH ALL NUNR(JIN9' AIR IIANDI,ING 0341'1'([)III,(IIHICPMI MI3CIIANICALI'I!li
S (IRr IIy[..'S�'.ULAI'IONS. (,
O�,L _ 1 ,I!)p AIR HANDLING UNIT(OVIiR IU,001 CIM) CONSPRUCr10N'I'
�ApplicunVCommcun >a7 -1 EXHAUST II(IODIW/DUCT) HOUSING MITICAIEIi
HAZARDOUS MArERiALS DISCLOSURIi
WIIlmcappll,minr litmc hmIdingoccopmn slnmorhandlc 1111.111"L31mntedat HIiAi'ING UNI'P GO 100,000 BELL
as defined by the Caveman Municipal Code.Chapter 9.12,and the Health and Safety HATING UNIT(OVER 100,000 BTU)Section 25532(.)'1
p YO, C]No PAID
VIiN'1'ELATION PAN(SINGLE RIESIDI Doc Ncreiptp
Will the applicant ur furore building oecu ant no,equipment or desires which BOILER-COMP(3111'OR 100.000 BTU)
n,it hannluue air conmmin:nnS as dclinod by me fiat Arca An Qaamy Management TII IAI,:
DiWim^ BOILER-COMP(OVER 100.000 BTU)
❑Yes 0 N
I have lead the heart material%requirements under Chapter 695 of the Cali AIR COND1'I'IONFR ISSUANCE DALE
hsmia Health.@ Sultry Caie Sections 25505,25533 and 25534.L nmleraand that Bar, NEW RESIOIiNT1AL MECIL SQ.Fit
M1uilJi ' talo unlly1, ut ton Like 11 iv uty aropon.vihilily mnuami l'y the lsatpam
Jihe requ�c - n 1 na 1 t m ivsnvncu of a Ccnif at OYc'up�
O au IT r 1 agent /)ale TOTAL: ISSUED IM �O
i OFFICE