29434 APPLICANT;TO'FILL IN INFORMATION WITHIN RED LINES-USE.BALL POINT PEN ONLY'
CITY OF CUPERTINO .. BUILDING-ELECTRICAL PERMIT NO. //�
t, BUILDING DIVISION. APPLICATIONIPERMITI � PLUMBING-MECHANICAL'- 22A34
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - SANITARY NO. APPLICATION SUBMITTALDATE
1(1 ,
i Zo �ityNs2L s" .. G
OWNE�SNAME. /N HO E: CONTRACT ORS NAM E: 'LIC NO:
•aunt Y cL A.N�-�/ -L7-0&.• •N/C= CON ROL#
ARC TECTMNGINEER LIC NO: A DRESS: ❑
srr s. .� S .1
CONTACT, - PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELE T PLUMB ECH
r - LICENSED CONTRACTORS DECLARATIO ,QTY. ELECTRIC PERMIT FEE LF
I h eby affirm that I am 1 ceased i d p im s of Chagler commencing 70B DESCRIPTION
aZ @S 0 900a)Of D'v' ni of 0heflusi dPro[ession.Cole,andsoIw alis
F4Otl_ in fall f c and effect p PERMIT ISSUANCE RESIDENTIAL f :.
oUzU LatinLic.# `Z - ❑_SFDWL ,• El KITCHEN REMODEL '
N6i Date. Commctnr ! APPLIANCES-RESIDENTIAL ,- 'OADDITION ' El PLUMBING RB-PIPE
ARCHITECTS DECLARATION - ElMULTI-UNIT El STRUCTURAL /
Z C y I understand my plans shall be uaed ue public records PANELS
cZ�F+ + UPT0200Ah1PS ❑INTERIOR ❑CHIMNEY REPAIR
MODIFICATION
Fca[�'.,1qqrr W Licensed Professional - -
G W2,'.�I OWNEFBUTLDER DECLARATION : 201-1000 AMPS _ IMPROVEMENT:: +
C4 CCS 6 1 hereby affirm that i am cocialpf from the Contractors Lic
so L f pre ER IOM AMPS El BATH REMODEUREPAIR El DEMOLITION
a 6 C0 folio g (S ti ]H9I 5 B d Pr ,f .Core:An,,citymy - SIG ELECTRICAL. ❑DTHCR
which ac,citurn t.twelle,l,all, p d 1 I rpa y i mere
�`"vr prinrt 't - I q 're.the ppl if M1pe 'u file.oli d wt ent, SPECIA IRCUITIMISC. -
y Ihah 1 Jp a they fd C 0 0 L n. 1 (Ch pmer9
00 (remounting ithSection 7") fD" 'o 3 of the Business andProfession;Cale)or ,TEMP.MGT OR POLE INST. � � COMMERCIAL�' '
dypJ ea that hes pt th ref nd the basis f Ilialleged mptin Anyviolation of - - -
W N Section]Otlsb an _ WB ' DEMOLITION
y yappl amt permit hl t0h pplwu 'Ip ity of POWBR DEVIC ANT ❑FOOD SERVICE
Zim mom that five hundred dollars($50P,
p+Q ❑'I as Owner of the property,- y employees with wagestheir I pe t n, SWIMMING POOL LECTRIC ^ IMPROVEMENT, _
' e'CI
will do he work,and the r r of alluded ff df 1 (S 7044 Blume'sa []OTHER
"m and Professions Code The Commuters License Law does not apply to an owner of OUTLETS-SWITCH -FIXTUR
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such imp 0. as not intended ff Fed for NEW RESIDENTIAL ELE R
sale.If,however,the building or improvement is sold within oney (completion,the - SQ.FT FLOORxA'RP.A - $/SQ.IT.
Owner builder will have the b4cl n of proving that he did not bu Id nr'maove for per- - 4 .}`vY, '
luau upside). ,
- ❑ 1,as owner of the pr Peny am exclusively contracting with licensed contracts m TOTAL:
construct he project(Sri.7044,Business ad Proressinn Code)'the Cmerson rs U. 151996
use Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING FERMI FEE
who contracts for such projects with a conmracmores)licensed pursuant o the Connector's
s
License Law. PERMIT ISSU
❑.I am exempt undwS ,B&P C for this reraon - 11� OF
Owncr Date ALTER-oRA - A -. - VALUATION
WORKERS EN
COMPSATION PEEL ARAf10N t BACK FLOW `
I li eby R" u d pn O -perjury FC f 11 ig Aecl t m ' f s
pith and 'll to C tf 'le fC rt elf msu t W kers Compen- DRAINS-FL (ft +
letinn
sation provided f by Suction 390 of theLbs Cade,fortheperformance of.the eQI COaYLMEN s TYPE CONSTRUCTION
_
work for which thispermt is issued. � FIXTURES- r., l '1'�,jG �i
l i nave and will maintain Worker's Compensation lnsurancr,les reyuired by Section ,tt
370 of the labor Code,for the perfonnanceof the work for which this pown't is issued. GAS-LA.SY SftaT s
My Wory�r Cele �aliou lnsur�nce curl road Pollc �yifycrO OC .GROUP _ .APN
Carrier:/CLYVO L IL) Policy No '/Jr��SA y`�Qg CAS-EA.S ) .•. •5
rCERTIFICATE OF EXEMPTION FROM WORKERS" - GR[iASFIIN- 5 PI'O
COMPENSATION INSURANCE BUILDING DIVISION FEES
section need not be completed if permit is forest hundreddoll$rs($100) GREASETRAP unless.)
�• - PLANCHECK PEE '
I cemfy that in the performance of the work for which thispermit sued,I shall SEWER-STEL STORM EA.
not employ any person in any manner so as to became subject r rhe Workers'Compen- - ERGY FEE
Date
O Applicant - WATER HEATER W/VENT/ELECfR GR I
action Laws of California -
lin NOTICE TO APPLICANT:If,shellacking this Certificate of Exemption,you should WATER SY _
abecome subject m the Workers Compensate.Prov sions of the Labor Code,you must _ SOILS E
W forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
Q '
CONSTRUCTION LENDING AGENCY
NEW RF,SI 4 PAID
I hereby th rte s.su nSe m' lending agency for the performonue of to Receipt#
the work for whah this Permit :issued(Sec.309],Ciw G)
O F•t Lender's Name • TOTAL:
{U Lender's Address � ' TOTAL: sy -
r}�t ..I certify that I have rood this application and state that above information is BUILDING FEE
!r (yf) coma.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V tom. building construction,and hereby audtorize repmsemwives of this city Inept,upon the _ SEISMIC FF,E
above-mentioned property for inspection pmposes.'^ PERMIT ISSUANCE OVO)agree to save,inddan ly and keep harmless the City of Copartner against - ELECTRIC FEE
liabilities judgments,costs and expenses which may in any way accmeagainst said City ALTER OR ADD TO MECH.
In consequence of the granting of this commit, z PLUMBING PEE'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT AIR HANDLING UNIT(7010,000 CPM)
SOURCE RE I fAT10NS. - .s MECHANICAL FEE-
[/�/❑{�7� O AIR HANDLING UNIT(O VER IO,O130CPM)•t . CONSTRUCTION TAX
Signaling oiApphcant/C rectum •Date EXHAUST HOOD OVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE .
Will the applicant or fpmrc building oceupantstore or handle hazation,material HEATING UNIT(TO 100,000 BTU)
as defined by rhe Cupertino Municipal Code,Chapter 9,l2,and the Hea th'sn l Safety s .
Cede,Section 25532pr?, HEATING UNIT(OVER 10D.000 BTU) ,
El Yes +^' •" VENTILATION FAN(SINGLE RESID) PAID
` Dam ffiethm#-
Will the applicant franc e,debated lam use e.Air t J cls which BOILER-COMP CUP OR 100,000 BTU)
mitnct?. Ius aircemani na t I debated the Bay Area - Quality Management A' +TOTAL:
DisticP' s
-' ❑Ycs f s BOILER-COMP(OVER 100,000 BTU) •
I have lead me hazard' tedals req ' nc under Chapter 61.9,5 of the Cali- AIR CONDITIONER, - ISSUANCE DATE ' -
Jumbo Health&Safety Code Sections 25505 2553] d 25534.I understand that illhe NEW RESIDENT
MECII. SQ.PP.
build ng tl e t my h t rant that r y fQp ns bidiry r notify tit occnp n, „
of in myuutre t hick most be met priorm uace faCen�
,•`OwrMonzed o6enr / t�/Dlllliite- TOTAL: + 9SSUEDR
Jhboyr
OFFICE.• . ,
Inspection Query for a Specfic Permit 4/7/97
NEW-i
RMIT. 199 1 S S EEMM WAN U' ESI to• a
9434 19320 IPRUNERIDGE MECH-R 3/18/96 3/18/96 CC 2�P
9434 19320 IPRUNERIDGE RGH FRAME 3/22/96
943419320 PRUNERIDGE RGH FRAME 3/25/96 3/25/96 CC 2P
9434 19320 PRUNERIDGE RGH DUCT 3/28/96
9434 19320 1PRUNERIDGE IFRAME 4/1/96 4/1/96 CC 2P
9434 19320 JPRUNERIDGE UNDRSLBPLBG 4/1/96 4/1/960C 20
9434 19320 IPRUNERIDGE UNDSLB ELECT 4/1/96 4/1/96 CC 2P
9434 19320 1PRUNERIDGE SHEETRK SCR 1 4/3/96 4/3/9 ICC +-2P
9434 19320 PRUNERIDGE SHEET SCREW 4/8/96 4/8/96 CC 2P
9434 19320 PRUNERIDGE FRAME 4/9/96 4/9/96CC I 2P