30155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 r^
CHANI CAI
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30155 O 1 S V
BUILDING DIVISION APPLICATIONIPERMIT PINGPROJELUMBING- 1 IDENGOICs 3
BUILDING PRf1JELT IDFNTIFlCATIUN '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
qGOWNER' - PH @ CO ACTOR NAME: r LIC NO:
NIC CONTROL#
NBC HI'rECUENGINEEW. LIC NO: AD RUSS� ❑
CONI'A�Cj�1P` 1 PHONE El ❑BUILDING PERMIT INFO
❑ Con Bl ant Foes Pell by AppB art(IBI[ep BLDG ELECT11LOMB 1:1
LICENSED CONTRACmRS OECIARAII QTy ELECTRIC PERMIT FEE
p T herby amrm mm I am Ikea,1 ander,o,kom.��r c amR 9 onlroc la, JOB DFSCRI ION
1 z wiN Satim](MXH of U'vision3afJc Huitcu od F'rvfasion dc. my liecmeia
Iy0 RESIDENTIAL
1- in full farce nM cD PERMITISSUANCE
QF-UZad U Licensee u I.ic.N OSFDWL OKRCHFN REMODEL
NQS Dam Cmmracmr APPLIANCES-RESIDH]NTIAD DADDITION [_1 PLUMBING RE-PIPE
ARCHITECPSDECIA PANELS ❑MULTI-UNIT OSTRUCTURAL
IZ[O-i2Z I uduleraland my plass,a h+11 be usertN+
d U Public cvMODIFICATION
OL.—O UPTO MAMPS ❑IMERIOR ❑CHIMNEY REPAIR
F.N.FW livnr iPmfeulunuL. XIII-IIIWAMPS IMPROVEMENT
g OWNER-BUII,DIHt DECLARATION GVHR IOOOAMPS ❑BATH REMODEVRFPAIR ODENOLfIION
u
Rf 6 1 hereby uflirm that I em exempt from the Conlrulo(a License I.w for the
x6x 1 U following dmsan.(Secuon 7031.5.Business end Pmlenan Cede:Any city or eVanty SIGNS ELECTRICAL D OTHER
W 3 LL y which oc toacs a permit to ctn,buct,dim,oan,,c ,dranab,h,or rc air any atowtutc
FLLO¢ Prior to its usuarce,also rtyu ims the applicant fnr.ouch permit to l i k esigttN oademcnt SPECIALCIRCUITMISC.
f RPjY tion be L.IicetwalW(slun11.the pmvi.cam of the Contnnvr'.Lunde U.(Cluper9
81tal
00 (conmcncrngwnh Salim]IXIO)ofMvisian3of Jc Busirca Pmfasiom CM)m TEMP.METER OR POIF INST. COMMERCIAL
a e c Iha he is exemp thertftnm vW the Paris f«ted alleged cxenFo..Any vtolnumn of 0 NEW HLMADDITION ❑DEMOLITION
�0 Se,inn]0315 by any applicant for a permit subjects de epplleant to a civil penally of POWER DEVICES OTFNANT OFOODSERVICE '
rtd more doer five huodml dollars(55m).
QDI,tB owner of the proll a any employ.with cages as their sole condpcttsuioru SWIMMING POOL ELECTRIC IMPROVFJMEYT
will do the wmk,end the rmcrurt is mt intended or offered f«ole(Ser.](W,BLOOsSs D OTHER
3 m and Profico,f.m Cod, TM Cantrmutr's Lkerto L.duce not apply to va owmr of DUE'LE1S-$WD CUES-FIXTURES
ti popery wits,builds or un,vi lenses,end wto docs such wait himself«through
his own empfoym,povidd that such improveorents me not into•-'or offered for NEW RESIDENTIAL ELECfII SQ ET.
ole.IL fawner,the boiming neo uvernendk WM willan one ycu ofcomplcoon,the SQ.PT.FLOOR AREA vSQ,FT.
mrbuilderwill have OclwNen of proving that Mdid not buil)«improve forpur- re a
D I,uowrter of the Se,7 ,amnda.sly xro flew ire with:)The Cc91�L .,, m TOTAL
anidous the,,t not (Sec.o too Blamer.and oywh i cui Cst , The Co hoo,or'a LIQ
u Wwdocssuch lylnun rousernfprofens who Forstmann
themcrrm.and QTY. PLUMBING PERMIT FEE JUL Q91996
Llee.. Lovv.r«ales 1xoXets with arantmClmt=)Bates pLnLentmthe emdrrertors
Ld¢me c.ca PERMIT ISSUANCE
D lam exempt uttrrSa. ,B&PCfor thix rmvon CItY Ur laDYr-_.
�(7uncr
Dart, ALDER-DRAIN&VINE-WATER(PA) -.•VALUATION
WORKERS COMPENSAT1 UFCIARATION BACK FLOW PROTECT.DEVICE
tI1 berebY affirm uncl'.1r,Of perjtvy arc of the,the,following deelonktrn:
Mve vd will mainuein a CertiRcwe of Enema uuelf-imurc for WoAcr'x Cortgam DRAINS-FLOOR,ROOF,AREA.CON'D.
os pov'tJnl f«by Sarion 371X1 of the Labor Code,f«ted perf..of floc STORIES 'TYPE CONSTRUCTION
f«which thu pemut is tvsuM FIXTURES-PER TRAP
0 1 hive and will maintain Worker's Cortpcmarka Inwrana,as de9vitcd by Swim
3]IXlof Je Latnor Code Mpaformame ofihe work for which his pandit ix msud. GAS-EA.SYSTEM-1 INC.4 OLICUS
My Work ,pts Cln r ecvrter mrd Pot
OCC.GROUP AI'N
Cvrticr Policy N �T � GAS-EA.SYSTEM-OVER4(FA) -
CERTIFICATE OF EXPMPfION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
it t
(Hdis.rn,itn ad not M cmdplcrcd ed prnoil isfar cede MttJml MI.(SI WE BUILDING DIVISION FEES
or ka,.) GREASETRAP PLANCHECK IFF
1 cenifythm in the perlarmnme oftie workf«which this Fernir is issued,l NdI
SEW CR-SANITARY-STORM E.A.200 FT.
cal employ wy pL'rt0^in any menrcr w u m bc«xdc subjct to Ilse W«4rn'Cmdpcn- ENERGY FTI
O Z .ours Lawn of CaIlGrmia.Ilam ` WATER HEATER WNENT/ELECIR
Z O Applicwt GRADING FEE
h NOTICE TO APPLICANT.If,after fordo,this Cenif.of Esecof you should WATER SY.SfEMrtREATING
abcune subj«t to the W«Lela Cortrfcnotian pOv,miona of the Ialtar Code,you must SOUS FEL
W f«tbwl a comply with such larviaam nr Ihia parrs eM11 be Jcendd revoked. WATER SERVICD
Q
5Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
I hereby Mfmm the rbert iaacomummim lcding ageayf«ddc perfmmndce of IAIe RcaipdN
lU� Nn work for which tbfs permit iNsod(Sec.309].Ci,C.)
Q U I-carl N. TOTAL
I<dc(aAdana
S 1 certify btu I Mve mad this applicvim tad Nate Wu the shove Information is BUILDING FTE
to correct.I agree to Imply with all city and courtly ordimnas end stale lewa relo6ng m QTY, MECHANICAL PERMIT FEE
V Z building anstmct'om,and hereby authonte reprea senutivof thio city to enter upon the SEISMIC THE
r "Nave uremia lampenY Err in+pmion lauryoa.
(WO asev.idermify: keep Mrnku doe City of Cuirarcm ageimtl PERMIT ISSUANCE E- CTRIC FEE
Iwbilirics,ju amu,ca avml cxpcnsn whkh may in bay weyanrvc ac eta said City ALTER OR ADD TO MECII.
in caSrym nflM ming of titter pcmdil, PLUMBING PF.E
APPLICAN UNDER TANDS AN WILL COMPLY WITH ALL NONPOINT AIR HANDLING UNR(TO 10.0(a CPM)
SOUR GUu INS. MECHANICAL FFE
_ 6 AIR HANDLING UNIT(OVER IO,"CFM) t CONSTRUCTION TAX
Sigmm prl' i e EXHAUST HOOD(W/DUCO HOUSING MITIGATION PEE
H IEDOU MATERIALS DISCLOSURE:
W1l the applicant or future baiMing occupant If=or handle harardvus material HEATING UNIT(TO I OO.fpO BTU)
u dented by ted Ctf im Municipal Corte,CloWer 9.12,and the Health end Safey
Code.Section 2553](eyt HEATING UNIT(OVER IFIL M10 BTU)
0Y ONO VENTILATION PAN(SINGLE RESID) PAID
Date Reccipt0
Widlted eP confalerr Puts a building by the Bsea:eat Aur anlmd Maottwhich BOILER-COME'UHP OR IW."BTU)mit M'uadwdx unumiNmts as dchrN by the Hoy Arte Air(JuJily M1tanegemrnt TOTAL:
UartmP BOILER-COMP(OVER M"BTU)
❑Yes ON.
IMve the Fw drarmnlcrod'ONEuira.'. Chapter 6.95 of be Coli- AIR CONDITIONER ISSUAN E
` forma Hedda Safer C Sections 5.M533 toad 255X.I oMcravd that if the
tuiMute a Mvctdmml. iI rapansiodirY ro raufY tic oampt« NEW RESIDENTIAL MECH. SQ.FT.
Ofdlcroqui mmiuwna Me ifrcu ry.
Owar«ewhorimd agcm de TOTAL: ISSUED BY:
OFFICE