99090188APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY V o 1-�-A�—
CITY OE CUPERTINO BUILDING - ELECI RICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
I ItU11DING 1'ROd EC'f IDENTIFICATION
PEkM19' NO.
BUILDING ADDRESS
v�QE Wis
SANITARY NO. A'PLICA'1'1U. : A'I
t M13 I NE.
N R'S N.�AMcll: PFNIi: ��
U T �I' ii NAS : LIC
NIC
❑
CONIROI.k
ARCHII'EC'1'/ENGINP.ER: LIC NO:
D) ISS: (416D
TI",
CONTACT: PHONE,
DU ILDING PERMIT INFO
❑ Consultant Fees ]laid By Applicant (Initial)
BLDG ELISCI lilIJiB METCH
❑ L�
LICENSED CUNT RACIOR:S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chi 9 (emmnrncing
wid, Section 7000).f Division 3o1 the Rader_ and Prult,, a, Cale, undo, license.,
in full force cad elfr•w _
Lice, lav V I.I,.M
_
Uam Commcmr
QTY ELECTRIC PERMIT FEE
��OZO
F m •
W'UF'
GZU
C W�
7h
� m Z
Z!,
Rj�li]
C Q
�aU
'U.N
�5
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
CADDITION ❑PLUM111p:GRF.mpii
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ I3SE I I REMODEf1kEPAIR ❑Dh 101,ITION
❑OTIIISR "�' _ lZ•
PERMIT ISSUANCE q
`�"� �
APPLIANCES-RF'_SIDENTIAL
ARCfIITECI'S UIiC A UN
I imdemm�A my plan. nkJl be n.wd as public record,
PANELS
UPT0200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby allirm Ihe, I am xcntpt from the Cuntrucnrt's License Law ter the
following re.vand S«t 7031.5 LBusiness and l'mfcs,ion, CaMAeyciD oreard,
which rcyuire, a tenon In condloci. aper. Improve, demolish, or repair any structure
pon I I .: 1. i he pprc tfor-Ill renal 1.file. lillmd lamerearlit
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
r
at}
Cmontmaneng
X o C
ESQI,u,
1 m
that lie is licensed priplantl the provisines al the Contrartur, License L (Ch par 9
asilh Secitn]WO)ofDivision 3of the Bur:nuss and foregone Code)cr
that he Ls exempt therdrom and the basic for the alleged exemption. Any violation of
Section 911315 by any applicant cur a permit snhjene l he appliper man vel,a,rAI,of
un e, thin live mocaleddollars($500).
owner u(ILa pngmny, ur my mnpinycc, with wngcs ns mcireolu mngtcn.vudnn,
k. and thtructuis not oroRemd for .sale(See 7044. Business
will Jo the work, the re m
an I Pree,in is Cale:'I he C'ontractor's Liee,oe I.aw does a,), apply at an owner of
pro,say who builds or improves Ihemon, and who does such work himndf nr though
his own employees, provided that such imprnvenmms are no, intended or offered for
site, If h the baciffing or unproverevent is sold within one year of vorindefion.lhe
Id will have theburden provingfthth JJ th IJ p f pan,
'I EM P. MET ER OR POLE INST.
COMMERGIAI:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT El FOOD SERVICE
❑OTHER
(- `�"""'� •-��--�.�e
POWER DEVICI?S
SWIMMING POOL ILECTRIC 'IMPROVEMENT
O
OUTLETS-SWITCf1ES -FIXTURES
NEW RESIDENTIAL ELECfR SQ rL
)' e,1 A I I F
I SQ.1 I IPLOOR ARITA
t$ISQ. I'll
F"h
r, " Fl f Ihp M1Y <IcIY <Imng 'm licensed c m nn
SEP 2 1
999
TU1'AL:
ciresirmith project (S 9044 Business IP le Ciel,) HConuaelar, L'
f
seLadow, notapply t f pro,wity who M1TJ: of -ourselves thereon. Paid
QTY PLUMBING PERMIT FEE
who cmumu,forechpmye,wof, .e+tlranonU I'reelpu¢ou ittuno, Contmuan"
�t
PERMIT ISSUANCE
License law.
em acm num en oe.
I I S .Bic PCrmmisremon
1
L ��--
"""--
--�'—
ALTER - DRAIN h VISN I'-WAI'ER(EA)
ncr Dom
VALUATION
p
]s CSO
WORKERS COMPENSATION DECLARATION
HACK 17LOW PROTECT. DEVICE
I hereby affirm under penalty of sejury one of the following declmctione;
[J J O
DRAINS- FLOOR. ROOF. AREA, COND. 3,
❑Ihavaand willlnnicamr.CcniGCmenf Ceownnamlf-insnrc for Workuv Cooper-
scion, as provided lin by Section 3)0) of the Lads, C+de, for the performance of me
STO IILS
T) Pir CONSI'RUCfI(
FIX'I ORES - P17R'IRAP
work for which this panni) is issued.
I have unit will rearnan Worker's Compensation ho rnme, as required by Section
39 )of me Labor Ctde.Fortheperf,,rnar,rtf the walk for
^wihijchl this perrin, iseuN.
-Z
My Workr,{{GyNlpel xyQoq lnnePolicy
GAS - IiA.SYSIEM-I INC. 4 OUTLETS
O[C.GROUP
�PN
Currier: LL�LII �I FY No.:
CfiR'fIPICO DEISAI[ON INN PROM IiRS'
GAS- EA. SYS' I'EM-OVER 4(EAl
_G
T
COM PRndete ON INSURANCE
ANCE
(This action need not becmutlemA i(me rynnit is forms, hundred dollars (311101
,it less.)
GREASEINUUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION PEGS
GREASE'I RAP
I'hANCHGCK P[F.
SIiWIiR- SANITARY - STORAI EA. IT
0Z
Z
a,
0
Uz
C. pactshal-
Iramify that in the perforanyrmvncco as
walk for which this thepernalWorkers
not employ any person in any munncr m as m Notice whjm m the Workers Compact-
,,I'll 0 Lawn of Call l iani:n Date
Applicant
ISNERGV PEiT.
WATER HEATER W/VENODELECrit
GRADING FEE
N0'TIC17 10 APPLICANT: 11, allcr ranking this Cenhicmc of E,minpdom you should
become adrer. m In, W..lees Cmnpensatien pmvisimn of the LP Code, you orad
tinmwidt comply with inch provisions or this hermit shall be deemm mvohel
CONSTRUCTION LENDING AGENCY
WATER SYSTEMITRP.ATING
SOILS FITH
WATER SERVICE:
PAID
NEW RESIDENI'IAI. PLM1t. SQ. FE
I mrtbmlherc issued(Sec. Cm, ugencyl nheperfonnonce or
Ulm RecciplM
Fthe
LI.
for 301 ,
work Nor xhich this permit is issued (Sec. JIH9, Crv. C.)
lander, Name
'rIYfAL:
-
Q
Lendds Address
'TOTAL: 43W
F0.
OZ,
Z
1 celery that I have rend this application end dam Iflat the above inhnntmfon is
huilAing con, ucuon.:md hereby uuthorivc rep gcnWives of avis city menmr upon the
ab,momentimod prTeny for impaction purposes.
(We) agree to .save, indemnify and keep hent mind e City of Cupertino aga
BUILDING FEL?
QTY MECIIANICAL PERMIT FEE
SEISMICITiB
Plik Mll'ISSUANCE rnrn
�J .Jv
ELECTRIC FEE
liabilam,judgmmF¢,codsTold TMP whdbutrynclay wayar,em agairo avid City
in cat tce4ucnec of the griming of this permit.
ALTERORADD'TOMECIL
PLUMBING FEE
AIR HANDLING UNIT (TO I0.000 CFM)
APPLICANT UNDERS']ANUS ANI) WILL COMPLY WITH ALL NON -POINT
SOURC"1 _IULAI'IONS.
1
MECHANICAL ILE
AIR HANDLING UNIT (OVER II1.gp CPM)
/} -
Pi0-'I
CONSTRUCTION TAX
Si, nu c Apphwnt/Connumo, T;a
IIA9ARDOUS MATERIAL S DISCLOSURE.
EXHAUST HOOD (W/DUC )
HOUSING MITIGATION THE
HEAT INGUNIT('1'OININ)0RTID (.f,O
Willtbe applfaamor future balldin Ose,upradineor handle hamNouc material
a, definW by the Cotentin,, Municipal Cale. Chapter 9.12, and Ibe []catch and Safety
ock. Semon 25532004
HEATING UNIT (OVER I00.000 BTU)
❑Yes 0 N
PAID
VENTI[.AT]ON PAN(SINGLE REMD)
Date Rneipt n
Will thea applicant nr fat tiro hit IdiPi nacu quipmcn
Pt g eBaywc un des
mit hmarJnur air nrnmminnnn u. defined by the Bay Arca Air Quality Management
Himarim'
BOILER- COMP CHP OR IOO.gp BTU )
Yes
❑ C1 No
TO
BOILER-COMP(OVER 100,000 BTU) �a,a
AIRCONDITIONER
L
I have read the numerous nmlerials requirements under Chapter 6.95efmc Cali-
I'nmin IIrnINM1 S tie! ly Cafe, Sen +m 255115 5533aoJ 255311 umkmvnd mat i(me
y1 ry nnnl.m nmyrerpntnl eirti Mond hCuc Cy"
of me requi ter yJf%p. � s,Npy�iu tssuanccyfx CenidicrlUco�cypayCg„
ISSUANCE DATE
(//I ^ I� 0
7 % T
NIiW kISSIDiSNTIAL MIiCI 1. SQ 1T.
ISSUED BY: