S 0583 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.MECHANICAL S O
BUILDING PROJECT IDENTIFICATION
583
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAR
,14-97
OW ER' NAME: PHONE: CO A I SNAKE: LIC NO:
S x N/C CONTROL#
( ARCHTIIC
II' GINI:L'R: LI No: AU RESS
� : ❑
\ W yu-��& i FT
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cowu11BBT Fm Paid by Appy[(INriel) BLDG Fr ECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECFRIC PERMIT FEE ❑
1 hereby affimt that[am licensed um I ,visimn%of Chapter 9leommercing JOB DESCRIPTION
OoZ with Serion 7")of Division 3 m lk Busircuvd Rote w•Cede.and my licen•c is
WOO PERMIT ISSUANCE
Fp� — in full force e----� tl Cr� $IUR'1. ❑KI'fCHI'.N kIJNODIiI.
QU5~j IJccnm Cln I:Ic.x - s APPLIANCES-kESI1)ENTIN. ADDITION ❑Iy.UMHING RE-PIPE
R.Zd6 Dam Contracmr
tF-Dh ARCHITECTS DEC LA TION PANELS ❑MULTI-UNIT ❑STRUCNRAL
ZOr�Z Itmdarwaml mY A.%ball ba uruda•'blic records MODIFICATION
OZ—O UPT0110AM11PS 1:1 INTERIOR C]CHIMNEY REPAIR
u1 IJcrnwd Pndessiovl 201-1000AMPS 1MPROVENIENT 0SWIMh11NGPOOIS
OYC G 1 hereby alfinn tllatN OWNER-BUILDER DCLARpt mE heCantrx5el,Littnse for the OVER 1000 AMPS TION
[I BATH RENO r F 1
X6X06 U following reason.(-Sacrum 711311.Hosinnas and professions Ctde'.Any city or county SIGNS ELECTRICAL ❑OTHER
LJ a R.yEa' which reyulre%a pennh to coMrxv L alter,impnwe,dartollm,or repair any soma,mm
F'LLOJ priormits icuenux.il•o rcqubcs the upplirAru fm.such pcnnit to filcadgrcd sWcmcnt SPECIALCIRCUITIMISC.
f�} than he is littnsed purowom to the pmv""niom N the ClmlrMlN.Laceose I..HCTuprcr9
(com.ing wi m See t ion 70000f D,vi siw 3ofmc Heti sorts and Praftsom,Codc)'r TEMP M BIER OR MILE I NST. COMMERCIAL:
6 p.o y mm he is eacmpl therefrom vW the Iasis for the elkgN exemption.Any viclmioo of ❑NEW BLDOADD TION ❑DEMOLITION
W-4th- Seetion]0313 by whyappticam Tara p:mut auhjc,D the applicant to a civil penally of POWER DEVICES
g more Nan fist,barrel lS5oo). ❑IMPROVANT [3 FWD SERVICE
FZ} m OTHER IMPROVEMENT
6 wi Las ownernflhlthexi ermeors.imeyeeswithw'egexax le(SCc 04,1,Brarian, SWIMMING MI(Ih ELECTRIC
O
will do Newaes,Ccdc TheCareiafor',Use.
does mapplyI mr slier % ❑OTIIER
6 3— amt Rnfevss,b Cotle:Thee,es,lClrala landve<iswdaa rtvmrx hiralfur rcrM OfI11.FTS-SWITCHES-FIKNRES
— prape„r who built,,m impo•t,e Ih[reorl,am was does such work nimaev m mmugn
his oven employees,pnwided tel such imPnwt,menrs ere or imerukd or offered for NEW RESIDENTIAL HLECIit SQ
satc.If,however, be Wildingorimprtverreal it sold wlminunc yevufComplelio t,thu SQ 17,FLOOR AREA SISQ.FT.
now. will have me burden or pmving Wm he did son Wild err impose,fm par,
p rye of silc).
Fl 1,e,owner of Inc pgs:rty,am cacla ively cmfracong wish licensed Contractors to T L' P A 1 D
construct the project(See.TW.Husi has and PrufAxion,Code:)IIIc Camtruetesr's L- _
amt,Lew dos wtapply to an owner of laolea,who milds or imports-Nuhn.and QTY, PLUMBING PERMIT FEE
wlnconract%fmatecb pujcBwith.emm coot)licensed pmauvino decamlmrda asNN/� Q� �
L'cen¢Iww. 1'ERMI'I'ISSUANCI: 1tW�■i/IMA 2
❑ I amesemT under Sce. ,B&1'C Lr mit,reaan
Ov Date ALTER-GRAIN&VENT-WATER(EA) CIlY UY l,U
WORK ER'S COM PEbISATION DECD RATION BACK FLOW PRUI'FCT.DEVICE pZ,ao
1 bores,affirm under vehalty of perjury sore of the til lwar,dadahral ons: 1//
I have"will maimaina Cenlf ale of Cesn.em tos.elf-insole fm Worker's Compen- DRAINS-FLOOR,ROOF,AREA.GONDSTORIES 11 TYPECONSTUJC`DON
soul,, provided fpe by Suriw 3'ltll o(th<I.alaar Code,fur Oe,pcHumurcc of dre
work for
which this permit ix issued, X'N
IERiS-PER TRAP
❑ I hese and will maintain Worker's GmPCnwlinn Ircunrce,as myuirN by$ttriun
3710 ofdsc labor Code.for Nc p:ff.of the work fm which dds perrrac,issued. GAS-FA.SYSTEM-I INC.I OUTLETS OCC.GROUP APN
M1fy Workt,r'a Ction lnwn� rd Polity nu
CarrierpaheyN' ] GAS-PA.SYSTEM-OVER4UTA)
vT XC'ERTilai;ntl I�S1PI'ION FROM WORKERS'
COMPENSATION INSURANCE GRGSMNDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thus section need a#benxnplclM if mcfenrtit is farmchundred dullars(SIM) GREASETRAP
m Ice) PIANCHIiCK Il?I?
I certify that in Jt,perlurmarccof the work frwh'mh this penott is issued,I shall SEWER-SANITARY-STORM G.11X1 Pr'.
rut employ any p:rsan in any manner•o as In becm w
objam t the Workers'Camper- ENERGY FEE
C) z smis r IAws of Cadimrel.,Dare WATER HEP%ER WNES-OH ECTR GRADING IlJ?
z Q Applicenr `
NOFICE TO N'PLICANII If,ahcr nwking the C'ertlfrare of liaemptire,You shuld WATER SYSTEMsTRGTING
I'+ become mlhcl n)the Worker's Cmnpcmaaion preGam a of de LAbm C'udc,yon mlut SOILS FEE
Wforthwith cont with each pahimonu or lois permilsholl be,dttorM revoked. WATER SERVICE
az CONSTRUCI ION LENDING AGENCY NEW RESIDEN'IIAI,PLMB. SR FT PAID
U Dore Receip#
1 herehY>Rrm that Gere is a eemtmctian krding racicmy fm th perfmnwae,of
the work Na whim Nis pmmit a ixwd(Sc.3119'1.civ.C.)
F hmuh/s Name,
O Israk+' AJths< 'I OPAL
TAL
:
crnify ChB 1 have rrW mice upplicuiw old erne my the We infortrutisn is NUILDING FF.F.
Z) CmRCL Ix,rse to cmnply wim ill city and eounry oNiof and son laws main¢to QTY MECHANICAL PERMIT FEE
V z building cwsnuclood mrd hmcbyuulhxi'm repc,enlvives ofthi%city locoor upon the SEISMICFEE
utarvc-mentirmcd property lin m%perion pmpncs I'BRMTI'ISSUANCE(WO agree to save,hameafy and keep larml¢•the City of Cupertino epainst ELECTRIC FEE
IiWilitin.jWgrrerv.�coos aMspenss which may in ery wray accrue attain%I said City ALTERORADDTOMECH.
um"trorce of me gnmin,m Chis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,1X10CF1v1l
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAN
Slclrawm of npplicenUCrmrmcrm Dme EXHAUST I IOOD(WAIUCI'1
HAZARDOUS MATERIALS DISCLOSURE HOUSING Atl'i'IGATION I
Wdl Jt,epplw-enrmfoturc building occupw storemeNkhnamdws mrterid IiGTING UNR(TO 100.000 RTU)
es defined by the Cupertino Municipal Coda.Chnper 9.13,and me Health end Safety
Gdc,Section 25531(.)? IIEATING UNIT(OVER 11)(M)IO B'IV)
ElYn E]No VENTILATION FAN(SINGLE RESID) PAID
Will thea cam rr future building Yu t use e 1 or device,whish Dare Rcei N
ppli cloy pen yuipr Qu BOILER-CDMPI3HPOR IIXI.M0BTU)
Cam,hwnrdatr nit ttmtamiwnu un JetinW by Ilea Hay Area Air Qualy Marwgcnum
District'
❑Yea Fl No BOILER-COM1IP(OVER IW.IXp BTU)
I eve rual the laaaudwm natefials reyuirenenrc under Oulxm h95 of lbC Culi. AIRCONDITIONER ISSUANCE DATE
fame Health&Safery Crate.Section'25585.25533 ofd 25531.1 mdns end that if the NEW RESIDENTIAL MECH. SQ.FT.
building data,M c orcrxly have a tmlara,dot it 1•my d Nwouthlity to rutty me eaccupmn
of Is which rma be net pita to issuance M a CeniOnle tfDe,.p tray.
re ✓1� .. ,_ Iday- �
OvsnereezomancombCcisnipm, I
— TOTAL
ISSUED BY:
OFFICE
F