29143 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUILDING-ELECPRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29143'
t BUILDING PROJRCT IDENTIFICATION
BUILDING ADDRESS: olmSANITARY NO. APPLICATION SUBMITTAL DAI'E
OWNER'S NAME PHONE CONRACItTR'S NAh I O: 1
N/C CONTROL N
RCHTFECf/ENGINEER DJC NO: ADDRESS: ❑ O
CONTACT: .- PUONIL BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) sLDO P{.U�MT_Bi
LICBNSEDCONRACIYIR:S DECLAMATIONC=Z QTY ELECTRIC PERMIT FEE T`tgTi' �X�
1 Immo tuff t this l am heenral mi rosisixis of Charterer 9(eomme.ing JOB DESCRIPTION
WQ' with Section 7000)of Iusis.3of the]fair..end Professions Cone.unlet license is RESIDENTIAL
��Ofull y PERMIT ISSUANCE
Fd_ in Ch and cRm. '
V♦,j License Clue � Lica N [I sEUWL' ❑KITCHEN REMODEL
In z Dasc Contractor APPLIANCES-RESIDENTIAL ❑ DDII']ON ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION LTI-UNIT ❑STRUCTURAL
Murd
Iucnmy plans shill bn used u public retorts PANELS // -- MODIFICATION
OL UPT0200AMP5 ❑INTERIOR . El CHIMNEY REPAIR
Licrnrd Pmfeul.ul 2W-1000AMPS IMPROVEMENT
' �SOWNER-BUILDER DECLARATION
tY W Q 1 heuby affirm tha I am esemp fmm the Comidemus License Law fn the OVER 10(0 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3=U EUm og reum.Sailor 70313.Bu.and Pmfe.imn Cods:Any city a couny SIGNS ELECTRICAL ❑OTHER
LL which"sires•I omi'm cmmnicl ohm,improve,nemalub.m repair ony amewm
FLL0 prorm iu iswvuc.Win requ'vestM appliun forvuh pcmut m flee signed swemcot
vh SPECIAL.CIRCUIT/MISC.
vWW��i 0d he is liceruW Pursuant it)the l rossiom;ofthe Cammcmr'.Liccnse L,i.(Chepur9
C��a (emaereing with Section 7") Division 3 of Be Buswe.0 end Prefaedeas Code]or TEMP.METER OR PO t COMMERCIAL: '
a e 4, the he is esen t them(.na and the had,fm the alleged!camnpta,ot,Any violate.of ❑NEW BLDG/ADDITION ❑DEMOLITION
1+• Sadism 70315 by any e,,licwt fora mit wbjecn the applicen toe cisilpenanyaf POWER DEVICESM. -❑TEI:ANT ❑FOOD SERVICE
not more then five hundred dallan(SAX)). IMPROVEMF7,9'
G ❑1... . athe pmpen,or my cmpbYee with w.'s es rhes,rale compemaion, SWIMMING P96L E' GLRIG
will do the work.and the st tiure is cur intended or offered fiirxle(Sec.IDN,Bus ❑OTHER
Wand Pro(essiarts Cade:The Cmvatm"license Law der not apply to an ostler M OUTLETS-S W C RCS
a 3 pmpeny who builds or improves thereon,and who does such work Lot nor through
his own amloym,pwo the such ind"a.nu we not intended a oRnd for NEW RESIDENTIAL E S
aIle.If,howcvernhcmildingoriinpmvemem lswld willirmcycarofcanpkudo-the SQ,FT.FLOOR AREA SIsQ FT.
txr-bniildm will to do human n(poving Rw be did rut auditor
impmvc f«par- �� k y yl°I
L as owner rcommr da prapa,y,anmxeadvJy e.trtsning w;tn]Toned emnxmtmam _ roA� - ,
met Ne em,.too
......
. Il ..I mal who
Lai dho ur Tile CmVecmr'n IJ- Al
xlnw deer much plroo ithacaico liceW imucnpmva Convn.ed QT-Y. PLUMBING PERMIT FEE
wed contracts for such pmjeen with.umtncmgs)licrnud Wrwmntmde Contractors ,
U.Lbw. PERMIT ISSUANCE 111 "I [� ��qfz .
❑ I am exempt uderSa. ,B&PCI thr—o wo JU 16
AUIER-DRAIN&VENT-WATENIFA) - VALUATION
Qw Lou CITY(.
WORKER:SCOMPENSATON DECLARATION BACK FLOW PROTIiCT.DEVICE Q ell rlamommomme
Ibadw ill under pmtuhyof of Comortofexitrmeor Wckrntimts q,3 2'1
❑Intsvetsd willfomaintainby a Ccnif sof Gmsemrto sel4 fee shor Worker's of Re, pILMNS-F100R,RWP,ARIJ.,CONp, STORIES TYPECONSTRUCHON
worn,r provided for by Section t]ql of th lobar Code,fie de perf«mm�c of the
wok as which this Pcrmitir orker FlXNNIS-PER TRAP
❑1 hove and will maintain Workers Comp.filic Imumrcc,a ryuirnl by Schon
J](IDorkersCar Codc,fmthsurane mnerftheube fm•herade i.Pamir is i..ud. GAS-FA.SYiTEM-I INC.(OVTLEIS
OCC GROUP APN
My Workers Campcmetiao Insurance certier.ed Pulley numher tie:
Conner, Policy No.: GAS-EA.SYSTEM-OVER 41EA) ,
�I CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETNDU.SIRI,WASTE,INERCurOR
COMPENSATION INSURANCE
BUILDING DIVISION
(Thou ee-rim.ed not hecrompkrd ifthc pemet is forme hurtdred dbllerx(5100) HE
r.leu.) _ GRPASF,TRAP PLANCHECK FEE ` 6
�I� lenity ewlo in pttf.mmor of dx work rm whkbthir the W rlico'Cluma II -
mtemployanyperamin.y nun.Ywasmh.00ru.w hj.tmthe Wmkmti Cunnpm SEWER-SANITARY-STORM EA.IfO Pf. ENERGY FEE
O Z cairn Laws of CJiroroia Doc WATER HEATER WNENT/ELECTR
Z 0 ApPBaen GRADING FEE
y NOTCE ro APPLICANT:If,Nm making Nis Catifime of Exemption,you should WATER SYSTLFI/DtEATNG
a ; hccomesubject mthe Work—Compenwnim P^'viionrrfthe IUMe Gde,yna moa SOILSHE, 1
GQ raMwith comply wile wch puvuinns.tivs permilJWl be dccned mvkd. WATER SERVICE
7 Z - _ CONSTRUCTION LENDING AGENCY _ NEW RESIDENTIAL RLMIL SQ.PT. PAID
U 0 ]hereby affionthm more iso construction krdingegcn:y for the perf.cif Data Receipt
the work f«which this Imrdt it ivwnd ISS.J(N],Civ.C.)
p ("' Loc der',Name - TOTAL
Icdv
V 'a Adtlmxc TOTAL:
y1 ecnify that 1 Imve mad this tsppl'cutian acrd crate tit the ehovc infmmxtim is BUILDING FEE LVL `
rn eamzL l tsgrtt m comply wiN JI city W moony mdiwnm and Tone Daws mlaing m QTY. MECHANICAL PERMIT FEE
V J building construction,and hereby island,upesemaives of oris city m must upon tK SEISMIC FEE
aluvc-mentiond pmpaty f«inxpcaion putpuser. PERMIT ISSUANCE
(We)agree m.mvc,indenmify.nd keep hurmkss the City of Copcnioo ug W cot ELECTRIC FEE rol
EJelities.judgtnass,cvas tsd expenses which maY in anY waY ecce+c egains said Cty
ALTJI OR AUU ro M[CH. 10
• Ucousryuence of the grondne of this prmdr PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) M1fECHANICALFTE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IO,IXO CI>M) CONSIRUCTIONTAX -
Slgoamerl AfTliexn✓Cmnanm Dam I-AHAUSI'HOOD W/DUCF HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will de,epplicea or future Wilding ucculrent store lir handle h:ovd.s romenal I(EATING UNIT(TO I00dXO HTU)
u dctiinil by the CopeN.MourdloJ Cone.Chap.9.12,vd the I"th tsd SWmy
Code,Seem.25532(x)] HEATING ON]](OVER 100,W)BTU) ts
C]Y. ❑No
VBN'IIATIDN PAH(SINGLE NLSIU) PAID ,
D. Receipt x
Wilkie arcomginflame Widiey comby Int Be,use ryuipmemlane alma which HOMER-COMP OR 100,000 BTU)
emitters Wrcmmmirntsntxvdefind by IM BAta AirQwliny Menag.nem T ,
DIrWn[
[I yes 7N BOILER-COMP(OVER 1(0,!1(10 BTU)
I Mve red ted hmadous mar me,dicalso model Chaamr 695 of the Cali. AIR CONDITIONER
ISSUANCE DA
(amts No&SWay Cork,Sccuom 25505,25533 and 25531.1 wdctvmd the if de NEW RESIDENTIAL MECH. SQ.ITT.
building tLte�usecurrencyndve eaet mimlit ismy of. leritycanotifytherm1aN
of de rcgJirtrtens sMicb mmhc mel primmisstunc rfa Certificate a((kvvpatcy.
Owner m tsuthoved agent Dau TOTAL: ISSUED BY:
OFFICE
Inspection Query for a Specfic Permit 9/15/97
PERMIT# ITUS;ST SIT,UStSTREET Lot# MINSDESCRIPT4MIlii-sTkOIDATEDESIREf DiWDode
9143 IHOMESTEAD BDG SHEER NAIL 7/30/96 7/30/96
9143 HOMESTEAD BDG SHEAR NAIL 7/31/96
9143 06 1 FORGE BD 1 ROOF NAIL 8/12/96 8/12/96
9143 20631 FORGE BD 1 PLMBG 8/29/96
9143 20631 FORGE BD 1 MECH 8/29/96
29143 20631 FORGE BD 1 ELEC 8/29/96
9143 20631 FORGE BD 1 FRAMING 8/29/96
9143 20631 FORGE BD 1 ELECT-R 9/4/96
29143 20631 FORGE BD 1 PLBG-R 9/4/96
29143 20631 IFORGE BD 1 MECH-R 9/4/96
29143 20631 IFORGE BD 1 FRMG 9/6/96
9143 VFORGE
RGE BD 1 INSUL 9/6/96
9143 RGE BD 1 UNDRGRD PLMBG 9/6/96
9143 RGE BD 1 RGH FRAMING 9/11/96 9/11/96
9143 RGE IN UL 9/12/96 9/12/96
9143 RGE BD 1 R/C CHANEL 9/12/96 9/12/96
9143 RG BD 1 FRAME /1 6 9/12/96
914 RGE BD 1 INS L /1 / 9/16/96
9143 RGE BD 1 SHEETRK NAIL 9/16/96 9/16/96
914 OR E BD 1 LATH 9/25/ 9/25/96
29143 20631 IFORGE BD 1 STUCCO SCRATCH 9/30/
9143 20631 FORGE BD 1 ELECT REL 12/9/96 12/9/96
9143 20631 FORGE BD 1 BLDG-F 1/27/97 1/27/97
29143 20631 FORGE BD 1 BLDG ENRGY-F 1/27/97 1/27/97
9143 20631 FORGE BD 1 PLBG-F 1/27/97 1/27/97
29143 20631 FOR E BD 1 MECH-F '11'27/97
7/
• 143 20631 FORGE L -F 1/27/97 1/27/97
•
Page 1
Inspection Query for a Specfic Permit 9/15/97
ns ento Uhiff Pass/Fait IC'odel
J 12P
CC P
CC 2F
C 2F
C 2F
C 2 P
C 1P
C 2P
S 2P
S 2P
J 7P
S 2
rSS 4P X
S 2P
S 2P
S 2P
® 6P
•
Page 2