S 2854 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO .BUILD ING-ELFCTNCAL PERMIT NO, ...
BUILDING DIVISION APPLICATION/PERMITPLUnmmG-M?CHANICAL
BUILDING PROTECT DMINT IFICA'I'[ON S 2854
BUILDING ADDRESS: SANITARY.NO. APPIJCATION SUBMITTAL DATE
10181 okksoI-t Ali e-. ..
+(Lo y _¢
fN' HIRS NA F.: PHONIi: n ,y /' CONTRACTOR'S NAME ` n�- LIC NO:
W� Q-1L� Z'I �WzW VLUIA �I bLLki Id Q' NIC CONI ROLIt
-CI III CITNGINEER; LIC No ADD1tBSS( ❑
CONTACT PHONE ! / BUILDING PERMIT INFO.
uwL AML�(Q(.I, C� /LOO `�102� ❑ Consultant Fees Paid by Applicant(initial) BI.DGEC, 1'1-UMB MECH
LrtJy/ Ir61/ ❑
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT FEC
T hereby affimt that I cut Imrnsed under proviaian+ar cnapmr v(kammendng . , _ JOB DESCRIPTION
OaZ with Seenum7rxxpofOivision 3 arihe Business arta Profexsion+C,d4 ane my liecau,"s RESIDENTIAL
WOO I'I:RMI'1'ISSUANCE.
FXWF in :u,d effect. DM'DWL F}KI'rCHEN RF:MODIiI.
<-U himnw Clxss hic'N APPLIANCES-RM. IDENTIAI, ❑ADDD'ION ❑PLUMBING RE.PIPE
F�SW Datc Conhamar
FOy ARCIII'I ECI"S DECLARA'I ION PANELS ❑MULTI-UNIT DS'1RUCfURAL
Z O w Z I understand my plana shall be used as public records MODIFICATION
UP10200AMPS
OZ-C iNTFRIORCHIMNEY
FyfW Licensed Professional 281-I(0X)AMPS IMPROVEMENT r]SWIMMING POOLS OOLOL
S
s a 1 hereby afrnn
OWNER BUILDER DEme ConmaOor's License how for the OVER IIXXI AMPS e�1ATH RETMODEIIREPAIR D DEMOLITION
that I at ekenipt bon.xdx O W O following mucron.(Section 7831.5,Business and professions Code Any city 1.r county SIGNS ELECTRICAL DOTHER
u13 0 whichrequirespermit it)construct, Iter, mP demolish, p y:tuarone
�sprior to itss the ppl' t for,chpe G filea signed statement SPI CIAI.CIRCUIFMISC. _
thin In, I'veri,edl) .mante IIl t the Contractors Livem,Law(Cl ,Torg
W..SCO (+1.,n L,v',gwth Sect700(ool Uvtsi itltha Bun....actProfession,C,J,)or 11MIR ME Illi OR POLE INS1'7, GOMME
LL a n C IInn Im is uompt tnerefrnm and the basis for the alleged evvonpticn.Any violutio.ofNEW BLDGIN]DITION D DEMOLITION
Is. Section 7031.5 by any applicant lira penoitsunjecu the applicant In a civil penalty of `CW-RDE
CES DTENANT DFOOD SERVICE
tZy t ore than five hundred dollars(45mB. IMPROVEMENT
h < (�/I,ns owner n(thepropeny, xs employees with w1.es as theinnle cam tion. SWIM1IMINO POOL EL[CTRIC
y emp y 6 pensa
f n will Jo the work.and the stmmurc is not immnJN oroRered for tele(Sec.]tX14,Business OTHER
Wand Professions Code:The Conlfeao',Liecnx law dues not apply m an aware of (III'1'LI1TS-SWITCHES-PI%TUHP_S
et'3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
vile.If.however.the building(ir mprovement is sold within one year ofaanpledim,the SQ.1•T,FLUOR AREA SosQ.IT.
puncnnoilder will have the hueden of paving Nat he did urn braid or improve for pur-
sn it sale.)
CI Los owner ofte u
hp ,,rly, n,cxclunivuly centutong wim lin„sed cn df anars m 'HYIAL:
ash act the project(So alone, nd Pon essimn Cad,The Commenr's Li-
.it, law does t 11,humowner of or peny who builds or improves mermn,and QTY. PLUMBING PERMIT' FEE
who contracts f r �hpmjceawl0tumn aogS)Iiccnselpursuannathc CammcNls
License La, PERMIT ISSUANCE
D1amexenit B&PC for this mama
AIDER-DRAIN&VENT-WATER(EA)
IN Date �\
WO ER:' ' MI'ENSATION DECLARATION BACK FLAW PROTECT.DEVICE
herey anion under penaltyof perjury one of the fnllawing decimations: zj _N
D ILmve and will maintain aCeniicumof Consent toself-insure for Worker's Chmpeh- DIdAINS-FLOOR.ROOM,AREA,CONO. STORIES 'fY1'EC 5 UCI'InN
,at i.as p,,,v,d,d far by Section 3700 of me Lobar Cute,far the perlbn once of the Q9
work lbr which this peon is issued. Z� IIX,URE -PHRTRAP APR O 7 999._
I have and will maintain Worker's Compensation Inaumuce,as requited by Section
J]lX)tel the Labor Code,rnr the performance of the work for which this permit is issued. OAS-IiA.SYSTEM-I INC.4 OII'I'I.LS'P.S OCC GROUP
My Wkers Campensmion Imumanec carrier and Policy nombre am:
Canner: Policy No.: GAS-IiA.SYSTEM-0VER 4(CA)
CERTIFICATE:017 P.XEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GNEASOINDUSTRL WASTE INTERCEPTOR
DING DIVISION ICES
(This section ncW not roe nimpleteJ ifthe,erten is throne hundred dollars($I00) CREASE'1'RAI'
,it less.) PhANCHECK FEE
I Oaff,that in theperlinmaneentam work for which thispcomit is issued,l shall SliWlilt-SANITARY-S'IORM 1iA.200 FI'. _
nm employ any,conn m any nnnmer so ns u,hrenme subject in the Wnrkcr�Cnntpen. ENERGY FEE
O 'z aulln iIawvn(C,b I(jola Dam WNIHIR IIHA'I'EIt WNEN'fIEI.IiC'I'R GRADING FEB
7 Applicant
p % NOTI CE'H)APPLICANT:11;after ninking this Cenifiewe of Esenput...you should WAFER SYSTEMITREATING
a ? become subject to the Wake,Compcnsntion provisions of the Labor Cole,you must SOILS FEE
D1Iimimou comply with,ach novkharco,this pem,it+hall be deemed revoked. WATER SERVICE
Imas
CONS'I'RUCI'ION LENDING AGENCY NEW RESIDENTIAL PLMT SQ.FT. PAID
U z Dam Receipt M
L) 0 Ihereny alarm thmthereisuam>tmaiandin
leng agency babe pcdmm
onre o!
Its � the work for which this permit is issued(Sec.3097.Civ.C.)
Len 's Name TOTAL:
U derL ader's Addne, '10
I eerily that 1 have acted(his application and sate that the above infnnnsom,is BUILDING KA
V1coI'net I agree m"amply win,u0 city and is n dinm,ces one sen”11.11 m1ming to Q'I'Y. MECHANICAL PERMIT FEB
U Zbuilding cons(mO anharize mprescmmives of(his c lty e,enter upon The S177ISMICF E
uhnvcmcn" Propert5,7N
ncl vtion pntpnsrs. I'IiRMI'1'ISSl1ANCE
ev m save,Inde i(y nnJ kecp ham,less the City of Cupcninn against IJ,IiCfRI EC
lian11 judg sentn,cmaen spenses whi"h may in any way anmeagainst send City AL'TIiR OR ADD TO MECH. /
in cot teen ofinegmn' gofthisperm I. PLUMBING IS 2t
APPL. 'AN' UNDER ANDS AND WILL COh1P1,Y WITH ALL NON-POINT AIR HANDLING UNIT(TON).000 CFM)
ti0U �GUL N4, MECHANIC LFEE
AIR I IANDLINGUNiroovE.R pfaro CEsD CONSTRU ONTAX
Signa ors sf Applln,WP e� ,
)ale HXIIAUSI HOOD(WIDUCI) HOUSINGMI GATIONPEIiHA"LAICl IALS DISCI. .URI:fhevpplicmuorecmpan(st 1.r handlehBeurt1,and"ideal III?APING IINI'f(TO IIIB,(X)II❑'fll)
ux delinW by the Cupertino de.Cha 9.12,and the 11.11h imd SafetyCole.Section 25532(x)7I IIiATING UNIT(OVER Inif,,11T1'U)
❑Yes VI?NTHATION PAN(SINGLE RESID) PAIDDate Receiptis
VAR the applicant 1.r g a equipment m tevltts which BOILER'COMPOHP OR 100,(PXIli'fU)
,m,it hazardous air contaminby me B y Area Air Quality Management TU
Distrkt,
❑Yes , BOILER-COMP(OVER 100,000 BT U)
I mehxeunlausmnteriuls �quiremmne under Chapter 6.95 critic Cali- AIR CONDITIONER ISSUANCE DATE.
fondul (breafrfyCol,Seatiao .05,25933ond25534,Inn),,It Ilimit fthe NEW RESIDENTIALMECH, SQ,FE —
buildin rren(lyhuvcnfe t.tbml(i,aryowpmoj,lily 1,ani l' the swrnPvn1 (. /
of ref ichmnn ten prior to issuance nfu Ceni kale, kc
sad thomrod agent Date TOTAL: ISSUED BY:
OFFICE
ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATION VALUATION
AILDlrvc
DOREss D /
f
oAERs
ME
FEE SUMMARY
NE
...FRAcrORs BUILDING
UC,N. PLAN CHECK
CONTRAcrORz FEE 4•S
ADDRESS
PRONE SEISMIC FEE
OTpY�. ELECTRIC PERMIT FEE
y UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES
PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS WPY
SIGNS TRANS. To
SPECIAL CIRCUIT 3
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
O SERVICE CHANGE
ZZ
F y°— TOTAL:
W > OTY. PLUMBING PERMIT FEE ISsunrvcE DATE
BLOQ ELECT. E. MECH.
CL 0
::) Z ALTER-DRAIN&VENT-WATER(EA.)
U O BACK FLOW PROTECT.DEVICE
C w DRAINS-FLOOR,ROOF,AR EA,COND.
}
IS. FIXTURES-PER TRAP
(— 2 GAS-EA.SYSTEM-I INC.4 OUTLETS
L) GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1.INC 5 V,B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200f1/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO10000C.F.M.)
AIR HANDLING UNIT(OVER 100 C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT
OVER 100,000B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-OOMPO HAD,100,000 B.T.U.)
BOILER COMP Ion•.IOp.000 RTuI SEE FEE SGR.
TOTAL
SCC, Iso I°= s '-
J 't5
i
APR 0 8 1999, 0
csLuG. INSPECTION DEPARTMEK� NT
CITY OF CVPERTIN(
izi » ��
FIr)
\ ' 1
30 v-He
�
V"WT ]PLANS Oyu e�� to
o .s
b-7
/�/�f��� Gam/✓ DATE
BT,T3, DEPT. .