S 1530 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIB L.IIING-ELFICI'RICA L PES`.yT T No.
BUILDING DIVISION APPLICINFION/PERMIT PLUauDNG MECHANICAL V 1530
BUILDING ADDRESS BUILDING PROJECT IDE'I'IFICATIOY
ANI'FAKY N
S (1. AI'1'IJ( TION EHRMI'FIAI.II F
'.
/(012Z8
„'Z M15WA) L)4 ,
OWNER'S NAME PI ONE: C_O.N_T,�KA'C�`'(l�SNAy�F:: { LIC NO
x//12 T/!�/�lY ILW� o�5i�' ��rnv IT. L✓CJ/ 36g5Z(o NIC ca rol.n
�RCIII'I'IiC'I'IENGINIilill' ^ LIC NO: A DRHSS', MOt/l/� � C'v/005 e017 AD ❑
CONTA\ `7 PHONE: BUR DING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LDG IiLHCF IAMp h11iC11
❑ ❑
LICENSED CON'rRACI'OIt S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereny arfrm mal 1 am Ran.ea ander rr.....unroof chapter 9 aommmdng JOB DESC IPTION
z w;msnlion]110(Ilonlh;,innJonne Brsinea,and Pmrirm,c .anamyhc RESIDENTIAL
Y:p PERMIT ISSUANCIi
Fac_ in full force and sten. ❑SFDW'L ❑KITCHEN REMODEL
QUU License C);�,sT�d� LieN APPLIANCES-RTIMDI{INL'IAL ❑ADDITION ❑PLUMBING R171111117
yQa Dn;c Comrnc;ur ❑MULTI-UNIT' ❑S'IRUCIURAI.
ARCUI'UTCFSDI?l' 1 PANhLS MODIFICATION
p Z N Z I unJerennd my plum shall be used o' blic mcnrda
UP FO 200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMP VEEIENT SWIMMING pOO1S
W LiccmxJ Pmfcssional 2111-IIXXI AM1IVS ❑
Q , OWNITR-BUILDER DECLARATION \TH REMODEIBEPAIR DEMOLITION
(IVEN IIKKI AMPS
C IL¢ I hereby..(Ser,that 1 elimitl Gam the Cnnl.....C b License Law rnr the ❑OTHER
aW F fnhwh res ei �.raccoon 911.115,Ilaxinm nil m.d n Cn(lc:Any nun n ru rIlYsure SIGNS HLITCHLICN.
y whim rcyuims u permit m comvun,almrsianpmvc,Jemnllnh,or repair any xlmctune
1_'u'�.Q.t prmmits iswaree,dm airlines lheaplimard li+rsuch perminn file a signed statement SPECIAL CIRCIa /MISC.
fa} that he is licensed pursuant to the provi,irnsoDhe Commewrex Liceme Law(Chapter 9 COMMERCIAL:
W�QO (commencing with Section 7000)of Division 3 of the Business and Pmh.•ssionsGde)or TEMP.M1IL - OR POLITE ST.
E.0.o aa that he is exnnpl mcrefelo;mJ the naso rnr the alleged exemption.Any iWaunn of ❑NEW BLDG/AUDITION ❑DEMOLITION
X-NSntion 91UI s by any upplicnm for o pennil,uA'Iewe the nP011cunt m a dvil Penalty of IY)W" DEVICES ❑'TENANT POOR SERVIGIi
r1 mom Than five hundred dol ars(8501). IMPROVIiMIiN'I'
SQp 0 Lasnwncroflhe property,or my employes with wages as their sole cnmpcn.vatinn. 'IMMI NO POOL But
F will Jolhc work.and theswnurc it nm mmndcJ nratemd for sale(Sec.]fW.Rusincnz ❑OTHER
fiq
aim and Profexonns Cade:The Con sonar's LicenseLaw does not apply to an owner of UNUEFS-SWITCHES-PIF
fru
pmpeny who builds or impmvos thereon,and who J«s such work himself ar through
his own"playas,presided thw ouch inapmventenb me nm imm�AW or nrinW h NI?W RESIDENTIAL Ii1.F 1'R S
,dr.if,however,the building or impmvcmmit iv old widinune yearol'cnlmpletlmo the SQ.PI'.Il.(l(IR•�AREA Affil 5/SV.I•Il
nerbuilder will have IM burden of proving that he did nal build or improve lin pur- APR 17
poxofevlcJ. 'r L
h us owner of the property,am exclusively contracting with licensed coneranun In
mama the project(ser.70,14,Business and Profeaaon,Lei 1n,Cotnmclor'a 1.i- clT`( Uf uumn i a J
x law doe-lo,apply m un owmoufpropery who baud—r improve,thon,
ereand QTY. PLUMBING PERMIT FEE -
,hea( trues,retouch prujmte with n contra"...(,)licensed'a eantotbc Conoadnh
Liccnx Law'. PERNII F ISSUANCE
❑1 ann exempt ander sec. .B m P C fm flu,rcmIm
ALTER-DRAIN is VENT-WATER(Eel p �
Owner Date
WORKER'S COMPENSAII ON DECLARXI ION RACK FLOW PROI ECF.DEVICE
I hrn:hy off ml under penalty(If 1w1jury ane of the Iillowing declamtinnx'.
� Ihuvc andwillmaintvanuCcnifcmc ofCnmmn lopelf inwmlar Wndcd,ConlT.
pcn- DRAINS-FLOOR,ROOI',AREA,COND. S 'I'YPECONSI'RUCHON
satire,is provided for by Scetion J]RD of the LMa Code.Iia the performance of the ,
wad for which this panne is issued FIXTURES-PI7R TRAP
0 L Emotional will maintain Worker's Conpurnalmn Inormloc,as myuned by Section 1 INC.J OUTLI'1:5
l](Xlolam labor CuT for the pafformvnecof the week for which thin por ,ix isom,L GAS-EA.SYSTEM- OCC GK(IUP APN
My WnduF',Com union Laurance carrier ud liy'mynumberam GAS-EA SYS'I W-OVER 4(EA) •
Carrier: Policy Na:
CERTIFICATE IIP EXEh1PIION FROM W(INKIiKs' GREASE/1NDUSTRL WASTE IN ERCEPIOR
COhf1'P.NSATION INSURANCE BUILDING DIVISION Mr-S
Qhix. �r need nm letnlil the pC•rmn hunJma dollar(SIIXII GRIiASE TRAP
or I...
J 1'LANCHECK hili
Ile i1Y Turn, per t ,Ti Jm. 1") C, thnlxrmiu I......J,lx bull SEWER-SAN]TARY-STORM RA.200 FF.
m aPln un lime ,
ut I ur�syx + s nice rlheW�crd Contpcn- ENERGY PEE
Tion u
urn L� al' r '� xYY W'AUEER HEATERW/VITNTMLECfR GRADING FEE
Q Applic
z' N YF I T APPLICA .1,a er making this Ce arcate of Formption.You should WATER SYSTEMn RL?ATING
[-^ be object to the Worker',Crmpansation molder,of the[..No Code,you mmI s014S FEE
Cat 'y with comply.,In ON moi,CHON LENDING
shall be deemed re, IT I WAFER SERVICE
G Q FAH)
= z GAGGNCY NEW KITSIUITNT'IAh 1'LMH, SQ.IsI'' 1)' RCfeirin
U C I hereby offiml that hem is a Constructionlending agency for the performance of
LL F' ,he work for which This permit i.issued(Sec.3091.Civ.C.) 'I OTIC:
Q U Lender's Name TOTAL s
}U Leadda Adders, RGlI.DING PEI:
I eerily mal I huvc«tel this applicant and 11.11 that the ebrrvc adonnmion Is
.F-aN creel.L agmen comply with all city And countyordinanaw and x,am lawsmluEngm QTY. MECI IANICAL PERMIT PEE SEISMIC FEE
U building Communist,and hereby autherbe reprexnmtims of this City to enter ugmme
abu'c-naminnea property for imprOwn Impo wl. PERMIT ISSUANCE ELFCfRIC 1$E
(W agree In save.indemnify and keep harmless the City of Cupertino ugainI o,
Iiabilill .la Igmcnn,c 'xpc sex whh
'mnF. Y 'yaccmcagaim,viid Coy ADDCAD
Aid IiR OR A 'FO MECII, I'LIIMBING I'Eli
a rt a Cor, sten r al,remit.
APPI 'I'U ' ERS'. NITW ..COMPI WL'I'IIN.LNONVOIN'I' AIR IANDLINGUNI'I'(T0111Egd CPM) MUCHANICN,ITeII
SOU ;REG AT
q—/7-98
AIR HANDLING UNIT(OVER IR.(X TME) CONSFRUCI'ION TAX
mammot Appliear in,, or Dae O GXIIAUST H(H)IIIW/IIUCTI HOUSINGNIGIGSDONFEI:
HAZARDOUS MATERIALS DISCLOSURIi
Codii
e, h,the C", ninnWi 11 tire applicant or fMunun cipalin me lCoding e Chapter and liom ho 11,e Healthinvind+and Safi,'y IIEA'IING UNIT('all In I0.000'U)
as re
IIIiATING UNIT( IiK IW.W(11TI'U)
Ycs ON. VENTILATE FAN(SINGLE RESID) I,A
[)all Receipt
c WIII the upp]inml or Ieum building ncaupant me cynipmcm or devices which HUILE -COMP LEEP OR Ig),gla n,O)
mil hamrdo m I,courrelerls a d,fiimd by,he Ray Aro Air Quald,Maleagetnnn 'I OPAL:
District? it .ITR-COMP(OVIiK IIXhIXXI B'IUI
❑Ycs ❑No
I huvc mail due hwuNom mataridsneyui de,Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE,
Wmiu that,AT Safety Cede.Sections 255115,25533 5JJ anaR un d 255JJ.I understand than it the NITW REi51DENTIAI.MECH. SQ.FL
nodding doe,not enrc rely baso a ar.m.mw i1 is alt,m,pordhtftl to non y tire IscoPanl
of the wumo mus which Inns,bem"prior to I,,Cane of n Ceatinneul Occupancy.
Owner ur tulhorizN"gem
Date TOTAL: ISSULII BY:
OFFICE