99080144 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL N
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL
BUILDING PROIEM IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. A .CATION SUBMI' AL DATE
LOS-o► N.Tk JT %J lkVc
OWN/ER.S NAFIE: PHONE CON A(TORS/y'�1 LIC NO:
V^`,A�A(Q . .1 . V T NIC CONTROL«
(CHIkVCTn'`Nf EE -Masi
LIOi at ADDRESIS:: ❑
CONTACT: PHONE: BUILDING PERMIT INTO
410, S 10 -21.1,
nA / MID
Z- ❑ Co¢wltant Fees Paid by Applicant(Initial) � ELECT PLUMB MECH
LICENSED COM'RACTOR'S DECIARATION ' 'I UTY ELECTRIC PERMIT FEE •I�j�I
I berth'drino that 1.toPERh11T ISSUANCE RL:
licwnd Ltder pm...hms of Chapter v(c,nmetuing JOB DFSCRIPTION
O
p�Z with Sectwn]ODI)of Division BWdc Busiric..und Prufcn .Codc.und my lies.is ESIDENTIA
WO
Fes- in full force and.Ret. USFUWL El KITCHEN REMODEL
QU� Lice.Clava Lic.♦ APPLIANCIS-RFSIDFMIAL ❑ADDITION DPLUMBING RE-PIPE
d L Dart, Con.act«
Fly ARCHITECTS DECLARATION PANELS DMULTI-UNff DMUcTIRAL
Zp 7,. odcmturd nrypono, .N„public neonls MODIFICATION
OZ`-. p UPTO:Z AMPS DINTERIOR DCHIMNEY REPAIR
E-t?� an.i PmftaSLL ]o1-IOBOAMN IMPROVEMENT DSW yMm ING POOLS
OWNER-RUC'C Q I hneby affirm that 1 em cttlmpERr�Ethc DECLARATION
Littre law f«the OVER IOW AMPS D BATH RFMODEUREPAIR D DEMOLITION
K O 1 U following rca.wm.LSocron]011.5.Business end ITnfe,,oll CMe:Any city oc a umySIGNS ELECTRICAL D OTHER
LLl�+u,Fy. which.yore.a Iannit to......cost,alter,improve,Jennlish«mlwir tiny.Vrvcmrc
FSO¢ Ammo its i.cm,Inee.aLm rtyeirta the upplicwt for such pamitln Bile a,i,ordsmmrtent SPFAIALCIRCUITIMISC.
�y has,islkrn.Wputanaauethcpov,iomefts,Cwtnnolsl.kenselaw(Chadn9
W 0 (sotnmmcingwits S,efi.7000)UDivishm3ofoe Rini..and Pwfeuiwus CoclO)ar TEMP.METER OR POLE INST. - COMMERCIAL
a.F
a a e K ohm he is 31-1 bt tiny.,m w 1 the t eir f«the dl Ithe Gumption.Any viPenion of D NEW BLDG(ADDIIION ❑DEMOLITION
y not. atha-1 by lu apdic-ollt forapermit suhjmtahe opplimnt too civil Date17 of PoWPJt DEVICES ANT FOOD SERVICE
} F-1L. woe Bine bunJrtdd,lor m,,h,I MPROVEh1 P.NT
Las owtur of the n SWIMMING RH)L ELECTRIC
S ❑ pops X«my employees with road tactle(S-wlccompBa,oress
p
6 3 mwill dothe work,end Ne Vrucwmixnot intended! L,t lines re,hPlicc.]t]i4.Buxincsa DOTHER
and Profe.a i«u Cak:ITre C«uracro(s Licen%e law Jeca'rut apply w an awoer of OUTLETS-SWITCHES-FIXTURES
pmq,ty win,builds or impov„Thereon,aml who docs tach wort bimulf or through
bit own employee,,prenidad ttw ns.h im arcoar ts.not inteMN or Berried for N'EW RESIDENTIAL ELECIR SQ FT.
.1,,If. do building or impmvcmcnt is sold withirtmon—ruf,vmpletion.the, SQ,FT.FLOOR AREA ESQ.FT.
er-builder will have the hoiden if quving that he did not build or improve for puris, 11
-
'se.f sala.)
D I,a.owner of do propcny,am eacluaively contracting with IkaN emconvol to AI.:
c«ssvun do project(Sec.]OW.Nu,ineu and Pmfeui«ss Coda:)The Chm ow w'.li-
rnscLaw a..n mtapply to an.wrcrofgopcny wh.builds«imlauvs tMcoa arta Q'fY. MBING PERMIT FEE
whocarnxu f«tuch rcjamisuh.concachou%)liccnxed pwwwt otic Contractor',
Licca.law. PERMIT ISSIJA
❑ 1 ant ucooq Lndcr Sm. .B&1'C fir this..auto
ALTER-DRAIN& ATER(EA) VALUATION
Dra` 3
WORKER'S COMPENSATION DECLARATION BACK Fl.O .U
1 hereby eirmt utdn p<mlty of pttjury enc'of the foBmwing akclanvimrc: �-J
I hevc eml will meintaina Cenificae of Comenui sdf-imam fa Wurkera Compen- DRAINS- F.ARFA,CO,ND. Sf0 FS TYPEC'ONMUCTION
,anion,to Mo Osi 1 for by Senium 3II111 of the I.alxx Cuda fur tic perf rmamc of the
wid for wh'ahIhix roolivia,«d. 19%7URPS-PIiRTR7
D I M1avc and ,If maintain Wndets Comprnsution In,comec,as oc ho l by Section
1700oftbe labor Coda.for the perOt softhewmk f«winch this permit is isu,ed. GAS-EA.SYSTF_N-I IN O OCC.GROUP APN
MyW'arkef%Conpenwiam lnwence cenier and Policy combo are: Otp
Cartier. PolicyNu.: GAS-EA.SYSTEM OVER J(U)
CERTIFICATE OF Ii%EMPf1ON FROM WORKERS' GRfiA51%INDUSTRL WAS 117 INITRCEPTOR b
COMPENSATION INSURANCE BUILDING DIVISION FEES
Ilbi,station need rut h<nmplctel itW- is lar«e huarache lars'(SIIMp GREASE TRN'
or Ic%.) PLANCHECK FRE
IanifY tha,Nthe pcn(nmurce a(thew'«kfa whichthi%pmnit i%iasned.Ishdl SEWER-SANRARY_STORM EA.200FT.
to emgey any smmn in any roamer w ton.hecunc wbjeat m the W«ken'Contpnr ENERGY FE
Z Lotion l.aw,of C.lifomie.Date WATER HHATER WiNTNOVELECI)t
7O O Applicant GRADING FEE
q � NOTICE TO APPLICANT.It..fle,onakin,IN,CcniEcmcof Excmgi«o.you should WATER SYSTE?,vTREAIING
a ; N,cmca subject to the Worker'.Compcnx.h pm onow of toe Lehi Cork,yw must SOILS FEE
1 O finhwils comply wits such goviniom or tw,permit ahallh deemM revoked. WATER 1'RVICE
= Z CONSTRUCTION LENDING AGENCY NEW'R SIDPNfIAL PCMB. (-�gQ.Fi PAID Ih¢ ndgN
U 0 I heathy affirm that them is a cinVmfbor lending agency for the pnfixmantt of
the work fon which On,permit la is<mtl(Sm.3tN].Civ.C.)
IxtdsT's Name TOTAL:
O U Lend) 's AdJras I IIQ -I a inn 21-
0. 1 ttnify tMt 1 have read this apdkvien enol sate thus ttr vbovc infomnWim i% _ _ yJ BUI.DIN
GA
ZZI s«rtL ape to complYwith a icy and cowry uNimxes and sae bus Lehi iog o Q'I'Y. A1F.CHANICAL PERMIT FEE
U Z building cun„rv.tioa antl herthy amh«ia,relxnenaivn Ofthis city to enter Often the. SEISh1IC EiE
als——mbted proprny fir impatimi purlow” PI?R I ISSUANCE
(W,)agree m xnve,ioccmnify and keep hannl,u the City iI Cugnlnu agenol ELECTRIC 19Bi
Imbilitic..julgmrnts,costs and npcmxs which mmy in any way acco,agdml suit City AL'I13RORADdTOMPC ---
mn¢4ucnccufdmgrwdngMthlyprnniL PLUMBING '
APPLICANT UNDERST AND WILL COMPLY WITH ALL NONPOINT ,MR HANDLING UNTf(TO 10,00i)CRI) MECHANIC FEE
SOIRiCB REGUTATIONS.
AIR HANDLING UNIT(OVER IO,"CFM) CONSTRDMITION TAX
puomnf JDAIDao EXIIAUSI'HO()D(WIDUCI') HOUSING MI ATIONME -
HAZARDOUS MATERIALS DISCLOSURE
Bill the appliceru or futuce building ottupmtsort or haedk hvvNoux matrrial HEATING UNIT(TO 100,(10()BTU)
u dcftred by the Cupeniut Municipal Ccdc.Chapter 9.1',and One He lth and Safety
Cade.SttGcn 3532(e)? HEATING UNIT(OVER IM."BTU)
Ym �Ifi
D V17M I IATON FAN(SI NGLE RF S ID) PAID pyre He
Will arc appliamt or Ornate Wilding ooxupam ma ryuipmcnl or Jnviccs which BOILER-COMP(3HP OR IW.IIW BIL)
,nit hvudoua au cowrrdnanu a dcfitcd by the Ray Arcs Air Quality Menagcrrcnt
Dorsi
DYn 54
BOILER-COMP LOVER IW.t]W BN)
tryuiam AIR CONDMONER
1lwvc rtaJ the harw4nn nuaral. crxxuNa Chagcr6.95 Mthc GW'I. ISSUANCE,DA
firma Iferllh&Safety Core,SaIion,25505.2553]and 25539.1 Lrdcmtund thv if the NEW RPSIUENTIAL MECII. SQ.FI'.
hIDding Jn xtxx
oOfathrcr«eun cuurwrrndaBM,00eobifry to wofy trheupq�qy,i�m
nt
Cndfcc Lf Ochich uV a ^I/✓/ �/
Lim, TOTAL.: ISSUED BY:
OFFICE