29991APPLICANTTO FILL IN INFORMATION WITHIN RED LINI
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONIPERMIT
1 herchy etrmt that I sm lie". ' under provisiam of Chapin 9 (commencing
with Section?gm) of IF virion 3 or be Hmirms ami Pmfeneionn Code, "my license is
In full force ed affect.
I.iccnW Clasx Lick -
Dom Contractor
ARCHI'IECPS DECLARATION
I nndmmM myplan shall he usd an public meow
USE BALL POINT PEN ONLY,
❑ Cortinultant Fees Paid by Applicant (Initial)
)TY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
PA NETS
U") 2W AMPS n
Q
3 a U
FLL Q
i byT
a a e
^ y
OWNER BUILDER DECLARATION
1 herchy Afum than 1 em exempt from the Contractor's Licamat Lew for Je
fallowing ... (Section 1031.5, B.6. and Professions Code: AnY city to roomy
which requires w m
a permit nslm. n. ante, wars anish, on or repair any sume ucl�nOJ vier. I. issuance. Avarc Innes, he apphcuu for such permit. fikesigred shot
that he is liana pursuant to the Provision, ofthc Conuectars License Law (Cheper9
(commrncint wiNSection]000)of Division 3 althe Business sand Professions C«le)err
the he is cxcmp Jereforn ald the hau for the alleged] excmpion Any vulval. of
Section 7031 by any Kjv icam for a P carnal subjects tar eppliann to a civil pemRy of
❑ADDITION
D PLUMBING RE -PIPE
❑MULTI -UNIT
El STRUCTURAL
DRAINS- FLOOR ROOF, AREA, CONE.
=O
yp.
41 ^ $
d i ^
oaI mase than five hudred doilws ($500).
D I.unwtmruftbe pnpcmy.urmYemmendeswiJtweQesaJeirsdc 0o 1. BaWrm.
will tic Jewu,CdtheurvnmeivmimcMcdm Land fs.;,,ly on 4, Business
ed erufeuionn Cask: The Cienmcturs License law does rot ole hi us if net of
prem, who huide «impnwn thereon, era who dues such wart Frough
DCHIMNEY REPAIR
IMPROVEMENT
intended or
Int,ad own empnyec� pnniJal Nan such impmveomnu aR rot immnAeJ m all'emd for
D BATH REMODEIIRFPAIR C1 DEMOLITION
DOTHER
is sod wild naneyamofmproveiar the
wle. If, hnwm'vr,the but dinguren
BUILDING DTVI. I ETF'
GREASE TRAY
r-bullJer x'In lava Jon burden arproving that Se cite not ootid«inlpm.erarPar-
ofpt vin
SEWER -SANITARY -STORM EA. 200 IT.
ENERGY FEB
Tona
GRADING FEE
WATER SYSTEM/IAEATING
I, owner of the pmpcmy, aan exdusivcly rammcting with Items m'
WATER SERVICE
PAID
Cmnmema
a -o t Ne Tho CLnlrixemo, Li
not (tin. oN4.. a,,a ad Py.IF. ns
Receipt Y
c, ckor
csms, L loan itha of Pmleoy whabuilJ.snr improver
aocommd
QTY,
BUILDING FEE
forsuchPr Coa«t,anJ
who cnnaaas for such Projects with a convvemrts) liaoscJ pursue. m the Convacmr's
Lia. law.
smlvuCFFE
Lem cxcmp oder See. .B&YCfm this rca.svn
0. Dem
WORKER'S COMPENSATION DECLARATION
I hnchy affirm uMm prna ly of perjury ane N the following deckvviwn:
1 here and Mill maimeio a Cenificele ssf Comem m sebris. forWasters CLmpce-
'
wion, as Provided fill by Section 377 of to labor Code, for Je performance of the
work for which tha Permit in issued.
D 1 neve and will nainmin W«kern C twion Bmurvtcc, as required by Satin
s
37W of Je C the o ercc fthe won for •'hich this Permit In island.
/
m er and Policy nJlmber ere:
Cemer: n Policy Nss: AA/ OP]A/'%/RI
CERTIFICATE OF EXEMPTION FROM WORKERS'
/
COMPENSATION INSURANCE
(Thio yuat reed me Magnpindi(thc permit infmorc M1ndrd ddWrs($1A))
or les")
1« miry that in rhe PnE.crofthewmk for whichthis permit in issued, Ishii
Oz
O
a;
0
U O
0 F'
WLendersASncu
6.
nm concoymy porout In any mann[catnn to Iv ore suhfae to Thu Work" C.....
nation lawsuf GWlhmIlLL Data
ApMicant
NOTICE: TO APPLICANT: IL after making this Ccnificale od Encmryion, you should
becomewhjecttothewnrismscompe--polis the Libra -Code, you mull
fulmo.ith comply withnurh mvisiom«thin pemdt dimmed! reload.
CONSfRUCIIOIS AGENCY
IMeby affirm that Jere inamnvw etdin8 agency I. mc pmfmm. of
the wudc fur which Nin Permit is real Dl1. CIV. C.)
larders Name
Wove infomoon
I.tar that I ha kepm and nm athv tic Wmu
N
U Z
comm. I agree m elfinithat ray ed county «dinenQ and sore loos relating w
buildinycmatruc0onOF Abell eWlWriu repetntmtives of the cityroenter upon Jo
QTY.
aIUVCrnnWad9,9v,hich
I Wc) eped kap handes Je City of Cupar lliabilitin,jdich Way in any way xrme epeimtWiJCitae al.T .WILL COMPLY�}�� n
1 LARUOUS MATERIALS DISCLOSURE.
'line Eli for la'.nuildia'auvwm ntore«Mndl, baoarJousn conal
s by
Tom.,MunkiPol CodanHcvth
Coate. Charter 9.12, J the and SafetyCndc..it 2553 Ill?
Y Dido
Will the applicant to future building «cupnt tra equipment «device which
erect hvasdoua am oclmar innts u dcflnd by Je Bay Aro Air Quality Manmgcmem
District?
❑Yes ❑No
1 have read tic mveriels ngdrtmemx Wider Clasper 6.95 M the CWi-
fwia Hulth & Safeny Cale, Sarum 25505. 25533 and 255. .1 mdcnmrd shot tf de
building dasa ru currently have a anon.lM it is my responsibility to na0fy the oampuu
N de rtW uearl When mut d urn poor to icwanss d a Cenificetc a Ottvpency.
OVER lr00AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITAIISC.
MIR METER OR POLE INS'.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS; - SWITCHES - FEVTURES
NEW RESIDENTIAL FI. I= SOFT
PLUMBING PERMIT
W ...... 29991
SANITARY NO, APPLICATION SUBMITTAL DATE
NO: ^� `ver
F fY-s NIC CON'TROLA
BUILDING PERMIT INFO
K ;Pdr_— A -
JOB DESCRIPTION
DSFDWL
D KITCHEN REMODEL
❑ADDITION
D PLUMBING RE -PIPE
❑MULTI -UNIT
El STRUCTURAL
DRAINS- FLOOR ROOF, AREA, CONE.
MODIFICATION
C1 INTERIOR
DCHIMNEY REPAIR
IMPROVEMENT
OCC. GROUP
D BATH REMODEIIRFPAIR C1 DEMOLITION
DOTHER
GREASMISIDUSTRL WASTE INTERCEPTOR
BUILDING DTVI. I ETF'
CNEWBLDG/ADDMON []DEMOLITION
ANT 1-1 FOOD SERVICE
'IMMOVEMENT
OOTHER
SQ, FT FLOOR AREAj{SQ FU
Cit Q ZS. f/.� .
PEE J JUN 6 1996
PERMIT ISSUANCEVIII
Ur "L)r,: YI IIvu
ALTER OR ADD TO MECH.
ENT
ALTER - DRAIN & VENT- WATER (III
VALUATION
I e O
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR ROOF, AREA, CONE.
STORIES
TYMCONST
FUTURES - PER TRAP
GAS-EA.SYSTEM-IINC.i OUTLETS
OCC. GROUP
APN
GAS - EA. SYSTEM OVER J (EA)
GREASMISIDUSTRL WASTE INTERCEPTOR
BUILDING DTVI. I ETF'
GREASE TRAY
T1ANCHECK FEE
l
SEWER -SANITARY -STORM EA. 200 IT.
ENERGY FEB
WATER HEATER W/VENODELECTR
GRADING FEE
WATER SYSTEM/IAEATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLEB. SQ. IT.
Receipt Y
TOTAL
BUILDING FEE
MECHANICAL PERMIT FEE
smlvuCFFE
PERMIT ISSUANCE
I ELECTRIC . E
ALTER OR ADD TO MECH.
PLUMBING
A IR HAN DUNG UNIT (TO 10.000 CFMI
MECHANI LFEE
AIR HA NDLING UNIT (OVER 10,000 CFM)
CUNSTRUCI'I0NT
Ii HAUST HOOD(W/DUCT)
HOUSING MITIGATI
HEATING UNIT ('1'0 100.81) BTU)
HEADED UNIT (OVER 100,M) BTU)
PAID
Date
VEIsLULATION FAN (SINGLE RFSID)
BOILER - COMP LET OR 100,000 BTU)
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
I!
NEW RESIDENTIAL MECH. SQ, Fr.
OFFICE