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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - FJ,F-CTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
S 3955
111DING ADDRESS:
SANITARY Is
APPLICATION SUBMITTAL DATE
104$ i N GA
OWNER'S NAME: PHON
CONTRACTOR 'S__NA. E: LIC NO
Sc Oral �C ,F TSO
NIC
❑
CONTROL#
ARCFILTELT/IlNGIN1:U LIC NO:
ADDRESS:
17 6q�s C
CONTACT, PHONE_'
BUILDING PERMIT INFO
❑ Consultant Fess Paid by Applicant (Initial)
BLDG ELECT PLU��M(F� MECH
El 1:1L'J Lel
LI I-:NSP.D CO[.TItACTOR'SDECI.ARAHON
1 Wmby affirm that I am Iicen-d m
edm Pmvidduper ons of 9 (cotruneraing
.QTY ELECTRIC PERMIT. FF -E
7
JOB DESCRIPTION
PPRMII' ISSUANCE
with Scct1au 01101E aN Drinan T ofthc Business and Profcaions Calc," my Moores it
in full force cost offal.
AEEiRE -
❑SFUWL Ta ❑KITCHEN RFL10DFJ.
ENTIAPPLIANCES - RESIDAL
Daansc CWsa
Darla— Caaveremlact«
❑ADDITION ❑PLUMBING RF. -PIPE
❑MULTI-UNR ❑STRUCTURAL
MODIFICATION
ARCHITECTS DECLARATION
1 cooknatard an, plus sMll be used . public tamB
BAN
UPT03f10 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ BATH REMODEURERAIR ❑DEMOLITION
❑ OTHER
Licemed ProfaciwW
OWNER -BUILDER DECLARAI'[ON
1 thereby Rrm that I am asso, f m he Cmarreactim, Lice. Lew f« the
follmv ng as n (Sectim, 70315 Busiri and Profesisfors Code Any city of mune
write oci r Perot, to w t her' ,r de lith very. WIe
301-I000AMPS
OVER IB)0 AMPS
SIGNS ELECTRICAL
SPECIAL CIRcun misc.
Brio t t .. a.a aI cone ,Bacofor .wch m in fl g«dsta mem
(hat he ! ummma toW Pre'sias tth C a t 1 w( per9
(can .«' gwith5ccunn7NX))of Dlvisiam3ofOm Bus ro i adc)or
'11?M!'. MINER OR Pi 1 -1si
OM�_MF+FADDU
that he is cacmq therefrom cord the Wein for the alleged c .Any violedon of
❑ NEW N ❑ DEMOLITION
POWER DEVICE.
Section 70315 by any applicant Ura Permit sujat, the a cant a civil penalty of
x score than Five hundred dollars (5500).
1. as owner of the proprny.«my empl with wa rsok mmpcnsation.
will do the w.xk, col tire trmcNe is sa int offered 'ar ct(Scc.7lkd,Bec..
❑FOOD SERVICE
PRO
El OTHER
SWIMMING UL ELECTRIC
land Pmfesdame Cade: Convenors L' rot apply to en mvm b'
,miaeny who builds a vas ttea and w work himself m tbreugh
his own employers, vstN thu snob prose mart not iruaded or oRered f«
x is withave.efmpletion,the
itemin « m
.sale. 11lawereo do ildiop«ry
OUT IE -SWITCHES - FTKTURFS
NE RESIDENTIAL [1SCTR SQ IT.
SQ. FT FLOORA
LSO�FT
w -builder will b e the hordev of vi Nat W m build or marmot far pur-
pmc a ads),
❑ I, u ownerof Hot sclusively c tnc'tin8 win litter -ail c«traaors to
TOTAL
nrst. the pmject (Sec. 7ess and Professions Code:) TheC«roctae dLi-
Ir
r<Law aWamoepplynt nf,ni who bmid-almpraves tMeon. wd
QTY PLUMBING PERMIT .FEE
who nmtroets fon wub praj«u F. cantmehi Meana#'osu.tm the Contract«k
lac sc Law.
❑ 1 am uumle under Ss . . B 81' C for Nix rrasm
JUN 11
99
PERMIT ISSUANCE
I -
Dem
ACCBH- UNAINk VFN'C-WATER (FA) 1(•
VALUATION
By
'.Owrer
WORKER'S COMPENSATION ,mrION DIiC1AINwingTION
1hndby.l under{craftyof perjuryanon
for dalvatioat
BACK IROW' PROTECT UF.VICF,
DRAINS-Fl.OUH, HOOF. AREA, COW.
Iffolhre
❑Ihave cost will mainmin aCmif mon Consenuo col( -insure for Wmker'eCmmpm-
ma
motion, u prnvialcJ f« by Salim 3]00 of Ito Ichor Cade, for the performenre of dsc
wM which this is issues
STORIES
TYPENNSTRUCHON
�<-T�-.
I+ITJ.PN
FlXNRLS-PER TRAP
haveudintit Compcmatim th mquier by S«tion
I ruse cod will vas.
it
iruufaxc,
for e, perWarkeor
3]00 of the Labor Cak.f«de pMvfmucc of the xvrL {«which this Banat is issuN.
GAS -I:A.SYS-IIJ.I-) INC.d OUTLETS
OCC. GROUP
APN
Wb.cr's CofrPcrwi. lrtsuraytt curler rad Policy nu
tn
Cvrtic �puze sr� iT.6WO Policy Nu:w 7�5
GAS-EA.SYSIEM OVEHJIFi\)
'
CERTIFICATE OF EXEMPOON FROM WORKERS'
COMPENSATION INSURANCE
GREASEVsDUSfRL WASTE INTERCEPTOR
BUILDING DIVISION FEEL
(This ani am cont ton be eomPlnul ifah, permit is fororc M1utdred dollars($IM)
«Itea.)
GREA.SETRAP
PIANCHECK FEE
lcenlfy that to the any orri of thaw«k a,mhja Nin Benoit is i.uucd,lshall
not employ any pcmrm In any nwnnn so ss m h amm nuhjn�uo Be W«kcrv.' Crampon-
gliWliR- SAN] TARY-STORM EA. 300 FT,
ENERGY FEE
WA'TI R HHAH7R WAIW!"TI-ECTR
GRADING FEE
.If .nt Laws of c:l,fomia. Dora
Appficant
NMICE'10 APPLICANT: If. eftn making chis Ccniticmc of Exemption, you shomd
Icarmc suhject m the Worker's Campcn.sation pmviuml. of the Ialou Ede. you must
WATER SYST'EMcMIlATING
SOIUS FEE
WATER SERVICE
forthwith comply with rah pmvisi«u« this pc ram Jill b, damn revoked.
CONSTRUCTION LENDING AGENCY
I hereby anima that Bare is aemsvunioa lenlieg agarey fart the pnfoevuree d'Due
NEW RPSIDPNITAI. PIJNR. SQ, FT.
PAID
Radpa
ala w«k f« which Nis pvmit is usucd (Sec. JO)], Civ. C.1
IrMn'.s Name
TOTAL
lender'sAddress
TOTAL '13, o
BUILDING FEE
1 anify Nu 1 have reed Nis applievim aM slam that He, eh,v<infomwim u
conect.I aemem comply win all my and coumy oNine«e, and sum, hews sluing to
Wilding c«vweti«, and hereby acdWrim rdremntatives of this city to corm upon the
QTY. MECHANICAL. PERMIT FEF.
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
uMve-racmimad pfaI fam,,ecticn puryose,
(We) ultra to srve, indemnify ant! keep ratio. the Cay of Cupecarm against
AIDER ORADD'ro MECH.
PLUMPING THE
labilifles,pdyments, rusts and expensis which may many way Cense against said City
in rnnugamncc of me gmma, of this Pcmat.
AIR IIANUIING UNIT (10 IgBp CFM)
MECHANICAL FFS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
RCE EOU1A Hg.
AIR HANDLING UNIT (OVER IO.WO CPM)
CONSTRUCHONTAK
7
Signatereo ApplicanUComoterm e
HAZARDOUS MATERIALS DISCLOSURE
IXHAU.STHOOD(W'/DUCT)
HOUSING MITIGATION FEE
I IFATT NO UNIT(TO I OO.BIO BTU)
Will the applicant«(umea Wilding« ,coral momor handle Moanlnus material
to deffrM by free Cupcniro Manocipd Code. Chapter 9. 12- cod the Health and Safuy
Csak, Sarian 25533(g7
❑Yes ON.
HEATING UNIT (OVER TO,000 BTU)
/
D. PAID"
Re<eiM Y
VFMIIATION FAN(SLNGLE RESIN)
BOILER -COMP (NHP OR 100.000 BTU)
Will the aW cam «future Wildingt use ev,mpnent «devices which
mvpan
emit hvudws air erntvoiwde as def rte] by de Bey Afro Air QualityAlavgemeN
TOTAL
BOILER-COMP(OVER 100,000 BN)
DotdcB
El Yes ❑ No
AIH CONDI rIONER
un mialn rcyuiraCI umla 6.95 of beCali-
l lac hrdauer
I have awu=n
ISSUANCE DATE
NEW RPSIDIlNTIAL MECH. SQ. FT.
Gonia Heultb irSrfcty Crek. Seomiras 1!5505,25533 .,1 IS5M. I tudcmud that tithe
hm Wing ben ton eminently have a tenant. that it is my mepsueit,dry to not/ljfy Nuccv,c,,,om
v D
e vlu mrenI hi �I M1C mC Poor to icvamme nl a C`nar�
i 9
r a5dumard age -�—�, 6 j ---i 1
ISSUED BY: `+� C ryN7Uti�-�+
TOTAL:
OFFICE