30310 nrrua.nns rvr - �(S 1
CITY OF CUPERTINO r err rvr.ear r nus tars.r rsr BUILDING-ELECTRICAI, PERMII NO. �] O J 1 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECNANICAI, J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANT IARY NO, AI'PLICAI'IUN SUBMIT IAL DAI
OWNS 'S NAhIG: )NI:: CONTRA G SNAME CN( _
NIC CUM RI)Lk
s •, ne-
R ;( .54
. ' NGINFLR: LIC NIO: ) E . ❑
COMM /,a f PI11�d BUILDING PERMIT INFO
h G l l a S l/ El Fees Paid by Applicant(Initial) HLIXI ruiCr' rLPLUMBnn!CII
7/^7'C ❑ ❑ ❑ ❑
LICENSED CON I RACI OR'5 UECLARA'I ION QTY ELECTRIC PERMIT FEE
1 hacby affirm mol Iran licensed coder powiao..of Chapter 9 tenmmcndng JOB DESCRIPTION
sCUU"Z with Section 9aXlMf Divilinnl of The Business nn m « m rile and= littnsc ix RFSIUENTIAL
00 bull forts and 61".. PERn11T ISSUANCE
L ❑$FOWL ❑KITC7HEN REMODEL
aVW ).it-tav flan Lick APPLIANCIiS-RESIDENTIAL ❑ADDITION O PLUMBING RE PIPE
F�W Date Contrmhn
PH.�y III he
CLn recon PANP.1_S ❑MU171-0NIl' �YMODIFI URN.
IunJersmwl my plans shall M1c used as puM1lic rmnrJs MODIFICATION
OZ-1 UP TO 200 AMPS C1 INTERIOR C1 CHIMNEY REPAIR
Fa�2tW Licenmd Prof"barl 181-10I0AMPS IMPROVEMENT
C C C Q I hereby nf(irm that em emER ltmt fmn me C nvvaor's Liccn,c haw for Ibc OVER ItXX)AnfitS BATH RUMO E UP IR F O ION
'aC 3 ll.oL F following reaarn.X5 rinn'/1131.3.Business and 1'nJcsaions Code:Any city or county SIGNS ELECTRICAL ❑OTHER� 1
LL1 0 which remrims a rrennit to construct.alter.improve.denvdish.err repair any gimclurt
CLLy paint,,its issuance,eFo rtynirea rhe applicant finsuch permit 1,file aligned smmmmn SPECIAL CIRCUITMISC,
y that he is Recover pnr,uant in the provisions of the Cornructm'.v Lireno,law(Chaplet 9 1
00
he treating with se001hof Div3ofThe lhssi .,,and Pmfes,ionsale
O )or 'TP.EMMPK OR MOLE INST. CQMMEBCIAL, Y r
ct 1 i an4
e,G M K Thar he is exempt Ibercfnmo and the hasia for Ric alleged cumrryion.Any violntin I of El NEW BLDG.ADDITION ❑DIiM(OLITION�
4W'
Section 1011S by any applicant fn,a permit mhjeel me apprcmn m a civil Penalty of POWER DEVICES
"m ❑rUNANT ❑FOOD SERVICE
t � our.,are than five honmN dollar,WWI)
❑I,as caner of the property.nrnry cal with wogs,as th&,olc c terrsati.n. SWIMMING POOL ELECT RIC IAIPROVIiM17NT
will do the wad,end the.amcmre i.s not imendM err offered fm sole ISec.](D4,Business ❑01 HER
W
we and Pndc..Iran,Code:The Comeschn's Livense Lnw does an,appy In an owver of OUTLETS-SWITCHES-FIXTURES
a 3 propcoy mho builds or mipnwesmereon,and who doessuch work dolwif or through
his own errrployees.Provided marl.such inrpnrve nens arc and Intended or offered for NEW RESIDENTIAL EITC71 R SO Pr.
sale.If,however.the building or irnprovcrrrent is wild within one year cnnplviait the SO.FL FLOOR ARIEA9 r SISQ,FT.
erhuildcr will have the bunlen of proving chit he did not build or improve for par-
lo a afsale.).
C1 h a,owner of the Property,nor exclusively contracting with licensed amaumo=m TOTAL: a
m,rmm me p,,-jest(See.naw,H.,mea,non rroa,,iao,Cadc., —C......mr'..Li- JUL 3 1 199
vcrre l,aw does not apply oil an owner of property who hued,or haprne,thereon.and QTY. PLUMBING PERMIT FEE
who contract,for such projects with a comranogq licensed pur,aten to the Contra am
License Law. P17RMIT ISSUANCE 1111 VI" s.l;r'l:rt IT.
❑1.,,1 cmmPr..,It,see. ,B&r C-fan his rrnsnrr
Owner USe
N.TER-DRAIN&VENT-NATER(CA) / At
_
WORKER'S COMPENSAT ION DFCLARAI'ION BACK FLOW PROTECT.DEVICE
I heaby nrfnn under penalty of pe juryone of the hdlnwing dwlarmions:
❑ Ihaveand%ill niainmin a Certificate o(Comcnno war-insure for Worker's Cwnpem DRAINS-FLUOR,ROOF.AREA.COND. STD�IES TYPH CONS I RUCTIO
etiero
n,as pvided for by Section 37M of the I.aMo Code,for tire performmnce of the
work for%M1ich this pemrit is issued. 1'I XI URES-PER TRAP
1 have and will nninmin Writer's Compenrarion Insurance,a,rc4uied by Sectin l
1)(0 afore larMx Cove.for the performance dime work for which this planar is issued. GAS-EA.SYSTEM- INC 4 OUTLETS OCC.GROUP APN
My W'orkerk Cnmpenvtirea Insurance carrier and Policy norther ore:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEaNDUS UU.WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thi,section recd nm h compiverl i(the permit 1,for me hundred Millan ISIMIT
or fell,) GREASE'I-RAP PLANCUCCK FEE
Ircnify lPm Enrun anMmmame nfrhe wick lar which this Winis el,C, nee.hall SEWER-SANITARY-STORM EA.Hp FE.
rvr,employ any Persian in any r M a rlyy ur me Wnrken'Cnmpcm ENERGY PER
0 z Brion Law,m t r'Tyu. a �;a n —� WATER IIEMIER WNIiNT/IELECTR
z O Applicant ugnuwG r,:1:
rho NUIICIE 1)A ' h after making this Cenifcme of lixenrption,you,baild WATER SYS'IEMM READNG
a ' t'GI I a au n a the W,/ 'a Cor',rnetion prat m-,of the I..hm Code.you mus SOII S FEE
fonhwim am with inch p—m n,or his pennilsshnll be sh,on,l revoked WATER SERVICE
LQ
P. 0
�:) z CONS'IRUCIION LENDING AGENCY NEWRESIDEN'IIAI-PLMIi. SQ Fr. PAID
U 0 1 hereby vlliun maldwn,i,,c talion hodingngDroy for rbc prvorm:mceof pan, RccennN
U. I-+ be cork fol wbidr this permit is i,med(Sec.11M97,Ci,C.)
0 U IsnJvi Name TOTAL:
'a Isnder s Add... TOTAI;
1 cvrtHy Thal I haw rend this appl icnrion and,=m than the aMwe of union isBUILDING FEF,
to core..I ague rr c...rply with all city and coo-ny onlinmme,and,rare law,=luting m QTY. MECHANICAL PERMIT FEE
m
U building conarution.and hereby ahorbe repre¢nmtives of Ibis clty ter crat'n nnhe SEISMIC FEE
nMne-mmalin led pmieny for in,pealion fit tpnses.
(We)agree in save,indannily unit keep hanolcss rhe City of Co,er ino aguinn III TWO ISSUANCE ELECT RIC FIT
liabilitiesjudgmenrs,cors and expenses which pray inany wnyacemeignittsr sail Ciry ALTER OR ADD 10 MECII.
in cone(luence of me grunting of this permit. PLUMBING FEF.
APPLICANT UNDER. i' NDS AND WILL COMPLY WI'I EI ALL N(N-POINT AIR HANDLING UNIT(TO 10AX)CFM)
SOURCI RG MECIIANICAL FEE
AIR HANDLING UNIT(OVER Io.IX()CI:M) CONS I'RUCI'ION TAX
Signrhy
t '( -m=otor 1 m EXHAUSr HOOD(W/DUCT') HOUSING MITIGATION FHT
A.All TO. MA'ERIALS UISCI(O.(IRE
cam or bnure huilding warpmn nrc n.hnAle ImmrJnw nmmril IIF.ATING UNIT(TO I(M.(XXI BTUI
depeni an Municipal Code.Chapter 9.11.and rhe IRabb and Safetyn1(.)? / I IEAI I NO UNIT I(OVER IINLIXp RI U) /�
❑Yea LTj'IP PAID !3
•e VIiNTI1.A1'IUN I'ANISINGLF,RESIU) Dam Receitk
Rill that air cieam or nsa building occupant y A ea Air Qu or ileums,which p
crit Grolier? TOCAU
m air nm=minnnta a;JefueJ by the tiny Area Air Quality Managenrcm RfOILFiR-COnIP OIIP OR 100.0001171J)
❑Ya 1 BOILER-[OntP(OVER IIX),IXM BTU)
I have rcaJ rhe hvmJama mmcrials AIR CONDITIONER ISSUANCE DATE
rcyuirencros umkr Chaps fi 45 of rhe Cali-
fornia Health&Safety Cade.Section,3558.5,8531 tell 25514.E umkn=od that if the NEW RESIDENTIAL NIECE. SO.Fr.
hilJingJrcanw�hr ,i,qomcl,
t is nw rt,punaihility mndif mew perm
rfrlrereynbe " ) or. Is It ImeUwn a .ud i U c TOTAL: ISSUED BY:
OFFICE