30285 i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY //�
tCITYF CUI'ERTINO BUILDING-ELECTRICAL - PERMIT NO. /� O L H
' RUILDINGDIVISIDN APPLICATION/PERMIT PLUMBING-MECHANICAL JK
Y BUILDING PROJECT IDENTIFICATION
jBU1LDIN0 AUUR1?SS: SANITARY NO. APPLICATION SUBMITTAL DATE
ak
6WIVERS ANTEONE: CONIRACroR'S AME // LIC NO: 7-0 0
Ko 5-95�/� &ti 2 'b 905 N/c coN aOLx
CHIIEC7PrENGINEER: LIC NO: ADDRES` Li' .F; t 97 S, fJ. 9Rz� 10
CONTACT: PHONE f BUILDING PERMIT INFO
A ConsWIatH Fen Paid by Applicant(Initial) BLDG ELECT PLUM MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby eflind that I ono likened anter Im dkiau of CM mm Y(commrrcing JOB DESCRIPTION
�p2
with S<Cllcm'!La'1p)ofDivision]oftlr Business amt Pmfmsions Code,aced my license is RESIDENTIAL:
F O in full force mal affect PERMIT ISSUANCE
0. C ❑SFDWIL ❑KITCHEN RES10DF1.
QF.VZ L) Licence Cl. lie,x
NQR Dolce Cwtmnnr APPLIANCES-RESIDENTIAL ❑ADDITIONPLUMBING RE-PIPE
I,•Oy ARCH[T]CCS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
ZOnZ IurMcrsmM my plan,shall Is,toedu public record. - - MODIFICATION
OZ.-a UP TO 200 AMPS ❑IKIFRIOR ❑CHIMNEY REPAIR
Ed Lianwf Profeauonal 201-1000AMPS IMPROVEMENT,
OWNER BUILDER
tn ate RATION OV IT 1"AMPS ❑BATH RENODEJREPAIR C1 DEMOLITION
C�Q 1 ter.
a(Rrm that 1 em exempt footnote Contrators License taw co the _
x0.x O 0.V following maw.. Corr to 90313,Itmimmr and 1,cIe mmh r.Cokle
or Any city or macrame
my SIGNS ELECTRICAL ❑OTHER
which r<yuvn a perMt to comuucm alter.Ngmrrc,Jrndish,m r<pav my slmeNr<
R•O I t uNcq ulwm Ihcv I tfnr such Ito flc esi el 4atancnl
prior of aiss yuim pp iron pcmll 6^ SI'IiC1AL CIRCUITIMISC.
�y ttw heislia
I+I?�00 (cammm�ng
with Sead.
ithiataw7(0
d0r)npmf DviivsiasrmaoJf othfe thCe oBnuusinknos aLndiamc Lw(ClugcrY
Pmfculon.CoJc)m II:MP METER OR MILE INST. COMMERCIAL: ,
d K
How Is,is exempt thmcfrmm and the Buis for the,WIegeI"croptinm.Any violation of ❑NEW BLDG/ADDIIION ❑DEMOLITION
Ilea.. Sation70315 by wy applicant far a pemdt subjects the applicvn to a civil faulty of POWER DEVICES
�y ❑TENANT ❑FOODSERVICE
1- Qn mmc then Ove hunJmm dollar,(S,500),
❑Las owovofoa!,ha enymmy eqi emewithwed umrir wk rnmlcmatiao. SWIMMING PWLfJ_ECIAIC OTHER IMPROVEMENT
willdothewMt.Clodthe he Co.ivnm,Liced U.
fscwoe(.\ca"lIH4.Buxineof ❑OTHER
W stdsn,whiomdd,o The we,themes lard.]Lewdocs,Iceapply toanowmrr of OIITLLTS-SWITCHES-PLXIl1RF5
thnoilth
Ice,...who builds or impmvm Hereon and wM mo; such sunk heA or mmmifor
his own owever, 1,ptovldel 1WJ such imov,is"nta arc ms inl[n.W or affeel for NEW RESIDENTIAL EIECTA SQ FL
owelLml a will
the buitbi horimpmv moving
is Whe dxI noneyearr mvmoletfacprc SG FT.FLOOR ARRA LSQJT.
wrcr-builJer will Mve Ne hurJen of pnwimgtMt he Jld rout buildmimprove fa par. ^C rs
pose of ole.). / (� , 41
1,m owner of the pryrny,eat exdmively mnlrvning wW lianwl rnnlmcmrs to TOTAL: 510
rnnwat He,Put(Sec.70aaL Bmirras am Promm fnalCa k,:)The Conuurds Li- ✓U
K Lsw arca tat apply to w ow"n of Pri who hada,or improve«I hence,amt QTY, PLUMBING PERMIT FEE (J( �O
' who rnnuuss fm xuch pmjecic withacontrriorfa)Ikertaed psSuarR to the Comrenara
Incense I.W. PERMIT ISSUANCE
oily 9gE'
[:] Lar exempt unmrsa. ,B&PCfor Itis reawn Uh
Owner - - Date ALTER-DRAIN&VENT-WATER HLA) VALUATIONVU
WORKER'S COMPENSATION DECLARATION ' BACK FLOW PROMCT.DEVICE -
I hereby mlDmo under penally of perjury ore of the following dedCmtimv: s
❑lMve dwillmeinuinaCcmflareof C"mmtoaf-immrfm Worker's Compcm DRAINS-FLOOR,ROOF, CO D. SfOR11LS TYPE CONS3RUCfION
vsiom,m ptmvidW G.by Section 3Iln of ton lot,Cocic,for, perfarmwmce of the
work for which this permit is issued. 'Jf FIXTURES-PER TRAP r
❑ 1 have and win maintain Workers Cmlpemar^m Insurance m"mom by Section
37M.flbe Llnr Grdc,fartheperfomnacofffew«k forwhich this permit is mond. GAS-EA.SYSfENI-I INC.] S OCC.GROUP APN
Myr
yC xpfq�v+� I '` arld Pd
Ciro NC4T2�Polley Nwyn /M2GAS-EA.SYSI'EM-GVER4(EA)
CERTIFlCA OTE P EXEMPTION FROM WORKERS' CRP.ASP/INDUSTRL WASTE INT1?NCjV
COMPENSATION INSURANCE -
(This.,am o eJ cut be mmp1meol ifdr pmnit u(marc hwdM dWlnra(5100) BUILDING DIVISION FEES
m IaSJ - CRBASETRAP
1 cadfy That m the pMormana ofthe wok fm which Nu pemml u owe l.1 moll PIANCILECK FEE
M employ any person in my manner ice as to become subject Ice Ile Worker'Conopen- SEWER-SANITARY-STORM G.20(1 FT. ENERGY FEE
Z satin.Dive of C^bford .Date
WATER HEATER W/VFM/ELECfR
z Appl�ra GRADING IEE
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should Wq'TER SYSTEM/I'REATING
bevrre wbjw to the Workers Cosnprnmtioa pmvisions a Bre Lhar Codc,you nasi SOILS FEF,
W fomhwith comply with such provisions or this pc-1 shall be roamed revoked WATER SE
RVICE
a �
Uz CONfffR is 2 conso LENDING AGENCY NEW RESIDENTIAL,1'LMP, SQ.IT PAID
V O k fnrw1hich mn Net there isacomsuvedmn lmC,, agerlcY for the peR�xnunxM Due <iq♦
tk wmkfm which this Permit is iswN(Sec.Jl19],Civ.C.) .
O F•'. LemJcrs N.re TOTAL:
Wleader's Adam+ - TOTAL:
6. 1 ramify that 1 have mom Nix applic.limm.rod stem th l me atone uArm lion is BUILDING FEE
to carecL lagrte mcomply ivilh all city end auNy wd'uwem grad uue bws mlatingb QTY. MECHANICAL.PERMIT FEE
V buildingmnsarmli and bcmby amhosim apmenmtivaofmivcitymrnmr urym the MISMICME
above-mentioned pmpe"y for impatiou puryoscs,
(We)ogre,to rove,indemnify and kap hvrmksx the City of Cuperrom against PERMIT ISSUANCE ELEC RIC FEE
liabilide,judgmers..+,mill espe.which nay in my way aaruc agw rq said City
in cm5ryuence of the granting^(th' .nil. ALTER OR ADD TO MECH. PLUMBINGFEE
APPLICANT❑ liAND WILT COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO U)."Cli
OUR CP ONS. MECHANICAL.FEL
-7— AIR HANDLING UNIT(OVEJ to,"CFM) CONSTRUCTIONTAX
Si ofAp eml/Conelm ^ !
1}m EST IAUSf HOOD(WIDUCI) HOUSING MITIGATION FEE
HALSRDOUS MATERIALS DISCLOSURE, -
WilltherMliemtmfutme building wcu,odl vtmre or handle Mremlouv material HEATING UNIT(TO 100,M)HTU)
as defend by the Cupertino Municipal CWe,Chapter 9.12,and the Health.ad Safay
Cade,gee11M 255321e11 HEATING UNIT(OVER 100,000 BTU)
F-1 Veer F7 No VPMIVSTION BAN(SINGLE RESID) PAID
Ilam Rcccim k
Nilo the vpplinm a furore huildi.g arhnnt y A equipment AiiI devices wbi<M1
emit hvaaNaua as mdaNioaNs mJcnrcd by NC Bay Arm Air QuJily Mawgrnrns BOILER-COMP(]HP OR IOp.tlpO BTU)
Disuiai lU'1'A L:
E]Y. FI No BOIWiR-COMP(OVER IW.000BM)
I have ream the h,,.,,ectal materials.xlaimm ena walerchapten 695 of the Cvi-
AIR CONDITION17R ISSUANCE DATE
fomu Health&Safety.Codarum
e•S255(EL 25533 sod 25533.1 Iudcrstard thw if the NEW RMIDENIAL MECH: SQ,PT.
handing dno
es t curemtly have a orrort,tMs it is my radmhky Ice dotty th<acapnmt
M Ne mquircmcros which mum be rout prior to issuance of a Cemificate MOccvryncy.
Ou'our a authMxd BgcN Date TOTAL: ISSUED BY:
OFFICE