S 1249 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
_ CITE OF CUPERTINO BUILDING-ELEC'I'RICAI. I'li ❑'KO
BUILDING
1) ISR
APPLICATION/PF,RMPP PLIIJIIIING-sIBCII.\h'IGU, 1249
F• BUILDING PROJECT'IIIENFIPICA'HON
B111111-DING ADDRESS /�fS_ ta0 � SANITARY NO. AI'PIJCATION SUIIMITI'AL DALE
�aV ER'SNAMEE: �'k._R7 III 3 CU TOR' AMIi: whl-CNO:ZC
N'�
I ECHENGINEF.R: IAC NO: ADU 1'�.,fc
�> SJ
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(In111al) III IiLEGI' PLUMB Milt]
LICENSED CONTRACLOR'S DECLARATION QTY ELECTRIC PERMIT FILE
l ner.ny mtinn m:. aa.liwttaed.m1er rrovkaana of Cleuner 9(,our enemg JON DI?SCRIPTION
O�Z withSmion]1p0)ofDivisionJof lhcBmincs and l'rofensions Cade,and my licence is RESIDENTIAL:
m O O PERMIT ISSUANCE
F-� In lull nav,and cr,l, ❑SFDWL ❑KITCHEN REMODEL
QUZU Licenac Class Llc.)I APPLIANCICS-RISIUENTIAL ❑AUDITION El-U) RE PIPE
yC w Ilan Contractor
CirI ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F h unenun
Z I dd my Plans shall bere
.,oil us public cmd. PANEL-9 MODIFICATION
ZOZ�-n UPTOW 2AMPS 1'ERIOR CIHMNEYREpAIR
4)
I- t'u01 Licensed Pntfeuionsl 201-1000AAIPS IMI'ROVEMENT ❑)]SWIMMINGPOOIS
sj E; OWNER-BUILDER DEChARA'I'ION OV17R HWOAMPS ❑LATH REMODV1s Rh;PAIR ❑DEMOLITION
p{a,,C d'Q 1 hereby affirm that I am exempt from the Contractor's License Law for the
X 3 d U following reason.(Section 7031,5,Bon—and Professions Gyle:Any City or county SIGNS ELECTRICAL OUTLIER
W LL y which requires a permit to comWcl,alley,improve,demolish,or repair any structure
O� prior o its ixxamee.also requires the applicant for such Winniuo rile it signed statement SPECIAL CIRCULI'IMISC.
E }
'bar he is licensed Purs..nlmme Pmvisiana of the Contractor's License law Whapmr9
�ap0 (avmn¢ncing wilb$cctinn]fl(Xq of Oivisinn lot Ne Boniness and ltufessiona Cmle)or TEMP MIPIEROR VO.EINS"E COMMERCIAL:
a a e C (bar he in exempt Ih...mot and the basis Lor IM1c ulre,di cxerplem.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by anyarplicam far.permit subjects the applicant to a evil pendy of POWER DEVICES TG ANT El SERVICE more than live hundred dallan With, I ROVEM"1'
~ZQ QLmowncr of the propcny.onny cmPloyccs witM1u'agcs as lhcirmle ronmenaminn, SWIMMING POOL ELECTRIC
Fowill Jct the work,uml the.druc..e is mearlcndodoroncodfnrsalc Xc,.7 W,la,invo, T 'R
Ia1- m anJl 1 CNc qh C t Irsl c - f J s apply 'neral OUI'LEI'S-SWI'ICHLS FIX,URIS
prop ry wh M1 lJx or' p th on I h J ¢h k h : If through
his pl Y h provided that h imp t. not intended lltil for NEW kESIDEN'I'IAL I:LhC!R
sale If.however,the brldingm improvement nsold within one yearofernanction.the SQ Fir 1:1 OOR AREA $/SQ.Fr
owner-budder will have the huNen of proving(hat he did not hand or improve for por- Vim/ ^ � ' D
E]L ..toile of the Prnpeny,a sclusivcly r'v.runing w.in llmnsad c tnr.aare tit TOTAL: M-
own r
onarva the protect(Sala.o ann Business and n,whoi bud Cade:i no Contractor's and
hoome JaeamaaPplymmt with
PmPonywhe sedporirprotheCountou,urJ QTY. PLUMBING PERMIT PEE FEB 17 ANS°p
who arommcl for such pmj¢u with a ntmmdnHn)licensed punu.nua the Cantmdnrs
LiccuW Law. PERMIT ISSUANCE
Cl I am exempt..do,See. .It&I'C for this reason CITY -
ALTER-DEAL N&VENT-WAIER(EA) AL
N
Owner Dale
WORKEmtdnRS COMPENSATION DECLARATM
ION BACK FLOW PROTECL DEVICE VIII /^
40 1 hereby d.nt renally of perluD ane of the fallowing Aanvnnians: «/��JJ
I have and uill maintain a Ccnifieate.1 Consent to valf-inmm for Worker's Compco- DRAINS-FLOOR,ROOF.AREA,COND. S'I'ORIBS 'TYPE CONS'IRUC'I'ION
,an i.us provided R.by Section Jlgl of the labor GNC,for the perR mernee of the
wok far which this Permit is iaued. FIXTURES-PER'I'RAI'
I] I have i it will muimein Worker',Comlwnwlion Insurance,as required by Section
3700 of the labor Cala for the performance oftbC work for which this permit is issued GAS-EA.SYS TEM-I INCA OUT LEIS OCC GROUP APN
My Warker'a Cnmpemation Insurance carrier and Policy mortar art:
Carrier: Foliey Na: GAS-HA.SYSTEM OVER SLEA)
CCRTI ICA'I'1:OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASDINDUSTRI.WASTI7 INTERCEPTOR BUILDIrkG D S
(This anion nuN nothcoinpleteJ if the .,mit is for one M1unJrcJ Jollan lSllq)
GREASE'I"RAPl� --
or ICs..) I'LANCH[CK PEIi
I sonify t . .the pernmmamc' )exik vhic thisltenmllisiswW,lshall SEWER-SANIL\RY-STORM EA.^_IXI I'C ENERGY PIJi
men"""u yl':nnirq of whlNmtheWorkers'CoPcn-
Z scion Lim, C iforma,I to WAI ER I IIIAI'Ek W/VENT/ELECI'R
Applicant
or ova o CRAVING IEE
(yr ICE'O '1'LICAN U 11,ober making thin C ilicute a Perot inn,you should WATER SYSTEMffRI;ATINC, SOILS FEE
FZ ? become_. 'cot .the Worker.,Cs'a Irs.,minnrmvr bnsoft `Latar Cao."mmast
ronhwhh mi whh such pct is or this porno s ul mMn,voked. WATER S17RVICE
Q
az CONS I'RUCI'ION LENDING AGENCY NEW RESIDENT IAL PLMIL SQ,14. PAID
I hereby turbanned them aar...tmninn lendingagcncy fonhc gromrme in Uotc ftucaplN
the work sur whiuh this pcnnil is issuol(Sec.l(XP.Civ.C.1
U lender's Name TOTAL:
R.1 Lcrout,Andress TOTAL:
1 I ,.try that I have read this appllcadnn and auto In.(the above irkomeniu.is BUILDING FEE
to camea.l.gme e.comply win all city and ammy ordinances and alae laws relating m QTY MECHANICAL PERMIT FEF.
U Z hand..,cmom,fon,and bendy act i,oe,c,nadl—ofmis city la iter nrmt me sElsnuc EEE
absoc-rcmioned prapcny for inspection purposos PERMIT ISSUANCE
(Wo)agieo v.nay..iodcmni l'y and kc,hurl Oto City of C.ponino mgearea ELECT RIC FEE
liabilities JUJgments,ens- xpenseswh h ity in any way acerae againd said City ALI ER OR ADD TO MSCI I. PLUMBING PCC
aft grmenguft in Pen
API'LIC iTdl ' - ANDS ) kD11
LL NON-POINT AIR HANDLING UNI'I'('10 H1d100CFM1 MECIIANICAL Fid'
SOUR': EGll.nn )NS.
AIR HANDLING UNI'I(OVER 10,000CPM) CONS'I'ftGG ION TAX
six moot Applicant onlracfat F.%HAUNTHOOD(W/DUCI) HOUSING MITIGATION IE
HAZARDOUS MATERIALSill theapplicaut or Inure budding oo,ards,ntmeal BEATING UNIT(TO Ip.000 RTU)
cfia d by the Cupenino Municipal CalHoalfl and Sa4.y
Cndc.,upon 25532fv1'1 BEARISH UNIT(OVER 100.000 B'ITO
C3 Yes No VENTILATION PAN(SINGLE RESIDI PAID
Vac Rcmi M
Will the applicant or future th Iding necapeol use equipment or devices which BOILER-COMP(311POR I00jXXIB'IU)
at hazardous air contnnitmtn as defined by the Buy Area Air Quality Management TOTAL:
)I rnol! BOILER-COMP(OVER 100.0MOBTU)
(]Yes E3 No
I hart rad the hwmokmaterials"ii"initiation,under Chapter of IM1c Cali- AIN CONDITIONER
ows ISSUANCE DATF;
omnia Health&Safety Cade Scabna 25545,25533 and 25514.1 under.,mnd that if the NIiW RESIDENTIAL.MECH. SQ.FC,
huildiag does not currently have.tawm,that it is my re,,r ability Io notify the accaaprn
of the recluirnnrnl which must be met prior to issuance of it Com feats of Occupancy.
Owma o,anhorieed agent Dale TOTAL: ISSUED BY:
OFFICE
- S ,
�y
Rpnevp
FEB 17 7998
BLDG, INSPECTION DEP,4RTMBNT
CITY OF CUPERTINO
1 I
C-faR�t�'
APPROVEDIN
THE CITY 01:,
CUPERACCORDANCE CODES AtND RD NANCESI
ICE
SIGNED,
SIGNEDI_ I
this set of plans and specd,;ations h1US - --
be kept on [hit job at ail limasand it is un ^
I Mul to make any Chan4,2s or alteration
•same without written permission from
building Dept., Cii!� of Cupertino.
the stamping of this plan and specification$
SHALL N0l' be haid to permit or to be art
approval of the violation of an iI
if any Ciiy Ordinance or State UWyiSi0p9 TIc
P
4Z -7 N1E _l LE0 L- �c.
.PAC,L Zg I
3z ' 1 . 25 l - L��--
Dn,
a
CPV ��
Qo�