29870 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING, ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJFCT IDENTIFICATION
^ ^ O
PERMITND. ^ VJ yV(
29870
BUILDINNGG ADDRESS: _
�-�(`F/TL
SANITARY NO.
APPLICATION SUBMITTAL DATE
PH`
O UNJ kL.�.0 it (:Z -
�N•J
CONTRACfORSN LIC NO:
NJC
❑
CON7�RO�
RCHITECTMNGINEM: LIC NO:
ADDRESS:
CONTACT: PHONE:
❑ Consultant Fm Paid by Applicant (Initial)
BUILDING PENMI'F INFO
Bj�.Dyf1 ELECT PLUMB MECH
SLA ❑ ❑ ❑
Q0O ZO
FF--
�yUV
LICHNSHDCONIItACI'OH:SDFCLARATIONQTY
1 M1achy .M. t 1 em Idcnned t r pmvEim d Cnapur 4 (cvm icreing
with Satin][IBB)of Division flusitre,erd Rofeuiom Code, and my liaaeu
in full force vM effmt.
IJcaoe Cleo Lic.g
Dae Contractor
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI, ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCNRAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMOD�IJRFP_ DF LITTON
[]OTHER
��-
pERMI'1'ISSUANCP.
APPLIANCES - RESIDENTIAL
NQG
FOn
ZOr�rZ
OZ -Q
ARCHITECTS DECLARATION
Iumavam my pDm shdlhumlmaor
Public rds
PANGS �
UPT03(X)AMPS
nY W 6
x O L O
N'-1
(:u]LLO-1
- g
H
Y
00
a a o Iy
-y
1-Z}
E,�Crnwof
W
W
L 3 -
use ,id Ptofe,imud
OWNER -BUILDER m Ce CorooON
1 hereby affirm that 1 em exempt from the C ,i.n, Cr'a Liarae Lew f.. th
ollowwhich inguim a (Satin 703", sommi t, alunr. and ve. di ro lk Codc: Any city ur amnrr
which rtquirmupermit In esu thin elltt,improve,h peolutt m, a sigedl ammann
primm,lio nr Toritu romthe thin ilio l lot pemdl lofkasigndavctrent
thaum,nci emN pur,uann to ))of isiom oflhe Contaace. LicenseLaw 'i.m, CMI,)
(omtmrneing with Seaiom 7(0)) of llivieim Joflhe Busircer and Pndasiom CaJe)or
Nv M is can si n derefmm end ole Wsil for the ellegal c,o mption. Any vimim. of
Seedon 70313 by any Wicam fare p:noit subjects theapPlicau to a cisil Prnaltyof
'lot lhanfve hondmldollm(Siff)).
thnNilM1 hllJ
Wil th wwk,Cdn avC isnrinteM is,, cdfa sslc(Sac. tato. Businca
h Code: Tie CennacnYc land wl law are, ora apply m ace orwrcr d'
and Rofc who
hi—wo who builds m iml Ith thcrtun, and subs arcs such, mk hcd o r or through
hie awn owe( ec, poo ung that nmeh rt& I% n d w am nm int of or offer n, I'nr
trr-beild[r will have tie hrtdcn of poviog that h did rwt Wirt a irnfvove f« pm -
owk -aid,k, illbssOx , ifingmimpf prroemisat Ix did borciM or imaowe for
M 1.of uk ),
❑ h m owner of lc, S.. 7D, em r i.& and am0acting with Tnud cnnact-, -
otrotn act tlpmjoa(Sec.tau, BLL of admyw1hotwi Code:)The Contactor'\nt
whIswdw owl apply tosuowrla nfpropcny who builJaoivryroves lheemn. and
o contract& for such project& with a comoo,tm(s) li==re purwann le me Cmtreaiwx
Lioe.Law.
tuoder5a. ,B PCfor Nin reuum
X11-HWAMPS
OVER 1000AMPS
SIGNS BLECBICAL
SPECIAL CIRCUIT/MISE.
-
TEM
TEMP. METER OR POLE INST.
COMMERCIAL
[3 NEW BLDCJAUDITION ❑DFIs10LITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING IYKB. ELCTRIC
OIfrt.LTS-SWITCHES-FIXTURES
NEW HESIUENI'IAI. ELEGTR SQ F1'.
.
SQ.'FT.ROORrAREA
,ryI
JU • 3 1996
1cI I Y Ur l urcrslll�U
S/SQ. FT.
TOTAL.
QTY'. PLUMBING PERMIT FEE
PERMIT ISS ANCE
AL RAIN&VENT-WATER(EA)
VALUATION
y
O eya'v
OZ
O
M
("' ^
W ti
7 Z
V O
O!-+
CrJ
Z7Z)
V G7
WORKER'S COMI'EbISATION DECLARATION,
I hrrby aff nn utnkr ptismy of pujuU ore of Nrc W
e folbwing aetior v:
,] I bass sort will mountain a Cenif u< ofCom.,rnt on self -hours, for Wotkrrs Ctm,er-
cation. a mvitInI for by Salim 3700 of thc later Code, for Ih perfrmenoe of the
work for which Nis .,it Is kmed.
❑ I love and will maintain WM<ir Cnrrrperuttim Imumnce, a reyairtd by Section
310Doftbe Lahr. Codr.(or th lerf«mvee ofire swrk for which this permit is issued.
My Worke, Cnmpensnoo lmmcncn,. er utd Pdiry numhr era
Conicr. Policy Nu.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPF1iSAT10N INSURANCE
(Tiffs scrimad nor rad compkucd ifthorton c pis for me hunbcd "hunt (S I (C)
or los)
Ieenifythninthnanymums,r fa to bb f which Nis th, Woaus Cormhall
ria employ any person N any rrmnna w a w berm subja't to the W'mkrn' Cmopcn.
m,im Tawe of Cebf—ot Dar
A,kcanl
NOTICE. TO APPLICANT,If, after rroking Nis Cmikinn of Exemption, you should
Name subjm to the W'arkai Curlpemaim Provision M th labor Cute, you must
forthwith cmtply with such pruvisims or Nis permit shall h J mscdl mvoaM.
CONSTRUCTION LENDING AGENCY
I hereby affirm Net there is a cmamictios koding agrrey for th pttftmmrcc of
the work far which this rcrmu is iw (,Sec. 3(N7. CivC.)
Linder', N.
B1 l'F.CT. ❑VICE
DRAINS-FLOOR.R RF OND.
STORIES
,
TYPE CONSTRUCTION
FIXTURE AP
GAS -EA .S SIE ' d
DEC. GROUP
ADN
GAS- FA. SYSTEM-OV1<4.
GRFASFJINDUSTRL WASTI CEPH)R
BUILDING DIVISION FENS
GREASETRAP
PLANCHECK FEE
�-
SEWER -SANITARY -STORM EA. XII FT
ENERGY FEE
WATER 11PTER WNENTELECTR
WATER SYSTFJN/TNEAtINO
GRADING ME
SOILS FEE
WATER SERVICE
- -
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
hale Rvelp0
TOTAL:
len ,Athheo
1 certify Not I have read this applicedan and sure Iha th alwve iof«mvim is
mrrat 1 Wg 1. comPly with ell city une county onirunce, and nae low, nch,mg m
building commictim, and hereby nucromon repcunutiven ofthu city to crmrupon the
above -v WO tillm in sacn fm impetion purpose,.
(w'e) agree to save, imdrEftfffiy and tap hamlru Its, City of Cupenim egaimt
liebimis.judgmmnt,cot& amiexpensm whi,h may inany wnynecruc again., vid City
in corocqucrce of de grunting of this' mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCEREGULATIONS.
TOTAL:
BUILDING ME -
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRICHE
ALTER OR ADDIT) MEC11.
PLUMBING FEE
AIR HANDLING UNIT (TO IB.000 MD
MECHANICAL FEE
AIR I IANDLING UNIT (OVER I0.000 CFM)
CONSTRUCTION TAX
'
$ignamrt of ApplicenuCwuncur Dae
HAPARDOUS MATERIALS DISCLOSURE
Kill thcapplicam or to,we building..,.I uomor landlc harankvs Tutcriul
m okfnul by the Cupmim Municipal Code. Clu or 9.12 and Ne Health and Safety
Coli Sncoon 255]3(.)7
❑Tor ❑Yo -
Will Ih epplicent or forms, building acopann use �uipntrnt or Jevitt, wh
It baardous air cmmurn000u a ckfaN by Ih Bey Are Air Qunlily Maoagetrrn,
arkt7
❑Yes No
I haver thin hnunous materiels Gri-
rtyu' 533 an 115 4. 1 ma 6.95 d that
fmdii Health R Safety Cole, S. o, m 25505, 25513 and 2553].1 undersnvtJ the firth
4thengdoxi ,which have a t I. mrn. leusmcsor.,i nIff..1. fythcorcapunl
t{ the tryuimtent& which must be item prior no iwutec of a Cmifuu of fAxuparry.
EXHAUST HOOD OMMUCI)
HOUSING MITIGATION FEE
HEATING UNIT (TO I00," BTU)
HEATING UNIT (OVER 100.000 BTU)
PAID
VENTILATION FAN (SINGLE RESM)
Ilse Receipl Nich
BOILER -COMP OHP OR I(D.IX10 BTU)
TOTAL:
BOILER- COMP (OVER IW.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY: ---r \ _
NEW RESIOENIIAL MECH. SQ. FT
Owrlrr or authmiral agent Dem
TOTAL:
OFFICE
-r{ Engineering
CES Residential & Comma_ d_el
- Collyn E: Scott, PX. {-T
ar
"OWIIPS'-.-tai !
859 University #79, Los Gatos, CA 95030.
(408)354-4537
- - CITY OF CUP�RTINo--------
1!;fU I L D I NQ DEPARTMEN
10 300 ToIZRE.
CU PERTINOCA,ISo14
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NO. -37174-
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O.37174CIV11v
9� OF CAUF�
TRU5E ELEVATIC)N
RE; REPAIR EXIsnNGi. GARACatE Russ
((-
RD 484 DEMPSDER
AvE. UVCENE—P.
CuPERTlNO/ Co.L-IFI
JUN -31996.
BLDG. INSPECTION DEPARTMENT
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