99110145 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY J
CITY OF CUPERTINO BUIhDING,FILECI'I.I CAI. i'I!RMI'1'NU.
BUILDING DIVISION APPLICATIONIPERMIT P[N(I ROJI0x n%rll)EANIFIC
ItU11.DING PRUJI?C'I IDEN'1'IFICA'1'IUN
BUILDING ADDRESS: . Y NU. APPLICAr1UN SUBMITTAL DAT
ff-z,?- fIT ;'
OWN 1L: I'HO E:��I- ONTRACIOR'S NAh ' ��a/� LIC NO:
/l ,(J NIC CONTROL#
_RCRLj"E GINIiLNi • ID(/JS1 19 NN(l: ,� ADDRESS. ElyV �J
CONTACT: IT l/I/ C
PHONEBUILDING PERMIT INFO
r2-2- ❑ Consultant Fees Paid By Applicant(Initial) BLDG I!LF:CI PLUM" MECH
LICENSED CONTHACIY)R;S DECI.ARAMON QTY ELECTRIC PERMIT FEE Lr.IK/ 2-_ LJ LJ/
1 hereby affirm that 1 am licensed under pumokime,of Chapter 9(commencing JOB DESCRIPTION
PERMIT ISSUANCE
DMZO with Semi.n1(ILYBnf Division3nfthc Ihminessand ProfensssioCodeanJmY license is RFSIDENTIAI,
W C
F- full forte and cfttt. ❑SFDN'I. El KITCHEN REMODEL
auu in
Class Lie .# APPLIANCES-RESIDENTIAL r�DITION [I PLUMBING RE-PIPE
FZIu )one Comment,
yQp• ❑MUITI-UNIT ❑s,rRUCTURAL
F-❑N ARCHITECT'S DECLARATION PANELS
MODIFICATION
O Z rn Z 1 undcmand my plum shall be used all public womb
UPTONIAMPS ❑INTERIOR ❑CHIMN17Y REPAIR
f atol_' Licensed Pmfesswritl 201-1111AMPS IMPROVEMENT 0SWIMMINGPOOLS
YE OWNER.BUILDHR DECLARATION OVER I"AMPS ❑RAI 11 REMODELIREPAIR ❑DEMOLITION
C row Q I hereby affirm Ill.,1 am camnpl from tbu Commnnr's License Law for the
nXj 3 a U following neem.(Section]831.5.Business and Profe..In I,Cade.Any city or county SIGNS ELECTRICAL ❑(H'1{I!R
y which requires a permit u)consvuct.alum.mprove,demolish,.r repair any suremre d
0 j priorm it issuance,also requires tbe.pph,.n,hn,uch pannino file a signed stmemem SPECIAL CIRCUI'DMISC.
f.�y that he,,licensed pursuant to the pmvl.a0ns of the Contmmols Liceme Law(Chapter9 :
WaO� (comnsommugotim Scctiou7fNNgol'Division 3nfthc Business end Professions Code)m TEMP.METER OR POLE INST. COMMIiNC1A1.
L Def e 9 mbar he Is eaenqu therefrom and the hasis for the ulb,,,d ,,q mplion.Any vinlvlinn of F1 NEW BLIT
LDGMUDITION ❑DEMOION
ae-N Somi7131.5 hynnyvpplicvnl for.feline,snhjecle,he upPliatm munivtl penally of POWER DEVICES ❑'1'17NANT ❑1'001)SERVICE
n inure Ihun live hundred Jollaru(ESIHp. IMPkOV1iMl!N'1'
SSC ❑ 1•as owner of the properly.Or,nY etgJoyms with wuge.aus their sole cnmpensalion, SWIMMING POOL ELECTRIC
F. will) thedo dthc t t m': t mol IOfferedlor (S BfW4 B ' ❑O'I'l11?k
A.
.null t cloth 'Ih C howl Li I I : not apply It, f OUTLETS \WITCHES 11X'IURCS
66 property buildsoruniprove%thcreon.aid whoduessuch w k l If Ih blt NIiW RESIDENTIAL LLLCIB SV PI',
lots own entpli'Vi,"Pmvidcd,hal ecdo intpnwemmois mac nal InlcaleJ nr ol14nv1 Inr
sale.If however,the building Or tmpmvenienl is sold within one yee,of complelion.the SR vI',IIAUIt ARMA USV.IT.
Ovorr-bui loos,w111 huvc the hurdm,of pnwm,that he did nal build nr inTeove till pill
pose }a� 1. 'I(YI'Ah
�J/ f Ih p I IY t t g I' dcomments
_I th p trimIS p(91UJ B Ilnf:. C Im J )Th C I Inr:Li-
sel J pPlyt -p my h hillsimprovesth on and QTY. PLUMBING PER FEE
who nrassf mels ,+cern with .1, bm,)Iocuodpurs II th C Int I+ra
Li, ns a PERMIT ISSUANCE
1 ,B h P C for this reason
ALTER-DRAIN&VENT-WAfF.R[W) VALUATION
w Date -2
WORKERS PHNSX1710 17CLARATION BACK FTGW'PROTECTDEVICE
G
[hereby affirm under perem,of Pcrjuryo ofthcfollnwingdcc,amti...:
I have and will maintain aCcdifcme of CnnsenuosdGinwre htr Worker's Compcn- DRAINS-FLOOR.ROOF.AREA.COND. grpglll, TYPE CONSTRUCTIOI
salion,as provided for by Section 3701 of the Labor Code.for the pe.f«mance of the /
work for which this Permit is issued. FIXTURES-PER TRAP
I have and will nmintam Worker's Compensation Insurance.vs required by Section
371U of the Labour Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLE1S (ICC.GROUP7�APN
My woolce,Compensmion Insurance carrier end Pone,mo nbe.art:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER a d:AI
CERTIPICATEOf•EXI!MP ION FROM WORKERS' GREASOINDUSTRL WASTE INTERCEPTOR O 0
COMPENSATION INSURANCE; BUILDING 1 M1 . ON ICES
(Thins«tinnnminm Mcamplmedif the pcnnit is fnrnnc ltunJtcJ Jollms(SIM) GREASETRAP - `
or less) PLANCHIiCK 171
I cenifyted inlhe peRotmanceofffe work(..which this permit is issued.l shall SEWER-SANITARY-STORM EA.211 n'. # O
ntp
rout en ,oy any Tenon in any tnannena vs m become subject,the Workers'Compen- IiN.RGY 11117
sedan Laws(if California.Date WATER HGTER WNENT/ELEC R
20APP licam 1 GRADING FEE
NOTICE TO APPLICANT If,ufmr making this Ccnifeme of E,lonnu on,you should WATER SYSTEM TREATING
become subject to the Worka"s Connnomaliun pmvlsions of the Labor Code,you must SOILSFEB.
tiforthwith comply with such ptivisinns )r this permit Shull be decmed.ev.ked WATER SERVICE
/ PAID
5Z CONS9'RUCHON LENDINGAGENCY NEW RF.SIDENq'IALPh.MB. SR lel'. Dal, Reecipl#
U O 1herebyuf ,holtatthee is a nemmnton limaing vgmuty for lheperformanceof
W f•-, Bic w.rk for which this penmtil istssucd(See.3097.Civ.C.7
,01'11:
O U I<ndcr's Name
'r0'IN.:
1<ndcd,Address
I�I..•..°t, a 1 Celify Ihnt 1 have read this igtplicnlinn and state Il.,the shove inlinntalion is BUILDING Il
?h
F-i t0 'one".I ugrceu+contply w,,hell dlymtd county onlinaille, stale laws relnlingm QTY. MSCI{ANICAI.PERMIT Fl.l! SEISMIC PHI!
U ,�ZZ. hoilding mnsuuelin I,and hn'chymnhoriec represen,a,ivcs nr,lu,s city Inciter upon the
above-mcnunnel property fm inapcalion purpnws. PERMIT ISSUANCE ELEM RIC PHM
(We)agree Io s,wc.Indemnify aced k«p harmless,lou City of COPI'doo agaiml
Iiuhili......... uen.,cmasand c,,w,wrwhichmay In any way:m,m,gOiu,,,ad City ALTER OMBTU)
ADD*10ECH. PLUMBING Plili
N .sapmnce of the grnnting ol'thls imnnim.
PLICAN'I'UNDI!RS'IANDS AND WILL COMPLY WI 111 ALL NON-POINT AIR HAN 'I(TO 10IM10 CITMI MECHANICAL 17":
SOURCE RI!GULAi'IONS,
AIR HANT(OVER IB.(N1 CPM) CONS'I'RUCI'IUN'i'A%
Signature ill ApplicuntlComruclnr Date EXHAUS /DUC1) HOUSING MITICAIION ItiH
HAZARDOUS MATERIALS IJISCLOSURI!
Will the upplicam or lummbui,dingOccupant more at handle hazuN.us material HEATINUNITUR,(N1 BTU)
as defined by the Cupcninn Municipal Code.Chapmr 9.12,and the Health and Safely HEATINR 100,0(kI BTU)Calc.Section 255321aJ!�Y09VENTILA (SINGLE RESIDI PAID0 I
Dam Receipt p
Will the applicant or future building occupmm use equipment or devices which BOILER-COMP(AHP OR IW."BTU)
I haevNous air conmminanls a' In- by the BuY Arca Air Vuu by Manugemem TIl I'
e I
tact? .Ll✓/ BOILER-COMP(OVER HXINX)BTU)
❑Yes Nn
I have read the hamNtna nmlerial.s requirements under Chapter 6.95 Of the Cali AIR CONDITIONER ISSUANCE DATE
fiacg N A,Safely Cu We,Sectum 25505,25531 and 255M,l understand that if the NEW RESIDENTIAL MECH. SV.191 -
hurrentlyhvv anent.tt'nisrymk ilitymnmifYthe«cupantrt hie nc ono' Ccnifeum Gteupa«y.
O ulhmne agent Date TOTAL: ISSUED BY:
OFFICE