S 1263M
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO HUILTNG - ELECI RICA
DIVISION APPLICATION/PERMIT PING RING MECHANICAL
PFIi�b+Ifl' No
J 1263
.
iorILDING
WILDING PROD F.(TI' IUh:MI'IPICA'TION
CE ID
•
B ILUING ADDRESS:
SANITARY NO.
APPLICATION SUBMIT-IAh UAl'E
20630 STEVENS CREEK BLVD
FNER'S NAMIi: PHONE: (FIS
BYER PROPERTIES
CONTAACIOR:S NAME: LIC NO:
MID WAY SIGN 707963
NIC
❑
CONTROLa
CI II'IHC'I'/ENGINF.F.R: [A aN& IADDRESS:
3290 BASSETT ST SANTA CLARA
CON 'I'AC1: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG [ FCT DME MECH
GARY ANDERSON 983 9696
❑ ❑
Od'Z
W O0
F.
QUV
NQ6
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm That I am licensed under provisions of Chapter 9 (commencing
with Section 700HOAoiva ion 3 oftbr Business and l'rol'essonns Code,andmy license is
i iceneworce and affect. �. 707963
License C'm w^ iLic.«
DeLL Conna"..r
QTY. ELECFRIC PERMIT FEE
_ _
JOB DESCRIPTION
RESIDENTIAL:
❑SFl)WI. - ❑KITCUEN RIiM0Uli1.
❑ ADD] T]ON ❑PLUMBING RI; -PIPE
❑MULTI-I1NIT El STRUCTURAL
MODIFICATION
❑INDiIt10R ❑CHIMNCY It EPA1R
IMI'ROVI?MENT �SWIMMING 1'OOLS
❑ RA'I'N REMODEUREPAIR Ll DEMOLITION
❑ O'Tlliilt
'-
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
fcnnZ
JZ�
ARCHITECTS DECLARATION
I understand my ploomdall be used u+ Public leaned,
PANELS
UI'T02(X)AMPS
{h1og'
C sR
0 O
0.
Ltwnsnl l'enlcn,fonnl
OWNiili-ntliLl)Iili DGCLARAI'ION
hereby no 1 am oe... t inan tPr Con tractor, Licence Law far da,
fislluwiug ranon. Serino Ince. air Print, Code: ( t
Any ciynr cru"Y
gal-11X)BAMPS
OVER InOOAMPS
IS HLN.CTRIGL ONE
oworn
aC00
I. X e
repair
i... a pencil t0 enn+nurl, nbre, n, assn ltpermit ,are a a, any .(Canoe
notion,':" Is q N ppl' if hp ill fl ._g d.nte nem
Thai he . ad s it Thp fie C I I f L L (Chapmr9
(cn t o ithSet 7") fD".i 3 of fire _ B: dProfe..' :Code)or
that he xnnpt Therefrom and he basis panic allcsN enemPl un. Any vfoiafnn of
_
SPE CIAL CIRCUIT/MISC.
TTN P M ETER OR POLE INS'i'.
COMMERCIAL:
❑ NEW HLOGIAUUITION EIDEM01.1'1'(ON
��N
=Q❑
a
Section 7031.5 by Any...land far a permit subjects the appliram to n civil penallyof
not aware into five hundred dollars ($500).
it Lothework,and pestruc,mmycmntendes wilhwagc asialeifor sale (Sec. Business
n License Law does nm apply to if owner of
adJmnrwark.Codd:TheCirel,arta®nenseLoedJsactaply1.a4.waa,if
and propertywho n,+ ib, or The C thereon, or through
p who builds or.HadTimplores and who dors such work
POWER DEVICES
[]TENANT ❑ FOOD SERVICE
1 i'ROVIiMI:N'I'
rHeR PAN FNANNf_6
SWIMMING POOL ELECTRIC
OII'TLLTS—SWITCHES-19XTHItliS
t u,h i,
derhimar
his own cntploye in, provided That such umal is Oold la arc outore intended m offered lar
, (,a n
+Nell; huwweq the buildingorimprnvcmem is udA within nuc year of uimpletion.the
NI:W RESIDENTIAL RLECTR SQ Ire.
SQ. IriI FLOOR AREA
AISQ. PI'.
for p-
i wtea-buer ildwill have (he bunlan of proving (hat he did nm build or impm
-c
e it sure.).
❑i,ns wnermf(hCPropanyv xCla,ivnlycomruningwilhlictrowdeenmmtors to
P 'A
I(YIAI,:
construct The pTujeel (Sec. 7f W, Business and Profession, Cale:) The Contractors Li
act Lnw Aoex not nPPly to an owner of mo party who build• Or improves lnmear, and
QTY. PLUMBING PERMIT EE
Qii
FEBO
FEB
�UQ
AMID
ato the Com
whosnnlacu for such projmis with a counnecals) licensed punnnt icati
i
PERMIT ISSUANCE
License Low.
1 and exempt under Sec. . R At P C for this nae mn
ALTER - CHAIN & VENT -WATI:R THAT
)xncr Date
WORKER'S COMPENSATION DECLARATION
VALUATION
/�YtlD
BACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of perjury one of the following declarations :
` V
DRAINS- FLOOR, R(KIF. AREA. COND.
I too,: dwill maintaonaCenificmcof Consrm maaf-irowne for Wnrkee's Comprn-
moan, as provided for by Section 3700 of the Labor Cale, for The performance of the
,'TORIES
TYPE CONSIHOC 'TION
work for whirl, this pennil is is,ral.
FIX 'TURFS - PER TRAP
s
❑ I hma anal will mainmin Worker's Compensation In. ... earn, as required by Sectlan
370X(of the Latah Code, for the perfnnnancaal he wokl ur which (bi, partial—otarld,
GAS -EA.SYSTEM -I INC. 4011 11.17'35
OCC, (HELP
AIN
My Warw C(ar n .too Rem.fan (intoes nu h
s
GAS - EA. SYSTEM -OVER 4(EA)
- - Cli I F. :X 'RUM WORKERS'
COMPENSATION INSURANCE
GREASIJINDUSTRL WASTE INTE PfOR
ItI11LUl_NO DIVISION FEES
(l his section need not be complied it the permit i, Gonne hundreddnllmx (Slfg)
nr Is,,.)PLANCIIf:C.K
GREASET
:RAP
(Bili
SEWER -SANITARY -S" MITA. 200 FI'.
Iran" cin the peRormance of(lie wnrk for which this pentJl isismed.lshall
not ear any Nis in in any manner so es ui Mnnne xubjea m the Worker' Cmnpen-
ENERGY FIA:
WATIiR HEATER W /STIHLECI'R
'T
P0
W�
la Lau, of California. Data
GRADING FEB
pPleaut
x(YI'ICH TO APPLICANT: If, after making (his Cedlfic to of Exemption, you should
becoma s.hi , (he Worker', Co. .... alion Pnrvi+ions of the Labor Code, you ouvil
I inane wntply with such pmvkial, ar Tons amnil nIrdl he dwnmdervoked.
WATER SYSTREATING
9 '
WA'I13R SF ICE
SOILS I:EI:
.7 z
Wr-
ULender'.,
L)
y
fA
U Z
CONSTRUCTION LENDING AGENCY
inn IAing agency for the pafmn
1 hereby ufllrm Thm there is u construe(vm nrnca of
the wn k f)rwbich this permit is i1,md lSce.3097, Civ. C.)
Name
PAID
Receipt «
NEW /1S DHWIAI, PI.MIL SQ. EL
'TOTAL:
TOTAL:
IemIcGAJdrens
BUILDING FEE
I waif that 1 have reactors application J,lata that (he above information is
y un
comdingco comply with coats and nmmy ordinances and statetolaws
ntr upon the
enter
bnildingamcocoon,andhereby amhnrizertpresenm(ivesofthiscity toen¢ruponthe
QTY. MECHANICAL PF:RMI'I' FEE
SIiISMICIAiIi
aMive-mentioned progeny for impeclian pori
(We) agree to save, indemnify and keep harmless the City of Cupenono against
PERM1'I' ISSUANCE
:LI:C'IRIC THE
ACILRORADDTOMECH.
I iabililies,judgments, costs and expenses which may in any way accrue against said City
i it saryrnce of The granting of this pemtil
PLUMBING THE
Apt HANDLING UNIT (T(1 IB.IXX)CFAI
MECHANICAL ITE
APPLI AN' JNDERSTANDD WILL COMPLY WITH ALL NON -POINT
SOI - ;GULATl0 /yy/'
-en
D
AIRIIANDLINGUNIT(OVI?RIE,(XXIC )
CONS I' RUC'I ION TAX
I?XIIAUST HOOD(W/DUCT)
HOl1YING MI'IGNITION FEE
.'neunanfA mu Ca lmemr Use
HAZARDOUS MATERIA( S DISCLOSURE
HEATING UNIT (TO IW,M 'U)
Will the applicant or future building m Captmt store or handle hazardous nintcrial
as defined by The Cupertino Municipal Code, Chapter 9,12, and The Health and Saltily
Cale, Section 25532(a)7
HEATING UNIT(OVE 1.000 BTLD '
E) yes C) No
PAID
Data Receipt of
VENTILATION FA (SINGLE RESIU)
BOILI:R—CO (3HP OR 100.000 H11H
I to
t
Will the applicant or furore building occupantuse component or devices which
iit IozoNom. Of, communitiesas defined by the Buy Area Air Quality Management
Dialricr,
CYea 0 N
TO
ER '
BOILOMP(OVER 100,00113'1 Go
AIR 1NDITIONER
Ihvvels•ithe hazardous materials raryiremnru (mticr Chapter 6.95 of the Cali-
ISSUANCE DA'I'S
IoW RISIDENTIALMECIL SQ. Fr
harda 1I SrhayCd S i .25.10525511 1255341 d.t i(1., it [,a
ball' tcrucially h ( ((1 tt y' ... p .b-Ityt mildly utpnnl
is nqu areas which must be tall it... li ••.......arta Conrail Ca(rof (k�upnncy.
ISSUE[) HY.
Owmar ar anthaci.ad agent Dale
TOTAL:
OFFICE