S 1998 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUHAIN➢-ELECTRICAL PLBpIT,No 199�8-
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL OAT
,(oZs Z-J21N W14'( -9 0
OWNER:SNAME: PHONE: CONTRACTOR'S NAME: —FIC NO
R 3 Mas. W . �t46-35E1� NIC CON'IHO/Lp
L —
ARCHITIiCI'/ENGINl LIC NO: ADDHISS: El4 ��7 .
L�VI N C213T�o D CI
CON'fAC'11 PHONE: BUILDING PERMIT INFO
V'n 1e^w -t96--38q
9 6--3 8q! ❑ Consultant Fees Paid by Applicant(Initial) Irl ELECT I'LUMII MECfI
0 Fill
LICENSED CONTRACTOR'S under
Dnsions AVON QTY. ELECTRIC PI'sRMI'I' FEE
I nonny antro dtm 1 ant Teemed ander provisions of enamel n mylicenci is JOE DESCRIPTION
O�Z with Sxdon7mtry nrUroisionlonneBmbess and Professions stale.and myfecn.e is RESIDENTIAL: '
RI o o rlsRMn'Issunucla
C-� in lall liorce and cRccf. ❑SPDWL ❑KITCHEN REMODF.1.
QVU Liccnx Claes Lick APPLIANCES-RESIDENTIAL �DDITION ❑PLUMBING RE.I'IP8
i-Q W Dam Comm.....
ARCIBI-ECI"S DECLARATION ❑MOLT1-UNIT ❑STRUCTURAL I.
F-'D'n PANE(S
�Z londerandm 1 hll be uwd aspublic records MODIFICATION''
Otel
YPamsa On TO 200 AMPS
El INTERIOR [I CHIMNEY REPAIR
FN u: Licensed l'rnfessiaoal OW NI3H BUILDER DECLAHA'1'ION 201-1000AMPS IMPROVILMENT SWIMMING POOLS
C Q I hereby xltirm thin :un nempf tram the Commoner's License law fee the OVER HXX1 AMPS 1]BATH REMODEUREPAIR DEMOLITION
X3 6 Ufollowing moved.ISwtion 7031.5.Business and Pndesslons Cock Any city or count' SIGNS ELECT RIC [IOTHER
W WT- which requires n permit ,,consryn,idem,improve,de WAIN11,or repair any structure
��Q prior to its issuance,also requires the applicant for such permit to file a signed smmmem SPECIAL CIP015 IT SC.
that he is liaromd,uramntmthc Provi er,of the Contractors Liscnsc Law Ch
WaQO GO (nmtmencing vdth Section700(def Doname 3 dohs[Tavares, ad l'..fmaiom Coker or TIiMP.METER RP( ,E •` COMMERCIAL'
d C.c C no,he is exempt thenefmm and the has,,for the alleged exemption.Any violation of ❑NEW HLDG/ADDITION ❑D17MOLITION -
ro U. Section 70315 by any applicant fin a pall nit ooh net,Ida appll...I ,,if civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
r`� not marc than five hundred dollars(551X).
FZY IMPROVEMENT
=Q d.fim as week.the pmpcnyonis cmntmadeswith wages nuhei(Sca. 0,14.Hwtitin, SWIMMING IYWi,IiLF.(TRIC
W will dome work.aside: he Contractors
Intended arafl do wast applyo an owner
of ❑OTHER
IL m progeny
eny weliom Gude The Contraeme License law does not apply m owner of a OUTLETS-5WITCIIP_S-IgATURPS •Z
property who builds or sided that
thereon,and who improvements
re such wank hour-Ifdorf NrongM1
his sen however.
provided Nat such demisold are not intended or pRefcJ for Nliw RESIDENTIAL IiLECfR SQ FT.
sale.If.however.thehuilAingmintpnwenent is mild within one year of completion,
SO 17.FLOOR AREA $/SQ.FP
owner-buddle,will have Ihc hunlun of proving Wat he did do build err improve for put-
' of sale.). -
f til 1 ri ly b i t licensed m 'fD'
onstmeted project(S7044.Bunme,andl b -CadymC t t :1 -
un..
Law e f applyt f property who build,,,, p se, add QTY PLUMBING PERMIT FEE
who onrstvf n.s.hpnj,r, ,If a umtrufore)[un:ed personal theC mreutry
Licence law. v PERMIT ISSUANCE J (J
El am clean under Sce, .13&P C facile,sumo
Al TER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date RRR---111
WOR K ER'S COMpePIINSAI ION DECLARATION BACK FLOW PROTECT.DEVICE "V O O O
I hereby under hole, nalty of perjury ane of the following declmm : o
ioas
[:] Ihaveand will maintain,CcnlfeatcdConsenfmwlf-insure fnr Workers Compre- DRAINS-FLOOR.ROOF.AREA.GOND.
cation,as provided for by Section 3700 ot'the Labor CMe,far the performance of the STORIES TYI'li CONSTRUCT 10N
work for which this P:mtit is issued. /{- FIXTURES-PER TRAP
I] I hove and will maintain W..Tor's Contpenwtima(muni vs required by Section 1L •�1
37M ofthe labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP AI-N
My Worker',Creepensmion Innurunee came,and Policy mmnbe,ore:
Curies Policy No: GAS-EA.SYS TEM OVER 4(EA)
CERTIFICATE(lis EXEh1PT1ON FROM WORKERS'
COMPENSATION INSURANCE GREASEYWHIUS'IRI,WASTE INTEItCEPIDR
(Timiretion need not2cae,letW ifthepermit a ftwonebuodredeallarOM00)
GRP.ASI?TRAP BUILDING DIVISIO PIiF'_S
3 0
or Ice,.) I'hANCIIECK PEG
Toy any thatinthe any performance(it
as tohe
subjectch to pamthe Wdir orkers
ed,I shallConflict- SEWER-SAN["TARY-STORM EA.'-(0 FT
oatemmnY any person in any manner run,to Mcome object Rs NC Workers'Compen- I.NI;RGY PER / O
Zz action Lawn o(Calilorden.Data WATER IIEA'II:R W/VENT/ELECI'R l
Applicant GRADINGIEF
y NOTICE'TO APPLICANT.If.other making thin Cenificum of Exenlptien,yon should W6P5R SYS I'13MITRI3A'1'ING
h nom subject a'Ihc Workers Contpcnsation provisions of the Labor Cade,you must SOUS FEE
aQfonhwith comply with such provisions in this pcmtit shall be deemoJ revoked. WATER SERVICE s Z�
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.En PAT
U O Thereby affirm that hem is.conuruction laraingagency for the perfonaanceof Tee Reveiptk
the work for which this permit is issued(See.3097,Civ.C)
0 U Lenders Name
Landers AAdrena ko 1019
FM I certify that I have read this application and state that the above Infomution is [TO .DING FEE
IZI correct.I agree to comply with all city and county nalinances:tad state laws relating ,, QTY. MECHANICAL PER M IT FEE 0
C.> 'Z buildingeumuuetlan,and lwebyarm...im reprc,cnlmivcs of Nis city lti eater aqm the .EISMIC FEE
aloove-madimmd prepeny for inspection purviews' PERMIT ISSUANCE
(We)agree w cv,c.indemnify and keep harmless the City of Cupertino against .P.CI'RIC PEE
Iiibilitie,,mi,comin,envision]vapeme,which may funny way accrue a,ainst,aid City A[:IR OR ADD TO MECH.
in onsqucncc of Ihc granting of the pc.all. PLUMBING 174 n ZR
APPLICANT UNDERSTANDS AND WILL COMPLY WIT IT ALL NON-POINT
SOURCE REGULAI[035, ' AIR HANDLING ON['I'(TO IT."CFM) M
ECIANIA,. EE O
AIR HANDLING UNI'I'(OVER 10010 CFM) CON ' U 'll T C'
Signature dApplcanUCfntmcmr Date F,XHAUSf HOOD OVMUCT) IMMINIrlMl'['IGATION FFE
I IAZAIt DOUS MAI[TRIALS DISCLOSURE
Will the applicant or future buildingmeopant store or handle haimduun material HEATING UNIT(TO 100.00 BTU) s-r')r B•
a,defnad by the Cupnnino Municipal Coale,Chupmr,9.12,and the Ilearlb and Sufay .I 17 sr
Calc.Section 25532(x)1 HI?AI'ING UNIT(OVER 100,001C)BTU)
El Yea 0N
VENTILAI'ION 1'AN(SINGLE RES IUI ('AID
Will the applicant of future building occupant use equiponem or device,which Dae Receipt k
`
mit hr,anho,air mn.mniner,as defend by Inc B,y Are,Air Quality Mountaineer BOILER-COMP(3HP OR I(hJXX)13'NJ
UishmTODean,,?
❑Yen Fl No BOILER-COMP(OVER 100.00 BTU)
I have road the nmardous materials AIR CONDITIONER ISSUANC )ATF,
regmmmenm under Chapter 6.95 of the Cali
foot,Ilwlth&Safety Cade.Sections 25505,25533 and 25534.1 undestand That if Ila NEW RESIDENTIAL MACH SQ.IT.
kNb, have a lenon,Nv it is my resp'msibility fertility Neoeupam
of=&ts when he met If lr iss nfa Cenffeme of Occupancy.
Ow authfuncher a antV am TOTAL
ISSUED Il
OFFICE