S1639APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
" `riG DIVISION
BUILD:
BUILIIIN(:- ELECTRICAL
APPLICATIONITERMIT PLUMB IN(:-\ILCIIANICUa
I'IiRMTf ISSUAN "'
PE tIT NO
1639
r'] con ca coq um@rk'. . B h P Cf or 11,u msvm
PANI:I.S
BUILDING PROJECT IDENTIFICATION
UP 10300AMPS
ater Date
NUILDINGAUDRP_SS:
HACK FLOW PROTECT. DEVICE
IMPROVEMEM'
SANITARY
NO.
AI'I'LICAf10NaSUBMITTAp, DAT:
iv �a o
CrJf�2
D
nr0 C
DRAINS- FLOOR. RIDGE AREA. COND.
1WNE.R:S NAME:
PHONE:
GAS -FA. SYSTGhOVIiHJIRA)
Cll IRAC'IOR'S NAA1Ii: �,I I.IC NO:
/C
GRP \$I%INDUSTRL WASTE INTERCEPTOR
CONTROL
CHRTI IICATF: OF EXENIPOON FROM WORKERS'
COMPENSATION INSURANCE
GRIiASH TRAP
CONSTRUCTION TAX
-r-I5QwfQ /2",:
❑
of the wort for which this lnmril is issuw..lrhall
I eenify mm in the re,
any pcmm in mty nlmunr.m on m Insnnc subyxn no nM1c Wmkcrs' Gnnpcm
ARC( I ITE.C'ENC.INIABit : LIC NO:
ADDRESS:
Inorcnrploy
wtionl'wanf Oulihrniu.Uw°
N
?hcttme
7z
U 0
Da
Q
U
y
Frpt
Applicam
N(TI'ICE TO APPLIG\M': IL ofltt making This Ccniticmc of Eacmlxinn, Ynu sM1auld
whlem In the Winter's Compensation pmvuisns of Ile, Labor Code, un must
forthwith comply with such provii6as m Nis permit shall beda<nrd revoked.
CONSTRUCTION LENDING AGENCY
isv construction kMing agcnry re pchrnounce of
IMreby vlfirm thauhcmr h
the work for which this permit is,,ud(.Svc. 3097, Civ. C.)
Ietlh 's Nmrm
c
NATER SERVICE
MiW kPSIDFNTIALP1Atls. SV. 14.
CONTACT;
PHONIC
1 cenify that I Iwvc (cad hie apPlicvtion and'tato hat III above mfnmudm is
cmm.I vgreewemuply with all city vrrd cmnry rrdnalaes rood sure laws ¢Wing to
LLKt a
U •Z•
BUILDING PERMTi INFO
PERMIT ISSUANCE
nhovc-meramoss 1prelaeny fsroopoxlion"Povcs.
(We) agree it, indemnify id keep bannlc.cs dr City of C-upeni no agwnu
❑ Consultant Ems Paid by Applicant (Initial)
BI.IY
ELECT PLUMB, NI It
u % o
6%0 `-97
AIR HANDLING UNIT (It) 10,M)CFM)
❑
❑ ❑
LICENSED CONTRACTORS DI!CLARATION QT}.
I bertby aRnm Thar 1 vat Iiartsca umber Provisions d' Chapter Y (commencing
with Section 7IX0)Of Diviu Jofhe Business e(n{d Ipnde �moat Code, and my license is
in full more and cf U Uc.N���
Date Conlmbotr
ARCHITECTS DI:CI.ARATION
I utdcnwnd my plans Shull M uwd m End's, tecn of
Licnscd Pmfcainnal
OWNER -BUILDER DECLARATION
1 hereby oflimo that I am exempt firmor the Cmlrncto/s Beano UW rvv the
following sawn. (Nation 7031.5. Budnc %and Professions Coda: Any oily a curably
which once ircv a permit w umonad, allo, improv,. dmi mptiir any muc urc
prig to it i,mnre,alvtre,ims he upplicann for such pcmoin In file a eigm+l nlolcncm
Ihnt he is lkenxd pornu to ant the pro ufl no Cowmen L.,cnr.c l.uw(Ch,",9
(cmmrKneing with Section 70(18)of Division Jofhe Bmins. uM I-od, ion, Five) or
door he is esemPn IBttefmns aIW as, fears For the ulleg J exemption. Any violation of
Sntinn 70315 by tiny ap,At.' f« o pemoit suhlm the appli— in a 61111-1114
rot (rote Klan five hushed ddlars 15500).
❑ Laswmaf the proprnY.mmy cmpWyccs nim xargexudeir.sole cumlcnsation.
will lathe xvk. emunhe atnamtue is mIinmlWel urolBcrd fm sak(See. 7(W Huvi—
and Professions Codo: Contractor's License Ww does roll appty ,, on owner of
prtrycny who holds or imn nven memo, mod who des such work himwlf In Through
h sinpl,yv pmvitlW (hat such impsrvmI ands a mi intcnrkd n olferod for
wlec lL hw +, IMC Wildhin,brontentoretv,ta ix told within one yenrdermpkfmn,the
nw er-builde will bove the burden of pnrving (but hu did not build or Illmnne for Pur-,
pose of sale.).
0 I. as, owner ot the 1'rol'mY• con exclusively contracting wind liberated 'brourticiort, to
construct the prnjrel (See. II". Bu6-1 mod Profc+sions Cu1e:)The Coamclors E-
cxnsclaw dues nor apply to or xwner 4 Frtis hit Wilds m improves lhcmn,and QTY.
who contracts for such peoccts with a cnmranmfel licensed pmsuantto the Conlmclolx
ELECTRIC PERMIT FEE
PERMIT ISSUANCE.
I'IiRMTf ISSUAN "'
APPIAANCFS-RIISIDF TAI.
r'] con ca coq um@rk'. . B h P Cf or 11,u msvm
PANI:I.S
CSTRUCIURAI.
UP 10300AMPS
ater Date
OVER 1000AMPN
SIGNS ELECTRICAL
SPI:CIAI. CIRCI/1TAUSC.
'I'I?ME NUD ER OR It)Lli (NSI'.
POWER ISEVIMS
SWIMMING PML ELECTRIC
OUn.ETS - SWITCHES - IIXTURF"S
NEW RIlWDENTIAL IJ.IiCIR SQ FI'.
PLUMBING PERMIT
OFFICE
FEE
JOB DESCRIPTION
hicenm Low.
I'IiRMTf ISSUAN "'
[]ADDITION
r'] con ca coq um@rk'. . B h P Cf or 11,u msvm
[]MULTI -UNIT
CSTRUCIURAI.
ACTI!R - DRAIN h V ENT- WATER (EAI
ater Date
CINTERIOR
HACK FLOW PROTECT. DEVICE
IMPROVEMEM'
WORKER'S COMPENSATION DECLARATION
C BATH RESIODELRIPAIR []DEMOLITION
I hereby vRrm under penally M prejury one of the following declarman%
C lhascalWwill maimvinv CcnifiaodConter, to sdfiesume for Wmlxr's Curtail
DRAINS- FLOOR. RIDGE AREA. COND.
wrim. - Iwvidd lin hY Section 37M of nk UMr Code. for the perf,.e of it s
>A for which his Permit is issued.
dwvc and will nutimain WnheLw Canprnwlinn bromanee. a,e nrtbr,d by Scetim
.7 1 of the W Mm GNC. Lrc the perinmmnn of Thu wort Lr whiuM1 tltia IKnnl1 Iz -bed.
19X1ORES - PER TRAP
OAS - FA. SYS'HIS1-I LNG J f IIPIl.FTS
GAS -FA. SYSTGhOVIiHJIRA)
❑ FOOD SERVICE
M1ty Worker's COmpenwtiun Insuruncc conics 1'olky 9
Ctuter:Gr(rC-aSPQ Pn1icYN � r �' Sr
Policy
GRP \$I%INDUSTRL WASTE INTERCEPTOR
C OTHER
CHRTI IICATF: OF EXENIPOON FROM WORKERS'
COMPENSATION INSURANCE
GRIiASH TRAP
CONSTRUCTION TAX
huhnd dollen(510(1)
m be ifthoil is famem
fB isrm. card e pcm
in Ii
SEWER-SANITAR\'-tiTURM IiA. 2(019'.
of the wort for which this lnmril is issuw..lrhall
I eenify mm in the re,
any pcmm in mty nlmunr.m on m Insnnc subyxn no nM1c Wmkcrs' Gnnpcm
WA'1'HROIiATERWNIzNI'/EI.ECTR
z
z o
Inorcnrploy
wtionl'wanf Oulihrniu.Uw°
N
?hcttme
7z
U 0
Da
Q
U
y
Frpt
Applicam
N(TI'ICE TO APPLIG\M': IL ofltt making This Ccniticmc of Eacmlxinn, Ynu sM1auld
whlem In the Winter's Compensation pmvuisns of Ile, Labor Code, un must
forthwith comply with such provii6as m Nis permit shall beda<nrd revoked.
CONSTRUCTION LENDING AGENCY
isv construction kMing agcnry re pchrnounce of
IMreby vlfirm thauhcmr h
the work for which this permit is,,ud(.Svc. 3097, Civ. C.)
Ietlh 's Nmrm
WATER SYSTENLO RIWING
NATER SERVICE
MiW kPSIDFNTIALP1Atls. SV. 14.
T(1'CA L:
lader's Art
1 cenify that I Iwvc (cad hie apPlicvtion and'tato hat III above mfnmudm is
cmm.I vgreewemuply with all city vrrd cmnry rrdnalaes rood sure laws ¢Wing to
QTY. MECHANICAL PERMIT
U •Z•
Wildingcaotnrtim.ars! thereby authmiae mRmrenlarivcs ofthuciuy tuemer inner the
PERMIT ISSUANCE
nhovc-meramoss 1prelaeny fsroopoxlion"Povcs.
(We) agree it, indemnify id keep bannlc.cs dr City of C-upeni no agwnu
AIA HR OR ADD TO M ITCH.
liabllities.l entx, urzrwnd of nwy In wy way aeumeagainn nail Ciy
Or, Narld.
' nnxCGucly�: f ILK' 6nnling of IM1iS permit.
rn
APPLICAF/� NDERS'I'ANDS AND WILL COMPLY WHO At.[. NON -POINT
AIR HANDLING UNIT (It) 10,M)CFM)
SOU LATIONS,
AIR HANDLING UNIT (OVER 10.800 CPM1
EXHAUST HMD(WNUC)
Si a Applicanl/Csmlractrc Date
HAZARDOUS MAT H UALS DISCLOSURE,
Will theti,lenm or future building occupant FnrcorhmWk bmanMws manorial
HHAONG UNIT CIO 100,000 BTU)
its dcfind by he CuTeninu Mwticipal Codr, Chrpler 9.12. and IMI Iluuhh and Surety
I'm 2., 11
'Irk. Buz 7
IIIiA'IINC UNfI'(UVIiH 100.000BTU)
VINfILAT10N FAN (BINDLE HESID)
�
�Yo ❑Nu
BOILIJi-COMP (JIIp OR 100.001OBTU)
W91 the, vpplicant or hlme building amupam use ryudinni or devices which
emol hsserdouos air contamin,Ms u dc0necl by the Bay Alen Air Quality Marugrrmtl
ROUTER - COMP(OVIiR ind.0101) BTU)
Diwic7
❑Yes ❑No
AIH CONDITIONIiN
I h 1 nl maNri l y�ton: mxl Llwl n (.15 of IM Cvl -
NI?W RFS'IUI?N'I'IAI.MECII. SVI'I'.
R Huvlt htiulry'tions 25511535]9 425511 wlcmt lnlnhal'f lBu
III.
Iw'Wi g +Icnanl IMI t'. y ylnn MI'nY any dr rrrupva
Mded - muab---p—m issunran of a Cen'Icam of Uculoory.
.
OFFICE
FEE
JOB DESCRIPTION
R SIRS
C SFUWI.
CKITCHEN REMODEL
[]ADDITION
[]PLUMBING BE PIPE
[]MULTI -UNIT
CSTRUCIURAI.
GRADING FEE
MODIFICATION
CINTERIOR
❑CHIMNEY REPAIR
IMPROVEMEM'
[]SWIMMING POOLS
C BATH RESIODELRIPAIR []DEMOLITION
C (MIER
TOTAL:
BUILDING FE
COMMERCIAL
O NEW BLD&ADDH ION
[]DEMOLITION
❑TENANT
❑ FOOD SERVICE
INIPROVFAIFNf
NUMBING FEE
C OTHER
MEC( ANICAl-FE
SQ. 14. FLOOR AREA I LSQ, Fir
BUILDING DIVISION FE
PIANCHECK FEE
ENERGY FEE
GRADING FEE
SOIIS ItiE
PAID
Braila N
TOTAL:
BUILDING FE
EFF,
SEISMIC FE
EIACTRIC
NUMBING FEE
MEC( ANICAl-FE
CONSTRUCTION TAX
HOUSING MEEGATION FEE
PAID
Date Receild#
Tool
I�IANCj} )ATE,
ISSUED BY:
Received: 3/30/98; 9:06AY; 4163690418 (; M3
MIDDLENFAX AKIO 4416369-0418 mo3l30198 09:32AM D3/4
03/30/1998 09:41 4082540883 FIM PAGE 03
I�
MAY 9 - 1999
DLUU. INSPECTION DEPiir,
CITY OF CUPERTINO
40 39VJ ONI Odr 9EE910999Z 0091 8665/LZ/EB