S1989 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL TIES rC No. ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.—MECHANIC L 9
BUILDING PROJECT]BUNT'IFICITION
BUILDING ADIIRISSw, SANITARY NO. APPLICATION SUIg11'I'IAh DATIi
9 4G 8
UNNF.R'S71'IIONL:` CO ACTOR'S AhtL /�� LIC NO-pe � NIC CONTROL
ARCIIITIiCT/ENGINIaIiR: LIC NO: AI`I)Rr� S"L��42-/� �I—A ❑
COMPACT: PHONfe OO BUILDING PERMIT INFO
❑ CungBllant Pees Paid by Applicant(Initial) xLDC, ELf:CI' Iq�uMECH
El C ❑ LJ ❑
IJCENSIiD CONTItnCfONlS nECIA�ATION QTY ELECTRIC PERMIT ITE
' 1 EmM1y.mmt tha 1 mtI uanwa anter pm.isnns nre�t.r 9[eanmeucing JOB DESCRIPTION
y�y1co
'
liiPERMIT ISSUCRFSIDENTIA
www full face and ctlect. 1:1M9)WI. L:
❑KITCHNNREM
ODFL
Lic",ClueI.ic.M APPLIANCES-RESIDENTIAL ❑ADDITION LUMBING RE-PIPEFQLDCleel
N ❑MULTI-UNIT C]STRUCTURAL
ARCHIECTS DECLARATIOPANFS
MODIFICATION
ZOyz IlntdsrwwW ley plunedwllEurxel as,1N.recant.
UI"r021p AMPS [I INTERIOR ❑CHIMNEY REPAIR
FyF'I.�+jI I.ieeuseci Pmfe.sional 201-IBf1(IAMPS IMPROVFAENT 0SWIMMING POOLS
�6 OWNER-BUILDER DECLARATION BATH❑BA'TH R'LNODEIAIH ❑
'AIR DEMOLITION
C IZ I Iturehy tenon Thal I am cxmop from IE CoOrachl ',I Icen,Lew ho, IXq AMPSor tlrl'.
X O a U following rt .(Section 7031.5.Buxaless ad IWc,oinls Code,Any city of coomy SIGNS ELECTRICAL ❑OTHER
which tntuire,,a Ierrin to nntUmct.allcr,improve.deronlish,or reMir any.nuclore
C) parr rnnn..ss..r..oleo nyulrex lh::grplicvm lorsu,M1 pmuitIII filca nignnl sla,naenl SI`ECIAI.CIRCUI 1SC.
f Y.- Fat be is licemal pu.11.the pm.inhma of ler ContraconI License law(Chalgcr9
�CpO (..in,wdUSeaion]IIOD)or Diwkiml Sof the Business and Pmfesiwn Colic) IIIDTP.M1IL'1'IiN OR POLE IN.S-IL COMMERCIAL,;
Ii m e C 'Shen he Is exempt IMaermm and the Mtvis for the ulle,cd e,cer,ion.Any v,oblion of ❑NEW BIJUGJADDTTION �DEMOLITION
-y SocI n7031.5 by my ahplleenl for a pnmit suhjseu the vpplicart"I v civil penally of POWER DHVICGS 'AM' FOOD SERVICE
IWI rltac Ikon Elio,hurani dollrn(SSIMry. 9FFE ��
MPROV EMFXr
Sap Q Las owma of lM1C ProPcrY,hr my mnpl%as wish m6mvtMir wlcammlcnwt:n. SWIMMING POOL ELECTRIC
e,F willdoth,wuk:oel the mincwre i.nn iu¢ndW uroBcntl Torsale(Sec.II1Yl,Bu.ince, l'fllE
W- mW PIM Cade The C rr 1or',1 Ls Joe,. w apply t rn weer of OUTLETS SWITCHES-FIXTURES
a 3- ��y h hurt.or rot to eon,aced who ll a stleln - k n ,:e1f or ihnmgn
hex I Yccs.P I hm. h p cmmot 1 rn ulicred for NEW RESIDENTIAL,FLIK7 R SQ Ur.
mlc.if,hew crlhe hulldmgtrimlromrent is.atld wilhinorcycmof completion,the SQ.Ir I'.FLOOR AREA fIgO.IT.
-bumder will Ince the buNen of Icroitr IIW k did ren EmilorimPo c for Pur-
e If
Paearce, .).
1,us htwner of Ile pn,,n,am c.d.,ivelr orro tin,with licenwel conorcil-bI IOIAL:
ant, a the c,,cropo�jrct(Sac-]Bw,B e rlof oro Pntfas'b,, Culex)T]e C thcocora G-
wlmneLatv,1,bir epPlytoan ncrnmof Pmpmy who EJJa nr improves lhermn,ard (i'ry, PLUMBING PERMIT
mtmcte fu wch pmjcd withaauvmcmr(A lirenud Putxuanl lu ret CnnitW'mr.
IJceo¢law. PERMIT ISSUANCE ro
❑1 am esealgr utter se,. .B a P C far bis ha.em '
AI:I'I1R-DRAIN k V LNT-WAIY,R(IA) VALUATE ION
0.ncr Dole
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT'.DEVICE
1 mrehy aBino carder Pccaty of Pe-jury me of the following declaraions:
� Ihuvc alt will nmm�wnn uCcnlficvtcul'Co Irl to If-irivum fn WnAe"Cmnpcn- IIRAINS-11.00R.R(e)P,ANLA.COND' STORIES 'rYPECONSTRUCHON
.union,as povided for by Seelian 3700 N the Iahrr Cadc,for the Pcffomnrce M the
or,for,hien IM1i. .it is i.wual. jg� FIXTURES-PER RAP o
[� 1 hum and will mainuin Wueker's CortPetleuiu.Insurance,as qulrnl by Section
1]IIfIN IE lalwr❑de.far the tealutvnttofllw work fiv wh¢h lM1ix pemlilai—crL GAS-EA.SYSI'FM.I INCA OUTLETS (XC GROUT' AP,N'
bIY Wlvke' - liP�nnJyP 1Yca�m�s mal Policy ml _
Curtis K�L...MJFMolicy Fri: Ldp GAS-f.U.SYSTEM OVIJtq(P.A)
CLRI'IFICA HOF EXIJNI LUN FRUM'WUHKLHS GRFASIUINDU.SIRL WASTE:INTERCEPTOR
COMPENSATION INSURANCE; BUILDING DIVISION FEES
isahe
ion neednx compined;flit,Permit o frmwhulWndlkrllers(SIME CRPASETRAP - —
nr Iw.J(ThmFLANCIIECK ITJi
Icertifyiba in the peefomtaeeoldewoo forwhieh his pmmit i%ic.ucd.l trap SEWER-SANITARY-STORM EA.200 FT
Penton me employ my Pon in any roamer an a to become whjecl to the Worker;Currier- FNFRGY FEB t
� Z ."on I.c"of Colifomie.ITh¢ WATER II HATER WIVENTIIiI.IiCIR GRADING F1717Z Applicant
N NOTICED I APPLICANT:If,afar amL,This Certificate of E, million,y,u,boii NATER SYSIFENMEATING
hceone whjM to The Wooer's Conrpcnsvom Pn,visians of the Iabnr Cub,ytu must SOII S FL'L'
forhwih comply with such prnvisiunv or this PcmN shall E dec.msl revoked WA'IF.R SERVICE
Qur`-
CONSTRUCTION LLNDINGAGENCY , SQ.FT. PAID
UQIhereb ,iniontiMl then,isouw.ouehmt lendingngcltcr firlMo peni.mr.ltec of NIiN'RF_VDIJJfIA1.PLMB
lyTOTAL
w«k rm wn;en roma p.mdl is i.s�d(Sn.xrn,hie.cJ
Tinders Nara '
U io,N 's Addreec
}I W� BUILDING FI:i:
[.y. I arify o c 1 nova mull thirty and lxm udl rfi IhW the aEvu.,,anion is
V) nvrtcllvyra mnmply with all city cert caumy oadinarnes Wswm Wws mladng to QTY. MECIIANICAI,PERMIT FEE
U Z M1iiincticonvctinn.ana beech,ae,[Fri,,relrcw,,.,ivaofbni Ory loentonPrn lE SEISMIC FEL
m
uEvonwmioned proencrty fnr'msparllnn Purryrem. 1112RMI'I'ISSUANCE
Ove)agrm lu svve,ildemnfy:tea kcI,P normR.s be City of Cupertino agunsl ELECTRIC FE
Iiabtilic.judglrcms.mus mde.Eel1o:wbi1O.yirm1w1yaceme.'mwO.RE City AlJFR OR ADD TO MECH. O
vnuyuenro of the gaveling of lhln p:n _ PLUMxING Pi
API'LICAN'r U LRS NDS AN L COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(fO 10,00007M)
5 1RCE .T S. �aX-�Gy MECHANICALF
�/L CJ AIH HANDLING UNIT(OVER IOIXFI CIM) IRU
CONS''HUCII(1N T TAX
SigmatuofAMI anl/Cw Dae EXHAUST HOOD IWMUCII HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCI.OSURE
Wllthe oPpl'ICminn flum bo'ddinpoccur, smr ...handl.hvurdoo,,oh,,r,l HHATIN(I UNIT LTO 101),n)()It I U) ,
uv Jefned by the Cu,nao Municipal Cat,Chopper 9.12 and the Ilcalat and Safety
Cliche.Section 25532h)' HEATING UNIT(OVER 100.000 BTU)
Yc No
VIIN'r11A'1'IONIAN(SINC1.1?RESID) PAID IYtc RmcipM
Will the applicant or furore ImiWing occupant use e'dPrelu or device.which
emit bavnraous ear contamitwnw as dclined b the Ba Arca Air alit'Mma eraenl HOLLER-CONY 13111'OR IIp.LUO BTU)
r r Quality s 'r(Trnl:
Dioe"I BOILER-COMP(OVER IIXO)OBI'U) �1
C]Yea ❑No L
l have rcullM M1mud.ws nmaduls kmatr Chu fi95 oflM Gtli AIR CONDITIONER ISSU NCE DATE
Icquinnen rycr
fumie Hahh&Salary Cat.Scctkm 25305.25113 vet 25533.1 um4TYJoad llwt it the NEW RISIDILNTIAI,MECI1. SQ.PC.
Etoc ocmtitresnrtlammBYnvc'c v roarhis myrcywnibixry ur n.lify Ile ncNParll L
ME ryimlrlals whish nWSl Elrte,rct laic to iuwlec ufaCnillatc o(Oa'uPaauy.
6wnerorauth,ri,edii l Date TUTAL: TSSUHDBY: 7
OFFICE