S4396 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4396
BUILDING PRfIJECP IDE IPIFICATIUN
' BUII.DINC ADDRESS: r SANRARY NO. APPIJCATION SUBMITTAL DATE
OWN 'SNA lE: PHONE: Cc TRA S E: LIEN ` 74 _
p 1 NIC CONfROLN
• ARCA /HNGIN R: - LIC O. AUU ;S. i i I' ❑ /�
CO ACR PHONE:///�����' l BUILDING PERM`R INFO
e-07M �/ 1 f/ ❑ Cona tent Fees Paid by Applicant(Initial) BLDG 1 PLJlp1p
LICENSED CONTRACTOR,DECLARATION bb QTY ELECTRIC PERMIT IT- Lod✓
1 hereby affirm that 1 em five nd udn povisiom of Cha,ler 9(comtrencing JOB DESCRIPTION
L'CZ with Seencri7000)4Di.ision3aflhe Boine.toll Profentni CUdco yllcenu is RESIDENTIAL-
X00 .,/ PERMITISSUANCE
F�� in full twee Iva cB ?l � � ❑$FOWL ❑KITCHEN REMODEL
aVLj htccn.w Cl - Lie. gppLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING l PIPE
ti�L Dulc Colo..,
FOy ARCHIT'ECT'S DIiCLARATION D\SEES' CMULTI-UNIT ❑STRUCDIRAI,
Z O v�Z I unlc rtrM my,Inns.shall be",I.,Ix,bl,c mord, - MODIFICATION
OZ—O UPTO 200AMPS CLNTERIOR ❑CHIMNEY REPAIR
W 1-leco-1 Pmfe.alonal 201 ]"AMPSIMPROVEMENT E]SWIMMING POOLS
CY;E� 1 OWNER BUILDER DECLARATION OVER I"AMPS ❑BATH RFMODMJREPAIR El DEMOLITION
C IY Q 1 hereby aram excmlx from thC
e ontraelor's Licence law Ln the
X O a ffim then U following rtAwn.(Smim]0313.Bu,ircu ad Ptvf¢vimrc GUdc:AIry city«county SIGNS ELECTRICAL ❑OTHER
W 3lL which"toin,a pr nlin to eae,Vuet.cher,int,in ,denwli• in reRur my,mtmrt
prior to in ixvurce.also Tec,.theapplicull fersuch peron to fha,ignd.. SPECIAL CIRCUR/MP.
that k k,,enioil u uenttotheConulctclsLieetuelAw(C'hvp !)
�p�0 fcommercingwith Secnion]11001 ofavium 3 ofthe B.not Podeoinn,CedOTEN
IR TER MM17K OR POLE INST COMMERCIAL ��//''
1 a e that he ie exempt therefrom ort the bad,fo the allcgd evemMiun.Any violminn of ❑NEW BLDG/ADDITION �'DEF1DLffIDN
m
Seetinn 7031.5 by any applicant fn a R.itwbjeev,theeppli.,toa civil,cwhy of POWER DEVICES
y txx nxxc Than five hutdnJ dnllura[SSI1B1, El TP.VANT L1 FOOD SERVICE
H Z Y IMPkOV F.MIiNF
dQ QLnshe orufthc propery.mmn,. .1nyw,with wacl fer. Ihe Nee.canpcnsutim, SWIFIMING Pf%)I.IILHCIRIC
willatthew,ck,endthe IT,
Ixmai Lice.,,ortD for.vk(Sce.](NJ, wncru
and I'nofc„irns CoJc'.The CmtmctoJx I.iccn,r law docs rx%aPpIY to ao�wter of OUTLETS-SWI'(CIICS-FiXTURF_S 1A I
Mine,who builds ex improve,not art who docs such watlo hiro,e f m through
hi,own employee,Provided than well imps co enu are not imrndd or oRml for NEW RESIDFN AL HEE SQ ET
seh.If.hoverer.the bluldingmimpmsemmt iswld within arc Ycerof[mlpMim.lte SQ,FT.FLOOR AREA I LrSQ.ET.
tiv.IvilM will e e lda
aen of proving that he dt ou « a r buiN itn,ne for par- J U L — 7 1999
, havd
In,e of eilc,.
F11,is owner of Be progeny,um exclusively conwcdng with licensed con to,ton to TOTAL'
ar .I the po ject(Sce.](/M1J.Busire,s and Profesiwo CdeJ The Contoneis U--
,e—Low ch—nnapply mon owner of,onprny who huilds or improves therms, ocl QTY. PLUMBINGP FE 8
who contracts fit te,,c."fli.eunurloo')Been,ipursmin I.hi Co.."',',
IJcanac Law. PERMIT ISSUANCE
to e,e 0oder Sm. .H k 1'C fnr hi,re—on
(h.our Dene ALTER-DRAT NI'-WATF, tVALUATION
• WORKERS COMPENSATION DECLARATION BACK ROW 1RCG ICE
1 heeb aflml fuM Penalty Mnor e of daroto following denl : v
❑Ihave.twill maintainaCrnif uof Cansem to xlLinwrtfor WUrkeft Coxnpen- DRAINS-FLOOR,ROOEAR OND. STORIES TYPE CONSTRUCTION
union,u Mvided for by Sectim 37M of the IAlxr Code,far tk performnee of the
woel:fee which this pamin is i,wrd. FlXTU RFS-PER Tli 11.11,
El I lure and will maintain W'Mcex foam enunim houfanee,as rquiml by Sectio
37M ofthe fAbm Cole.for IN,proomluce of the work for which this permit is is, d. GAS-EA.SYSTEM-I INC.40UDFI5 OCC.GROUP +� PN `O
My W, Comps c tiM hanicliry nu r
Curies IC No,: GAS-FA.SYSTEM.OVF,R4(EA)
ERRIFICATEOPIiXI1Ml'IID 14tOM WORKERS'
COMPENSATION 1 URANCE GREASUINDUSTRI.WASTE INTERCEPTOR
(Thi,grim had rut hu mngdad if the Tomtit ie forme hundred dollen
(SI(X)) BUILDING DIVISION FEES
GREAS
or le'.) E,TRAP' PLANCHECK FEE
Icmify that in the perfmnatKC Uf the work fol wh'Kh Ni,pemul iv l,wed.l,hall
SEW ER-SANITARY-SIURM E.A.2W Ff. O
net employ any persn io any menar w e,tU become objet to the Wnrk 'C�xnpen- ENERGY FEE
O Z union IAw,of C u.Detc WATER HEATER WNE- /ELEC II c
Z2 Appl1 .1 pp�;; GRADING
N NOTICE TO ATIOCANT.If,ifiir n .t W,Ccnifinu of F',enni ion,you,Mold WATER SY.Sfi\VHifATING
F becme wbject to tk WM ,;Contpcnwtion pro t,im,of Ne IAbor Code.)'on nam SOILS FE
fonhwith comply with,oeh pr—iti ,or Ni,perei,nodl be deemed mUkd. WATER SERVICE
LLJ 0. CONSTRUCTION
CONSTRUCTION LENDING AGENCY NEWRELDENfIA1,PLMB. SQ.FT. PAID
.^J Z ne Rceeipt N
V 0I hereby affnto lhanhert is a nmstruclmnleMing agency for the peK.t,.e of
the work for which thl,,a-,it o ivumd Nec.3(H7,CivC.)
I,rowr',Nene TOTAL'.
I.cmkr,Addrt„ TOTAL: Iiii
1 emily tMt 1 have mad thina,plicmim art sate thou the ab,we informlim k BUILD FEE
yaxrcct.l ogrtc m comply with all city and roomy udmamcs eIt aero rows mleting m QTY. MECHANICAL PERMIT EFF,
V Z building eon.runim.ad hereby tothorixe re(ne,enlwvn of this city to ether uponthe SEISMIC �E
abo'e-nicernnd propmY for inspction puv,n c PERMIT ISSUANCE
(We)ague to u.n idcmrufy old keep harmka,the City M Cupertino again.
ELECTRIC FTE
Iiabilitin.jedglrcw.cmu art expense,which my in any way eeeoue again.said City ALTER OR ADD TO M E.CH.
mnseyuetltt of the,onenngof no,permit. PLUMBING FEF. -
APPLICANT UNDEIl�AMLOMPLYWITH ALL NON-POINT AIR HANDLING UNIT PTO 10,"CFT17 MECHANICAL FEE
SOURCE,REGU A ION ../ /�//y{
AIR HANDLING UNIT(OVER 10,V)0 CFM) CONSTRUC-GONTAX
Signatem 0 A,pli dControcuu Date EXHAUST I IOOD fWMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applirant or future huilding neu,ant uore or hurdle hiorm ons materiel HEATING UNIT(TO 1W.00 BTU)
ani defined by the Cupeniow Flmiciptl Code,Cb,ro,r 9.12 arld the H,blth ad Stfvy
Code.S .25532(x❑ HEATING UNIT(OVER Ift"BTU)
❑Yes F1 No VEM9LATION PAN(SINGLE RESID) PAID
Date ReceiptN
Will the applicant a futlue tuikting ocmpenl uu equipmem a Mica which BOILER-COMP(IIiP Oft 100.000 BTU)
emit hvarolnua air cmtvoiwnu as oklircJ by the tlaY Arra Au t)uelitY Ftamgement OT
Dl.nctl
E]Ye, [:1 No BOILER-COMP(OVER 100,000 BTU)
ALR CONDITIONER
hove tend et hvarJln,nutenal,reyu'wmemxy}Ytodcr M.
I oo r ,,e l the Coll- 1"
LANCE"
lomio H"111,&Safety Coo4,5,t 1' L55U5,255 3 r(d� 31.1 u,notify ut thus if the NEW RF_SIUIiN'TIAI.MIiCH. SQ.Ff. ' 7�. �
hullBingtkms tux curt hove urn Iholi ' tilityto tlaifyth oxcupanl
orthere,tt, prltx [t Cmihntoof O`cu a
(house authori5 agent a` ouch 'TOTAL_ ISSUEDBY:�D
OFFICE
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