30121 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMRNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SU13MITFAL DATE
0 ERSNA PIRJE s ONTRACIT)R'S NAME. LIC NO:
• NIC CONTROL
LHHLUWENGINEER: TIC O: ADDRESS: ❑
7=z
NTACT: PHONE: BUILDING PERMIT INFO
❑ Catlwltant Fen Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby offish Inv I.m IeenaM under Povieinnn of Chapter 9(commencing JOB DESCRIPTION
hSmm]1M0)ol Division3ofrhe Busimv ad ltofcvieas Cr.k,enJ myiiccnsa is PERM1IIT ISSUANCE RFCIZ, Aull force and eticcr.anhc Clam Lic.N CSFDWI. CKITCIIfiN REMODEL
NQS Dutd Contrucl« APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
Fpy ARCHITECT'S DECLARATION pAN1iLS El MULTI - CSI'RUCfURAL
z 0 5,1 I ume�my Men. l oc a�.PNhI'a awf ..
O Z^M _ UP TO 2W AMPS MODIFlCATION
Q4t: . Licensed Pmfceioml ❑INTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
OWNFson exi rt boar CLARATION OVER 1000AMPS ❑BATH REMODEVREPAIR El DEMOLMON
Q 1 hcr<by eRrm slut 1 am BUILD from the RAT'Jctots License Lew(«Bre
fixx•O a U following aetml.(SBdm 7031.5.Business and Pnafnsbrn Cork:Any city or cauvy ❑OTHER
W 4 a� which nryuinn.pemdt L anstran,ahn,impnosc,demolish,rr neryr my saunune SIGNS ELECTRICAL
f-—CPrim tarty i,..also naryirts tbe.pplwantf«such penniin Tike siindsutenrm METER OR POLE 1NSSPECIAL CIRCUR/MISC
than he is licensed Peauset to We PLsisiom of the C«unacrort License law(Chaper 9 COMMERCIAL'
C. (commencing with Section 7000)ofDlvLoon3 of the B
thminnam and Profeascbs Code)or TEMP. f.
a a e K thin be is eUemP tbenefmm and ttc boil f«the alleged exempt".Any violation of
V-
[-)NEW
FeZr>n mr hl ❑ EWBLDG 10N ❑
ON
Secrim7t3Y ancanfinepemutsubjxbte applicwtmacivil timidly of POWER DEVICES TENANT ❑FOOD SERVICE
tnrxerhanfivhunKIrcd dnllvs(5500).
IMPROVEM
Q ❑ I,uawtur of the lropeny.or my BmpNyea wile wuga as their wlcsmtPBnwion. SWIMMINGPOO TRIC
wtllrN the wrrk,umlthe ntmmum is nNa inanded«otTctcd Ba wlelSa.ASW,Busircss ❑OTHER
and Rtlassit ri Citric The CrxmachoO,L erhro.law dnsx.mn aPply to an owmr or OUMEFS-SWIT E RES
4' ^ TrTioty who buihk or imlrrovcv Nn arn,vol who race such work hintmlf ur NnrtgM1
hix own cmployca,Po",rad Ilan such improvement we not intuwld(ir onerd for NEW RF_VIDIW L Iia SQ
AQ-
sale If,hnwcvn,the W ikling m improver«nt is mM within urc ycw ofmmpction,the. 5 S SQ.IL
ownicar-buildCr will hiva fle troll of Proving that ac did not build-instarroot lot par- rill Fy
prxcofvd,)., t
1,.a nx'«r of the ryopcnY,am cxduvvdy coNnering with liccmcd cauracr«x to IAL:
..the P Oyetn(Sec.TyLL BasNcss and PLfevimx Cuda:)The Contractor's Lt-
cemelawdoas.ispplytontownaofpeopenywhobar&orimpmvesrltnem.am. QTY. PLUMBINGPERMTT FEE JUN 261996 -
w W c.,f«wch pmjccis with.mntfanarls)licensd Pusan.to rbc Cminctor,
Litana.l.w.
❑lurSec.nexenaxtbr ,B&PCfimdisreascm PERMIT ISSUANCE
GI IT ur vur�rllBW
Owe ALTER-DRAIN&VEST-WATER 1 VALUATION
WORKER'S CCN?PEN5f'A`lIUN DECLARATION BACK FLOW PROTECT,DEVICE
I berctly affirm tdcr Penalty of perjury am of do following declvvions: �L [/
,]I have and will twintaina Ccnificveof Convent mxlGinmrc for Wmke,Cosh N.- DRAINS-I1.0C ROOF AREA. ND. STORIES TYPE CONSTRUCTION
,A.O,es Pav'Id 1 fnr by 5¢tiun 3700 of the Wdx Crdc,Int the IcOrOrri me of the
work for which this pertr
i,i.iool. FIXTURLS-PER Ir
C 1 havc and will nuim0in WofkCOI Compcnsvinn Inwmlec,an ayuitd by Sation
3700.1'hc WMr Crd,f«the perfmrena ofrM1e wnd:0rwhkh this permit is rested. GAS-FA.SYSTEM-A"0711=S OCC.GROUP APN
My Worker's Compcnwtiun Inhn cams end Policy number eW:
Cancer. Policy No: GAS-EA,SYSD i e(FA)
CERTIFICATE OF EXEMPTION MGM WORKER.S'
COMPENSATION INSURANCE GREASFAN RL WASTT R ETOR
(This shim need n t Sa cwntplicd it dte pemdt is f««x havarM dN Ws IS 100) BURRING DIVISION TIES
«�) GREASEjk PLANCFIECK FEE
1 a my per in the pmf«nurcc ofthc work f«which NN person is i Co l shall
nlaiempty r(Pentylmany vlamtn sou to become rto the H'mkers'C EN ANIfARY-. R• E.A. 00 FT.
Z swim lawnMCWJ«nin Dve 1231/0
�co anpin- tliERGY FEE
0 EATER W /EI.EC IZ
Z OApplicant GRADING FEE
NOTICtry Ecaa. bj APPLICANT:If.eller Leming Nie Cranoorosshlo r.J Lx-rdod y ushoold. W, RSY 4TING
F " bccorrc wbjeer to Ina W«ku's Compensvim pavidrm of the I�tw Code.Ym m v I SOILS FEE '
a ? Sotslrwith comply with such pmvisinns or this pcmut xlul l he damd revoked. A 'R)E 'I
y A /
CONSTRUCTION LENDI NG AGENCY NF. ESIUENI'IAI.%JNB. SQ.FT. PAID,
UO I heavy0rcmtthattW2ienametraatim r'7,C., tgB,teylmlW parram,ercear Date ReaiplN
tba woK f.which Ihie perm0 is rood(Sec.3119],Civ,CJ -
Q v Lrndcr's NmM TOTAL
W LrndclAddmst TOTAL
rlify That 1 have Head this 0pplration ed sinthat the above infomudm is BUILDING FEE
r0.iY I amrtecl l agree mcomply wiN all chy aha Boamy ardinarcee.rd Here law:-telNing m QTy_ MECHANICAL PERNITT FEE
() Z building Construct and hamby.adtodzemprnsmtetives of Nix city to tartar upon Ne SEISMIC FEZ
'—' .buve.meNlanrJ properly fa insPxnim rvh m .
(We)agra to snve,iMcauify and keep hanst the City o penim Of agarim PERMIT ISSUANCE ELECTRIC FEE
inonstin,jtdgmntb,O an,aan,pewhich may in any way ucnne agvwsdd City ALTER OR ADD MECH. PLUMBING FEE
in PLICAN a ofDEgravingolNisD WI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNR(TO 10.000 MD
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCHON TAX
Sigodamof AppllcsnoCmuan« Date MIAUSTHOOD(WNUCq 1110 IIOUSINO MITIGATION FEE
HAZARDOUSMATERIALSUISCLOSURE '
Will the t dicnntorfutwc Wilding srcupmt yore or hamlb hvzOrrhms Lverid H BATING UNI'I('H)110r)OO BTU)
a defend by IW Copeman Municipal Cod,Chapter 9.12,and the Ilealtb add Safety
Cork,Sation 25532(0)7 1 HEAD NO UNI'I'(OV ER I tM'orx)BTU) '
❑Ycs 0N PAID
VLNI'IfATIONPAN(SINGLE RES ID) Data Rmciptg
� Wi111ne applicant«futurt building occupantuseegtiPnentmdMarnagmand BOILER-COMPOHPOR100,O)0BTU)
t hvaadous ev contnmimnu u dcfircd by One Bey Arte Air Que111Y M.mBement TOTAL
District?
❑Yes ON. BOILER-COMP(OVER IW,IMO BTU)
I havc rem de hvndtaa tlauviats nBgahemerna trader,Chaptn 695 of tie Cal: AIR CONDITIONER ISSUANCE DATE
f«nlm 11.16&Safety Code,Sadat 25505.25533 and 25533.1 advsiand Nat if do NEW RESIDENDAL MECH. SQ.PT.
Wiwi,dors nla coronary havc.unni Chat it is mynesprmibilayto modify rbc occLand
of the rryave.which Mead W Ln pri«tu sismana ole CcrtiOcau of Occorpra y.
Ownn«aatF.macdagcnr Date TGTr`L ISSUED BY:
OFFICE
�r1o.��- �yISrG aoxAY
IrJ�ok1 � j�f'�t.4CJ� IJ�
_5l,l0(P_ ItJ e-_74mbo L o�
Axl`;_T- in -FJw-
�•M� L�crfolJ
REE� ENEIJ
f JUN 2 6 1996
BLDG. INSPECTION DEPARTMENT
CITY OF CUPERTINO'
KIo4-� OPY
rY U�����L14, t_
APPROVED
IN ACCORDANCE WITH THE CITY OF
CUPERTINO CODES AND ORDINANCES
DATE
SIGNED
This set of plans and specifications MUST trip
be kept on the job at all times and it is un
lawful to make any changes or alterations
on same without written permission from
the building Dept., City of Cupertino.
The stamping of this plan and specifications
SHALL NOT beheld to permit or to be an
approval of the,violation of any provis;ons
• t( vw City Ordinance or State Law.