S 044346
aw,
C
QWUC
�n <n
F=Z
oz --'c
F�E'LL
�OWQ
apaC
_n
L6cc
o
F
a3�
Is
Aocl Ir.ANT Tn cD I. IN wFORLAATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,CITY OF CUPERTINO BUILDING. - E:LKIN RICAL
BUILDING DIVISION APPLicivnONIPERMIT PLUMBING.MEICIIANICAL
BUILDING. PROJECT IDENTIFICATION
PERMIT No.
O 4
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
Litt co
OW ER'SNAMIi: M 11'(0�qq
'uHACTXU;MIV ,1LICNI'
6
NIC
❑
CONfAOLI
ARCHITL'Cf/IiNGINEER'. LIC NO:
ADDRES: �/39
A"Aj
CONTACT: PHONE:
BUILDING PERMIT INFO
/„mAC1 y6()G&,I
Conttani FePAby Appllart (Inla)
BLEGU❑CH
BO PLUMBDom
DECLARATION
CONTRACTOR'S D1i dam, of f."
1 hreby amen mm� I min ne,n,rJ ul.kr prnvi,mn, nr Clwpin v annilrercing
QTY ELECTRIC PERMIT FEE
JOB DPSCRIPTION
PERMIT ISSUANCE
with Scmitm 7M))or Division J of lineRusin¢\ AM Pafesines CME. and my Incense e,
in full force o�IJcR«yE ��/ ��
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCIS-RE,
1-�1tl'c y,q7 f0 GcN
Dom�w Cnina % ��/
❑ADDITION LUh1HING Rh1 IPE
❑MULTI -UNIT ❑STRUCTURAI.
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITECT'S DECLARATION
I undv,lunJ my plane ,fall he urnl an public ncmea
PANELS
UP TO 2N)AMPS I
Llcemed Nafe..innal
4111-IUXIAMPS
OWNER -BUILDER DECLARATION
1 hereby a1Eml that I an, e,empl from me Comrna[ors Llcen.x law Ins Its
following canon. ISm[irn 90313, Baine. end Profenim, Cute Any city m county
C1 BATH RP.MODFIJREPAIR ❑DIl+fOLIIION'
❑(TIER
OVER IIxI(IAMPS
SIGNS ELECTRICAL
which r,.I— a pRnal at, no him,. at,,, improve, demtli,h. Ir ri aiir any waawrc
SPECIAL CIRCUITAIISC.
Nice mI,,i.ualn,c.alai"itines meopplicmlrnrwch pennilm rilea,igrcd,umment
Ihm he is IicemvW Forwanun the provisitmA of the Cnnlracmr, Lkenw law (Chapter Y
(..an, with Sectirr]Ix1(DnfDl,..am 3 M ac Husaren aM P-F.auu Coale) or
ma fe i, em.N thmfrom end Ile Buis for IhC allege) etumn, m. Any violmion of
TEMP. FH:TER OR POLE NICE
COMMERCIAL
❑ NEW ILDChADDI'I'ION ❑ DEMOLUICK
Sec[ilm 7031.5 by tiny aPplleanlsof upemmnmN,,V%[he apdinnl Ina civil penalty of
POWER DEVICES
[ITENANT ❑ FOOD SERVICE
not mine then rive huMrtd dNlu. (SNX)L
❑ I.uowluY or the pntpcnY•or my employes win wager uv their vele rnmPcmaion.
will doth wok, enJ Re sl,umurt is not immWcJ rcNfeml for.ule (See ]Ma. Ho,inas
IMPROVEMENT
❑OTHER
SWLMMINGPOOLELECIRIG
enJ Prnfc.ions Codi:'llsT Gmtmc[«, Lrcnsc Low d,m, mit apply to m mar oI
RL14
OUTLETS RL
NEN' RESIDENTIAL ELECfR SQ FT.
paps„y who builds a inaM ves dnrnn, aM who deco ouch wort Inmrclf or through
hi, noun entploycer, pntvideJ Thal .ouch impmvcllwntn art rout inlenbidl er oaemd for
sAle.If. ho„'c,er,the nuitding wimpaocmcnt i, wW within otheyen.fcompinim.[h
io�aer-lmildcr will fact, de bm,kn of paving Tat he did not build or improve For par-
po,c
1, u, owner nl Its pnpeny, an, ndu,ivdY umlrx[ing win licensed conlmdorx to
SQ.FT II.(X)R nREn
S�� •'O
Q. PI'.
TOTAL
mount the Meet (Sec. ](HJ, Busies.. and Aofccsion, Code:) The C..'m, Li -
' ,c law do— nm.,Iy lomt owner ofpmpeny who build, or rations- lRmm, ale
WMccoumv for Mich paJKlswida a colNlYlnrfs)h[CMCd No ant lobe Cmnt Wv
�J
QTY, PLUMBING PERMIT FEE �%•
PERMIT ISSUANCE
Llan., low.
❑ I Am esemp alWv Sec. . B h P C fou this rtasm
Owner Doc
ALTER -URAINft VENT -WATER (EA)
/4 VALUATION
/-1
G
WORCOMPS IN IJECLP.RATION
HACK FLOW PROI'IiCT. DEVICE
1 Meby under p enjury
mai Iona pcNlly of perjury arc of site fallowing d
will orker'ims:
❑ Inave aM williovinby n.etion 37M of thic,I droll -amort a Worker's of dit,
wEon, a, pmviJhi far hY Section J]fxl of We Labor CME. for me pcH«mmas of Its
IINAWS-EL(l(IR.RWP.AREA. COND.
STORIES
T1'14 CONSTRUCTION
wok Er which this permit is orla,
FIX 'IVRI!S-1'ER TRAP
37 I nave aM,h, rtw. fee workers CrinprnWiul Inwhomen.Afi—tu h eiuild by Stttim
J](p nrllle labnrcMe. feeble peremn <nnnt,wltm frrwh;rn mits pCTlil i, k,w,e,
cx:c. cuour
ern
ens - En. sysT'Enf.nnc.aounl!rs
My Worker', C.,mialion Inwm. rnnier and Poll, number x:
Cartier, Policy N.,
GAS - P.A. SYSTEM -OVER a (EA)
GREASULNDUSTRL WASTE INTERCEPTOR
CERIl1TICATH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE:
BUILDING DIVISION FEES
rul dollrrs(S IIx)
The; .10", lxvrl rel hrnnlplmN if the Perini is fox hmdm
m ksa)
GREASETRAP
I'LANCHECK FTE
IehmifY lhy in the pNormnna ofins, work ffoorr which[hu pant[ is iVoi I Eall
nam nl subject a the Warden; Cumpen-
�lb¢/ r��N-4
SEWER - SANITARY - STORM EA.200 fT
FEE
nbw.olf ymiu /
(j4
ApplaeNOTICE
H'ATIJi HGTIJi WNENT/FI.I:CfR
GRADING IN
To APPLICANT': If, Aller making this Cenificme of Gxemgnna. yen should
hcca,es ssdtject to the Warkeis Canpe ention Provision, of the Labor Code, You mus[
WATER SYSfEM,7REATLNG
SOILS PEE
WATER SERVICE
fomhwith comply with such provnetnX or [hl, p,noil shall be dxnwrl ranked.
CONSTRUCTION LENDING AGENCY
1bei eRnnbit NereisxconuroemonlcMingaVmyfor thepmfommrccof
NEN' RESIDENTIAL PLMB. SQ. FT.
PAID -
1 Receipt♦
theuov f -which This Permit i, i.ticcl (,Sec. 3097, Civ. C.)
Tesco's Nems
TOTAL
1<nticr', Adds,
TOTAL:
BUILDING
1 amity the,1 have read Tia applicuian and woe duo N, above itifico moon i,
I cavm.I at at comply with ill city.nvi county ordinance uW ,mm law, miming m
building c.tion. aN herby Aulhanrc rtpc,cnulivcs cA thio city m cr.c upon ate
QTY, MECHANICAL PERMIT FEE
SEISMIC
I PERMIT ISSUANCE
IHRCfRI
ehnvc-mcntior d Ton,eny to, -,,ii p aTto.¢.c
(We) Agice m save, indemnify aM keep h umle. the City of Cupertino Against
I ALTER OR ADDTO MECH.
PLUM BIN
Iiabililia,judgmrnts. nets mrd expen,es which may in any way aecruc agmina cid City
n rnelsryuena of the atoning of ons pemit.
AIR HANDLING UNIT CTO IWill) CIND�
MECHANICAL E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON.POINT
SOUHC EGULATI S.
AIR HANDLING UNI 'I'(OVER 10,UX)CFM)
CONS]RUCTI( TAX
7
9-� 97
Sigrwum of Applicaau'Con ca, ."
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (WMUC',
HOUSING MI ATION FEE
HEATING UNIT TO I WW) BTU)
Willits, ahofianm fulurt nuildin,occvpansam, tw hmMlehvanlru, ntmcnul
u dcfrcJ by the Cupenim Municipal Cnk, Chapter 9.12 mW Jt, Hellin and Sefny
CMe, Semlon 25]J2(a)'!
❑Yes Ew�No
/i
HEATING UNIT (OVER IIXLDI(1 BTU)
PAID
ILIO c. npl N
VFMIlJG1ON FAN (SINGLE R15IIH
HOILPR-COM rJIlI' DR I W.IXp BTU)
Will the applicant or future hiWin6lccuPwr arc'o'sm, er Ilcv'r,i wh'rh
' emit hat N u, air copmeam em. e, defi el by Ih Bay Ama Ai,Qmliry Mewgcnent
TOTAL:
BOILER - COMP (OVER I(K." BTU)
Divined l
❑Yc Cl No
AIR CONDITIONER
I hove read lh haaadous romeluls exauhnni until Cher seerM195 of the Coli-
ISSUANCE DATE
NEW RESIDENTIAL MECIL SQ. FT.
foie Health h Safety CbJc. Section, 25915. 15.133 and 25534. I Mile," that if arc
huddling don not smrtruly have a taunt, that it u my rearymihility IIS notify the menionl
Ff
of 0n"texr roes which nnuu IN, nun Iriiw u) kimi of a Ccn10cvly of Occupmry.
ISSUED BY:
TOTAL:
Owner nr.mho 'ed.gent hat,
OFFICE