S 1600 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEIy\l}IT No
BUILDING DIVISION APPLICATIO [PERMIT I'LIIM HI NO-MECHANIC,% V 1600
BUILDING.YBOJh:Cf IDENTIFICATION
H LDINGAUDH ESS: SANITARY No. APPLICATION SUBMITTAL DAT:
19-111 � G 2 I>Y'
ON' 'ER'S NAM:: 1 ` �oNL" - !� NTRACInRS f\ l LI[N
-T\ A��nVI ` NA/wcf 3 n/c CONncol.x
ARCHTTCl/ GINEER: LIC NO'. DRESS:
CONfnCT, PHonli. BUILDING PERMIT INFO
wI__rC �w, 1ry1`\� ry /3y E-] Caosvltent Fees Paid by Applicant(In id) eO ELECT PLUM1tH MEC❑Il
/Q nLICENSED CONTRACTORS D4FCL,OtAATIO1N I O QTY ELECTRIC PERMIT FEE
I nerdy affirm Iha aW .a I m mxlvler pavldttat of er Cbap9 amlmetalnl; JOB DESCRIPTION
WOO
�tzg 1 ttn Section 9SXo of Dvivm 34ntc B.,lacad Pnnc,ion,cwt:,and my Item.h PERSI R ISSUANCE, RFSIDENTIA1I
Fly.- infull force and crttty > --/� Q ✓ ❑SFUWL ❑KrfCHFN RIiNODEh
<-U I.icctue Class C�J coror /C�
QZV T APPLIANCES-HISIDI;NfIAI, ❑AUIII'I'ION ❑PI,UA181NG RE-PIPE
yQ Ilam Cnmmutnr
FDh ARCIIIT[CTS DELTARATON PANELS ❑M1IULTI-UNIT []STRUCTURAL
Z O I uMsr.atd my plan;doll W asad x.public¢card, MODIFICATION
UP Tl1IlX1AM15
1-Qt?F'W L'Ianscl PmfcasinnU OVER IMAM IM1tIRUVEMF,NT E]SWIMMING POUTS
Ck�J
OWNER-BUILDER UI3CIARATION OVER IM)AMPS
El BATH REmODEI NOLI'TION
C C Q 1 Wrtny iffrm Inv,I ant escmpt from tW CVO.cars Liccnw Law for tlw . 1
xax O ea V FaBov ing amen.LSeelkm]0313,Business and Profeastara Cosi Any city or moray SIGNS G,ECMAICAL ❑OT1ER �aU
W a p HQ whkh rryuire.a panail to construct,alcor,improve.JCo ollW,or repair any swnme �ne3f1
^,- J primmitx is.uac.dvt rtywrc the vpplicmm[or such fcmtilm Blc avtgrcdetatmrcnl SI'ECIALCIRCUHUMISC.
Itlmhci.licrnvd W..,,. .mtW pmvisims of mcCmlroc,uls licrnsc LvwlClvper9
W�QO fcommmcing with Sucllnn llMq]nflJiv'uion3nf tlwllu.vinca mdl'ndovium Cwe7 nr TIMP.METER OR PDLL INYE COMMERCIAL
n d e c Ilial he C,nonpt Iheref.and Its basis fo,,M alleged esempinn.Any violmitm of ❑NEW BLDG/AUDITION ❑DEMOLITION
=y Seco n 1031.5 by any aWlicant for a lsrrnil subjccn the appli."",to a civil pcwlty of POWER DEVICES [I TENANT ❑17COD SERVICE
mM more than Eva hundtul tkllnas-(1650)).
H Z Y IMPROVEMENT
M Lxox'rcrof the pmlteny,mmy.amende]withwa,d Em IC rwle 0L1.Bamtim. SWIMMING I'(N)1.IiLliCIWC
will attWwork,aW IBC a ClttrCtonal,L.cmdeIoflel for•ale I.Sec."1 an Hu 1"1 OlT1Ek
3
and ITofexh me Gl,or Thc Cmm eteou,mail, Inca Aauv nmapply moor Ih of OlII1E1S-SWITCHES-FIX'rUHES
his Po
Io wW oyce,pr impm•c•theme,and who tlrcam art,
vorl,himself of mmugn
Nin own ovso y,the pmvii al that such inlltn,vc ornu we txtl imetde,I oa offend]for NEW RLSIULNI'IAI.ELECfR SQ Fr.
Bile.IL httwevcr.the Wilding nnmprovetremin udA within me yarnf contpktim.IFw SQ,IrI'.FLUOR ARG SISV-Ef.
rcr-builde,will Eave tle W tJcn of porting Inas he that matt W IM or impnve for Pm.
pxe oLmk.1.
C] 1,a comma the pen
opy,Nt exclusively conamcing with Iicen.d cm mclMmF TOTAL:
omm
wre,mct Inc lojeo liter.7BIT Bunimess and Directions Ctd J The Cnnu tar's Lt. P � 1 1�
WP.low dttcsw,l apply It-orc
wr ,r
-of ,,my won huld.m mpmvc.Inendm.and QTY. PLUMBING PERMIT E
MW ermateta Boston 1'Tlt'cu with a cnuramM(SI rcenaed'nam,Io Bte c namcorr\
Lrecnv Cast. PERMIT ISSUANCE
Fj 1 em eacmpl ntde SCC. .If&I'C for Thin rcnaxl
ALTER-DRAIN k'VIiNp-WAI'EH 11%\1 VALUATION
(Owner Date
WORKERS COMPENSATION DFCIAHATION HACK FLOW I'NOITCL DEVICE CITY Ur GUYCt511N0
I W mbv aRnm under penally of penury ate of me follawing Jccluuions:
I Tuve uW wlll nwintuina CeniOatu ofCmvmno mall-insure forWmkeh C'mlpen- DRAINS-TUDOR.RODE.AREA,COND, STORIES TYPE CONSI'RUCTION
calktn,as ptoviJcJ fur by Se vim 3101 of the Labor Cock,.for tW perfomwmc of toe
work for which thisp.1 i•iss & FIXTURES-PIR TRAP
❑ I nava aa1 will ominDin Worker',Cotnpenaioa Inwmme,as ayuhed by Section
310(1 laorGde.fmIIBC V,tnm.bCCit WwM for which this l'cmtil is i.awsd. GAS-F.V SYSTEM-1 INC.d OUD,IiIS OCC GROUP APN
My Wo lace,Cons wion Iwuance cartief and Put try number art:
Cmi"r FFbcy Nu.l GAS-EA.SYSIYM.OVEN d(EA)
CFRTI9C.\T3 OI,EXEMPTION FROM WORKERS
COMPENSIM ION INSURANCE ORfASP/INUUSTRL WASI'1i IND ERCEPI'ON
(Tniv ,T,.real IntlW anmlealdthepanni,ie finum hauled dollars f161 BB BUILDING DIVISION F1'.ES
or less.) GREASE TRAP 1'LANC1113CK Flili
I emify lim to dw perhxmanaeoko,wtxEftvwhichthivperinitkiw,IseJ.l;lull SEWER-SANITARY-STORM IU,31q 14.
nm employ any p taor in any mann�.1 o naoma to I I a t W W,trkuta'Cnngh�m ENERGY FEE
Z A h Lgy, umc 3 11 WATER IIP.ATiH W'NCNf/IiLECfft GRADING FEE
lo
IN , TO - 11e nm ng lois Cminamc of❑scorpion,yutt shxJd WA'ITE SYNOiNI/IRUAI'INC SOUS IIiP.
bemn a obeli Campertvwim ryoviaims of 11c Labor Cuk.Ym must
fonnwilh Comply wish such prnvin't na or Itis p:mat,hall W dankd revoked WAITR SERVICE
4 CJ
Z CONSTRUCTION LENDING AGENCY NEN'RESIDE.\TIAh PLS1B. SQ.IT PAID Date el
U O IMmby vllimtlhut mem isaam.ore.RYD.Civ, agency Tonne pcdsntwncc of
I W work forwhkh This permi,IC i.sted ISCC.3091,Civ.CJ
0 U Lmajcr's'NapC
AWn, fOTAi.:
U LcMct's AdJrtxv 'TOTAL:
Y' LLBUILDING FEE,easily That I love teal Nu epplicelion nlld caa da
ne that dwe infnmwtim is
F". In coram.I agnn to comply wtm all city and county ordirwnce%arta stale Incas at to QTY_ MECHANICAL PERMIT FEE
U Z Wilding mnnwvion.and hertby armil mbclme lalivo'nl thisci,y to enter upnlW SEISMIC ITE
move-IrcnOored popsy for inspection purl•'.•. PERMIT ISSUANCE
EE
(Wc)ag¢c at can,irdmnify aW kegt harmless the City of Cupertino again. ELECTRIC F
hahih,ks,judgnr...caslsmrd eapcn,es which may in any way ecru,ageinn, it City AL'ITR OR ADD ED MF.CH.
n.Rueac of me gruning of Thi,permit, PLUMBING FEE
APYLIG " t tNSTANIJS AND WILL COMPLY WITH ALL NON-P<)IN'r AIR HANDLING UNIT ITO Rldl)01 CITU
SOUR RIiGUlA1'IW MECHANICAL ITE
AIR HANDLING UNIT LOVER 111.(pll CFM) C0IN rHUC110N'AX
Sib cam .pplic oar m S TAW FXI TAUS f HOOD(W/DUCT) HOUSING MRIGATON FEE
11A%AR000S MATERIALS DISCLOSURE
Will the applicant txninon,bulding ncmNm.tore orhandle hamfKU ttwarial I IEU INC UNIT(1O I W.00011)V)
as reBnN by is Culsimim Munkigml Core.Chapter 9.I2,ud the Heath and Safvy
Cult.5ceti,n 25532DC 1IEAI'INC,UNIT(OVER I000C B'FU)
Dyes E]No VENTILATION FAN(SINGLE RESID) PAID
Dart, Hecaip M
Will the applimm or loan,building occupum are eym,omcal or devic,s wbmh
pail hamonsi air conarritwms as Ached by 1W Bay Area Air Quality Managctrcn, MOILER-COMP 13HP OR 101,gM1 BTU)
TOTAL
Dlatdc,". BOILER-COMP(OVER IIAI I0f 11TU]
❑Ym F-1 No
I have rtaJ me ImArdom•malarial,laiummomta undo C'bulxe 6.95 of ds Cali- AIR CONUTIONER ISSUANCE DATE
(mama Heahh&Safely Cock.Scctiotn 25505,25533 ted 25534.I ond,-mot!11.h de NEW RESIDEYfLM,MECH. SO Fr
Widiog Jae.m currently have a a ant,mat it in my mpauihilov to morly de occupcm
of IW"amarm,which nm.he int prior ut..,,or.Cmif.uc nf0.cupuey.
(Amar or msthoused,gem Due TOTAL: ISSUED BY:
OFFICE