31238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /] /� O
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL J L o
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. NSUBMITTALDATE
BMITTAL DA
Lrgild AV - � PEfZTIN6 CA1 / �j'�Q
OW +RS NAME: PHONE,• C NTRACfOR3 NAME: LIC O:
r c ILLlA NIC
CI11T U'HNGINFJ?R LIC NO: ADDRESS: - ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Conwltanl Fm Paid by Appilcant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 bersbaffirm not affirtom I ma lia ur kr provisiom of Cnnprer 9(comanaming - JOB DESCRIPTION
aO 0O OZ wish Sailion)BBB)of DiAxoi 3 o(,ba Budrca Cod Pmferaima Cock,• any lken.se is PERMIT ISSUANCE
FW fullf«ce and eRav DWL ❑ ITCHEN REMODEL.
�QIiac aria Cl. Lk.Y APPLIANCES-RESIDPMLAL ADDITION UMBING RF.-PIPE
QZ Dnl Gmlmcmr '.
F.
ARCHEI C6 S DECLARATION PANI7IS 7ti r ❑MULT6UNIT /El S UCTURAL
Z O 7j 1 urMIC61mW my plonn shalt x usal ar punhc rtcarJ. MODIFICATION
OO Z UPTO]BBAMPS
[- {..,G mac•.„-. -1El INTERIOR CHIMNEY REPAIR
OWNER-BUILDER DECLARATION
20l-tNx)AMP5IMPROVEMENT
Q 1 hereby affirm Nm 1 am eacroP from the Caeuctor”License law for the OVER I"AMPS ❑BATH RENODEURFPAIR ❑DEMOLITION
x 3 a U followog rcawa DS tion 7031.5.Busineaa mil Parfecsions Cade:Any city or county SIGNS ELECTRICAL El OTME
al LLra which rtquirtmm
s a poit to nuct,rwalter.imro
pve,demdi b,m rcpeu wunrt Coy u '�1 l
F.L Oo Pd«to in iu e'stao raquinc&the applium for such permit to file a signed wane o SPECIALCIRCUHDMISC.
f;!��- Jou he is licrnad purwan,,o dr Povisimis nittc ContuctaYs License law(Clulnrr9
W C40 (cummencivg wiN Section]MpMDivinion laf die Busurev eM 1'sofesai«m CMe]or TEMP.METER OR POLE'NST. COMMERCIAL'
d thin he is cacmpi thcmfrom nnA,lc hath for Ne al4gcd excmpfi«.Any violminn.d ❑NEW BLDG/ADDITION ❑DEMOLITION
55 Saliat7031.5 by any uoffcon,for a permitabj¢q the applicant w o civil pcnalry,of POWER DEVICI!S
nm}^^''����Then tive hundred Jolles.IkN1(L [:]TENANT ❑1'001)SERVICE
Qy11=11—ofthe pupmy,or my empinym with wagn us lMir.wile compenaetion. SWIMMING PSL ELECTRIC 1 PROVEMFNT
e�CC wII1 JU Br work,eed Rralrvcturt is mtimrndN or oRerM booaa Sa.7( .Rusiness ER
end Prafe,ai«n Coda:The Convectors Lki as law does od apply an an owrcr of OUTLET'S-SWITCHES-FIXTURES -
6 3 Progeny who build,or hnpsoves thcrton,anal who doe,such work himself or thsousll'
his own eap{oyaa,Iaovidcd the,urh improvemems me T,InaMN or•Rani for NEW RESIDENTIAL ELECTR SQ FT.
"ala.If.however.Nc building«improvemelw is s within one yarn ofcrnlpkvim II N, SQ.PT.FLOOR AREA ESQ.Fr
owrcr-W ildv will have Ne burden of Proving that ba did not Wild m imPswe or for-
ak.).
1,m nwp of N, propc,y,am exnru ml contnaing Coll:)Tha, cnmraross i- ]O'rAL:
ons,rvn Nate prajm(Sec.]UW,Bualneu vM Podwaiom Code:)Tie Cont tix'x Li-
soLow Naas nm aPplymnnow«r of lnycny who builds«impnwa lhcmm,aril QTY. PLUMBING PERMIT FEE
hhoo cco.TI.ai fo,,ch pnrjcu M,h a conomnonq lic.a"punwnno tM;Gmtrai
,_,�( PERMIT ISSUANCE O
LTr p,u� ;tl KPC Ln thix n
/ ALTER-DRAIN&VEbIT-WATER IEA) VALUATION
T D
WORKERS COQ fPPNSATION DECLARATION BACK FLOW PROTECT DEVICE .
I hereby alTvm Iedcr perol,Y of perjury«r Mdr fdloweg Jaarmhw:
❑IWvc and orifi rnuin,gnaCmificaaofConant to xlf-irmve for W,m:ch Corgcn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sa,ion,u M idol f«by Navin.377 of tic labor Coda,for dre parRmmstcc of We
wank far which this Parrott is iiai 1. FIXTURES-PER TRAP (�
❑I have end will maimnin Wnrkcr's Crmpenvsioa Inti.,as scquiral by Section
37poftic Lahr Coi for the Prf«mar,a of the work for which link permit is i.cruM. GAS-IA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Warkcr's Compcnvliun In.wrvncc carver and Policy nwnrer orc:
Cmricn Policy No.: GAS-'A.S'Y.SUN OVER 4 UA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCFJTOR
BUDDING DIVISION ITIS
(TAnamion recdmbe cannpMMif the pond,&Cm ane hanrhN Jailor(5100) GRFASETRAP
«Id.) PIANCHECK FEE
'm fy drat u the perfarnnttartM wok f«which this Permit is issud.I dull
rot employ any Pmae io my mamcr so as to bcnrnc mbjeo to the Workan'C«npen- SEWFJR-SANITARY-STORM Ea 200 FT ENERGY FEE
OZ ori.lawn of California.Doc WATER HEATER WNENT/ELECTR
z O Art4irat •O O GRADING FEE
y NOTICE.TO APPLICANT.If,gar making Ni.Cenifrnte of Ea orfnim,You sb uld WATER SYSTEMTtEATING
Fbcorrc suhjm,a the Workch Compenwlon pnrvision.of the IaMx Ciik.Yiu mus 'SOILS FEE rA
WbnhwiN comply Coif smh provis ao,nr this Penni,•hall he deme]rendeN. WATER SERVICE � -
Fa z CONSTRUCTION LE- DINGAGENCY NEW Rmi)iwfIALPLMB. SQ Fr. PAID
I hcrtby offimt,hat them is a cmnouc,irm krding agency for the perf«rmnce of DateiiI Rceiq"
F•' the work for wbicT this Permit is issued(Sc.3()9],Ci,C.)
C) U Ledkls Name - y TOTAL:
Lenders Addrta TOTAL
y 1 tar,ify that I Wax rad Nia appl'ratioe and sure that Ne above in(«romion i, BUILDIN
h canca.iagsa to mroPlY wiN all mty aml.wmy«divanccr and sraa hors rtiviog to QTY_ MECHANICAL PERMIT FEE
U z buildingamurvction.ars]heseby auN«ire rtprtama,ivc.of this city tocmcruprn Nc SEISMIC FEE
abnve-memiaeed psopeny for irlxpurion',tow'. PERMIT ISSUANCE _
(Wall aga<to vvc,iN ,raify anal kap lami We City of Ca,rtino,gains ELCTR
EIC
liabilitiu.judgmrns,cost andaPensn which may in anyway acco,arryirocid City ALTER OR ADUTO MECH.
in«umgoeineaffSr,ra tingoflhis Permit. PLUMB' 12E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.005 CFM)
SOURCE REGULATIONS. ME LAICAL FRE
AIR HANDLING UNIT(OVER 10.000 CFM) CO. UCIONTAX
Sigsuturt of Applican A]cntrc,a Ove EXHAUST HOOD(W/DUCI') HOUSIN MITIGATION FFP
HAZARDOUS MATERIALS DISCLOSURE
Will the app,.t ar futurt building occuam,,,.or Wrdk Wr»Nrws ramal HEATING UNIT(TO I W."BTU)
u&rj"by Ne Cupenina Municipal Cole,Chapter 9.'2 and the I"IN aM Sefay
Code,Saban 25532007 HEATING UNIT(OVER l00.M BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RFSID) PAID
/ W II Ne applicant«Pomrc building by 11,o Bay
Arco
Air nt«JMma which Deo Rcciq M -
arnil BmmJuur air conromiwnlu our depnal by Lha Boy Arca Air Q,mli,y Managmmn, BOILER-COMP(3I{POR 100,000 BTU)
Dialric,+ _ TOTA1,:
0Yci C1 No BOILER-COMP(OVER 100,00)BTU) '
I Wve read the ba,cmdo,m mot.alstaNiAIR CONDITIONER ISSUANCE DATE
5
Rmia Hra1N an Wary Cole,Satkw 25505.255]]533 ms under Chupm b.93 M tK Cgi-
ms]25534.1 an notify tb Nv,if tic NEW RESIDENTIAL MECH. SQ.Fr. /✓� Q
WIN,ragonnan.wtkiy have tbuo iamyrespomibilirymmtifydleon Gy, J
of the requirtsrlrnu which mut his,Intel Imo to issrmcc of•Crnifioa of Occupmtcy. 1,O 4S
v � A —1( K O
Owrcr«vuth«izcd ager, - DC,e TOTAL: ISSUED BY:
OFFICE "