S 3218 I APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUIII ING-IU.RC'I RICA I, PIE81'1'No
BUILDING DIVISION API'I,ICAT'ION/PI:RA71T rhumBING-MECIIANIGAL J 3218
BUILDINC PROJECT IDENAIF'ICAI'ION
SANT TART NO. APPLICNI(ON SUBMITTAL DATE
BUILDING ADDRESS:
22SS\ F-
OWNER':NA L: OI'1(1)Nli: C(1 "ItA1;TOlfSL\M�hi: �N LIC
(al-.OA,s�� DAV.VVnI b I qq�Lv2 -11-547 4+2 N/c CON Fall,
ARCHIFIECl'E,CHNIiER LIC N(l: AJIU OSS: S (YO OL ❑
p1n.c;md
THONG: \V/ DUII,DWG PIiRMII'INPO
D ❑ Consultant Fecs Paid by Applicant(Initial) BLDG FLEC1' PLUMB MI-CH
3 '7 ` 30 ❑ ❑ rte ❑
CENSED CONTRACTORS DECLARAUON CITY ELL'CfRIC PERMIT FEE
on ma 11..o Feel,.ed ander,pronixin:a of Chapter v(emnmenring JOB DESCRIFLION
CWZwith Division3af the❑usincs and Prolcssions Code.and mYliccnneis RESIDENTIAL'
g�,CO I'ERMIfISSUANCIiOSFDWI. ❑KITCHEN REMODEL
W 5`l 62 Z—
V hi I'm Class Lie.N APPLIANCES-RESIDENTIAL []ADDITION ❑I'LIIMBING RUPIITi
<-U Ute¢ Contractor L ❑MULTI-UNIT ❑STRUCIURAL
ARCHITECT'S DECLARATION )'(v PANELS
D y MODIFICATION
OZ4" Iunderxumd myplansshall be used ax public maordv UPT02g1AMl'S
❑INTERIOR ❑CHIMNEYREPAIR
F..F.W Lirerwed Professional 201-I000AMPS [mmoVEMENT ❑SWIMMING POOLS
=Y7� OWNCR.11TI.DER DECLARATION OVER HX00AMPS ❑RATE]REMODEUREPAIR ❑DEMOU TION
p,6' Q I hereby affna that I am exempt from the Colowelo rs License Law dirt the TQ 41
X 3 G O following reason.(Seetian 91131,5.Bn,aincw and PoE,,ians Clue:Any city or century SIGNS ELECTRICALkc. ❑(YI'HI?R
u: C) whish its sa aEwmso reasresthe alae:mpmvc.hPeralitt fie a signed
ig say structure
E.u-Oq hathe:imcensed personal
III the Provisions
o for Commuteiuoicense aw(Chaptetn SP[CIAI.CIRCUIT/AtISC.
y lhm he is licensed punuam mthe pmvnitns of the Cnmrxmrzs License law lClmpar0
�y QS. (commencing wllb SeeJnn 9)IX)afl)1.lsionl of the Buainexp nnA l'ndnsxionx GxleJ ur TEMP.METER OR POLE INST COMMERCIAL:
L Km y Lha he is exempt thereGnm and the oasis far the allege)cumprion.Any violation of ONE iW It1.DGlADDIT ON []DEMOLITION
_4• $ectimt]LLal s ny vnY aPPlicum lin v pcnnn xuhlrx7s tlac upplinam m u civil penalty of 1'OWHR DEVICES ICC$ ❑'IIiNANT ❑FOOD SERVICE
rn of more than five hundred dollar,($500).
IMPROVEMENT
.~+�Q Lan owncral'tncrro a toy intended
with groan' .boas'
FFD ❑ 1 pc y.arm In th war thcinnlu cam umn, SWIMMING IYgI.CL[GTRIC �p'fIER
willdo Ih0 work,and the he Care ur not s Lice License
offered fur sale loco.]M4.business
W ono property
who o Code:The oyes thereon.
License law tlsuc nal apply I^if owner of OIITLEI'S-SWITCI{0.S-FIX'TUBES
pmpeny cant hNs,m improves thereto:rod who Jswx such carve himself or through
his awn anployaec.main it that such imW is sol ware nm intended of m offered ter NEW RESIDENTIAL ELECI'N SQ FC SQ.PI'.FLOOR AREA SISO.Il'.
,ale.11,n:,w mllbrachicho spm l.,he thin
onebuild
I completion.....Rr-
cnhuilderwill have the huNen of pmv ng chat he did nm DuiIJ nr Improve lin Pur-
po c of sealed. TOTAL:
❑Las owner of the pmpeny,um exclusively nmmucling with licenced nvnrucmrt tan
conxtmel the pmi(See.91144,Business and Inaf evsianr Caul:I The Cammaor'x LL
se Law Jaws nm apply en an,,..1 of faulty who builds or imps.carncaom.ml QTY. PLUMBING PERMIT hE,
wen cornua,for sell projects with a cn shown x)eecnaad nartemnt m me Contractors
License law, PERMIT ISSUANCE
❑I am exempt under Sec. .If di P C far this eason
ALTER-DRAIN.&VENT-WATER IRA) VALOT'I'[ON
Owns U lot
• WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE:
I hereby uffimm under Penally Uf perjury one(it the following declarmmns
❑IL.rvuand willnmirain u CeniEcacof pmwmo,self-insure for Winkles Co.,-- DRAINS-FLOOR,ROOF,AREA.COND, S'IORIS TYPE CONS'fRUCODN
cation,as provided for by Section 300001 the Lada Cat for the Ierfoanance of the
work for which lila*rail is issued. FIXTURES-PER'rRAP
❑I have and will maintain Worker's Comnpensalicn Insurance,as reclined by Section
3900ol the luno.Cods,lin ahcperfnmmnaeof the work fur which this permit is inacal. GAS-liA.SYSTEM-I INC.J OUTLETS (KC.GROUP APN
Nil Wakers Compemsmltn nurce carrier it Policy nu'f�he
` Carie: 6TIEI LM"P Toss, is,Na.:�J_—a-�-.� GAS-CA.SYSTEM-OVER 4 CA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -IS-01KGRfiAol%INDUS'1'Rh N'ASTIiINfERCEPIOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
T his vection need not be completed if the Period I%forone hundred dollars.(511X) GREASE TRAP
%•' r PLANCHOCK FEE
or less.) / S�
I real fy End i n Theperfnnnunce of the work far which this Permit is issued.I shall SOWER-SA TAR)'-STORM&A,y1X11T.� - CNI!RGY ' Ii
not employ any person in any manner ss.as It become subject m Ns.Wndcrv'Compcn-
ter h NOIICIi'IO APPLICANT':IL after mdln this Cemificdte:f limn Linn,you should WATER SYS' 9
Z codon laws of Cnb Omnia.Daae WATER ILEA Bt /VENT/IiLECTR
Z 2 Applicant '� L} GRADING EEE
g p /fRli•1TMOtf U SOILS I'IiE
heanme subject o the Whero Campcnsmion poovi Lof the nal must —
Coke,you
Ernewithc...mlywlan such Pmviaioaammnis pnanl,shAell M1C Acuconal revoked. WATER SL'R ICE
iQ
GONSIROC'HON LENDINGAGENCY NEW RISTI SQ,FIl PAID
7 z Heedpl a
V O work
r,hich rm tin Parini
i is..ed(Sce.3097.Cing agency for the pedonnarme of
W f` lM1e worA far which this.area is issued(ties..3fN].Civ.CJ 'TO"fAl,:
p U LeuEri's Ne c TOTAL:
U Lenders Address BUILIA, iii ISD
G Ic,nfy Tho I Lave rcud Nova,,h1atiou and ams.thus the afmve In 11.11 his
sF. ZE c aect.l agmen.rnmply with all city and cod
ma,uninanccc mslme lewarero CITY. MECHANICAL PERMIT FEB SEISMIC tE
U Z naildnng omnsnoeaio,,,and nercnY oaatntd.e repreaeantame.N nni.a airy to enter ala�n lar
aMrve-mentioned PropenY for inspection pulpawc PIIRMI'IISSUANCE EI.EC'1"It FEE
(We)agree m save,indemnify and keep Rarmlcas the Cdy of Cupenina against
Ilnbililics,judgments,costs andexpenaos which may in any way acerae against said Clty ALTER OR ADD'TO MECH. PLUMIIIN( PEI:
in nw,once'If the gmndal of this Per and
APPLICANT UNIIP "ANDS AND WILL COMPLY WITH ALI.NON-POI.NI' AIR HANDLING UN I'I'(TO 10.1000 CRN) MLCI IAN ICA,ITiE
SOURCE:RP' ,AlIONS
AIR HANDhING UNI'(OV:u 10,0000:1,I) CONS'1'kUC7IONCAX
\HAUST FOOD
Signature u ppinmt/Com
DOUSING Nil]'IGAT[ON FEE
HAZARDOUS MAI£RIAL.S DISCLOSURE
Will the,"'Mena.ter Enurehuild ng oecapnm.rinrc or handle M1vmNnm mulenol IIEA'I'ING UNIT(TO 100,000 HIO)
ns defined by the Capenimt Moore l Code.Chapter 4.12.and the Health and Sal'cry HEATING UNIT ROVER 1110.000 BTU)
Cock,Saone 255321
❑Ys. VENI'ILAI'ION PAN(SINGLE REMD) PAID
Date Racipt M
. Will the applicant or to be ng uccupunt axe e4aipmem or devices which BOILER-COME'CUP OR IgLgX)BTU)
coil Lvallons air nmmminwtx as IineJ by the liay Arca Air Qual'ny hlnnngeaneml T( L:
Dixlydcl'I BOILIiR-GGMP(OVER 100,000 BTU)
C3 Yes
❑
I At it CONDITIONER ISSUANCE DATE
I have waddle hr xffI: nJa CIPI r(.95 of the Call-
da,
' t I Y hllYI tYCetpaSQ.ITli: it Il NSJ255W1understandIM1 ITJ'e NEW RESIDENT[At,MICN17
hu d eJ u
ofd 4 'm oll (u `,(J
Owner or oulhnriecd agent DIN TOTAL I5oU1;D BY.
�C