S 1703 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.1?LP.C'1'RICAL PI?ISITNO 1703
BUILDING DIVISION APPLICNFION/PERMIT PLUMBING-MECHANICAL \v
I{UILDING PRf ldliCT IDENTIFICATION �
BUIhUING AIJUHESS $ANI1'ARY NO APPLICATION SUBMI'ITAI.DATIi
OWNIiINNAME THONG C(N'I' r\Cr R OIt' nn
SNANIII LIC NO
4 /��-r�i�rz va9ass9 Nrc co 'Ral.»
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ARC]II'1'EC'I'/ENGINELR LAC NO �/75s/q ^e// .� ,/ ❑
CONTACT: PHONE - BUILDING PHRMITINFO'
� •�� � ��j_ /� ❑ Consultant Fees Paid by Applicant(Initial) I BLDG ELECT PLUME StECH
"LICENSED CONTRACTOR'S DECLARATION Q'T1' ELECTRIC PIiRMIT..,', FEE - ❑
I Teich,anon mm I.nn hecmcd tied,,pro...Inn.it rbapan 9 tea;mneming - JOB DESCRIPTION
O�Z wnnscrion MI),drua....m3mlheemmes.one Tm,fexanm Cl.le,and my hecn.elx RESIDENTIAL:
f 'r PERMIT ISSOANCU
F� nun Jelfect ❑SIUWI. ❑KITCHEN REMODEL
aUu License Cl...cm++ L'—e29 ue a -3 9�359
NZwj ❑.nr�j—�I9�YY C trvcnn-1z;1//ASS //dSC7N4 APPLIANCES-RESIDENGAI. ❑ADDITION ❑1'LUMIIING RE-PPE
ARCHITECT;S DECLARATION !j ❑MULTI-UNIT ❑S'TRUOI'URAL
PANELS
Z C, I understand In,plans shall he ocJ a,pubb,record+ N IFICA'1'ION
-�
OZ � UPT0200ANIPS C1 INTERIOR '111MN1!YRIEPAIR
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„'„qFG� I-eeomd Prdewumel 2UI-INXIANII'S SIPROVENIENT 0SWIMMING POOLS
OWNER-HUILDER DECLARATION O\'I?R IINN1ANi PS ❑ItATfi It ENIODIiI✓Rill',\IR ❑DIiN101.1'1'ION
C 5 G 1 hereby ninon that I ant czcmpt Iron)the Conlmm1or+hlcen+.Law for IM1^
06 V n lnu l�g reason (See, h 71131 5.Ilusmess and Posucwmon GoJr Any coy or ronnlY SIGNS ELECTRICAL ❑OTHI?H
W lLy which reymm+a Pemnl In,on+tnlc6 nhcL Impooc,demnh+h.nl reran anV in ec
Prior mus nsuance,also regmres the applicant lursuch punion to rleestgned aatememt SPECIAL CIRCUI I INIISC
f N� that hen LCCmed pumenn h.the Pl...'IVIUI1.efthe Qll........Lome Law l Chapa:t9
1+1 00 (cummenung with SCCUUn 7lNXBW Ine..Inn Sol the hu+m...and Pnde.vom Cwldar TEMP SIFTER OR POLE INS'lt COMMERCIAL:
6 d e that he is ricer,thmelrnm.sad the bast+for the alleged exemption Any v:oln, it of ❑NI?W BLDG/ADDITION ❑DEMOLITION
ad m_tv. Senwn"1DI Ty ar,"Plmant fnrapenuit lam"+Ihe applicant to a civil penalty of POWER DEVICES � El IFNANT E3 FOOD SERVICE
Sye mare than five hundred dollars($5101, I�f
Qp ❑ I,uslesurnl We prnpcny,or myentployee+."Itx ague as don,cle,oil"a.aua¢ SWIMMING I'UOLIi1.EC1'RIC Nf IMPROVEMENT
g,F•m° will do the wok.and thcammumo.notmnnd.d nr o0eord for vale(See 2041 Imanc+, �' ❑OUTER
4 3 we and Prot e.....-Code'1'he Co.......e,License Lae,dste,oat apply ,,an owner of OU ruEi S-SVJ1'Iums-ITS rURILS
pro,moy oho Weld+ar ,uprise+thereon,and who don wet,sonde hnnself or throes
ILA awn mu,layens,pow Wed That ouch Intpm,clnem+ore not Intended or altered Inr NEW'RESIDEN I IAL ELEC It SQ F1'
sale.If.hssewelhulaiddergonmpro\emmnt is sold xlthm one ycarol complenannh_ 6 SQ,FT FLOOR AREA $/SQ FL
o"rel hudder well have the harden of proving That he did not bold or improve for
pmc nl talc) par-
' /
hecmeJ ennin.nna m Y)lA.1 1s oxncl of the Property.ant culu+nxlywntra.ting unh
construct the project(See 7044,Business and lot.vons Cale)The Contractors U.-
+e Law docsnnappty man Theo at pl openy who hand.or.. rove,thereon and QTY PLUMBING PERMIT ' .PIiE
sense Law ear weM1 pngecl+wont acommetons)httnsed puocuam to the enmrscmr.
License Law, I
❑Ian eca dc
ntPt unrSn R
. k PClot the meson PERMIT ISSUANCE
Owner Date ALL ER-DRA INA,VF.N'I'-WA I 17 0710 I VALU O
0) WOIIKI?R;S CONI PENSATI or DI?he to I Th" BACK FLOW PRO]ECT DEVICE yJ+ ���/ D0
1 Thereby aI orm under Pcmhy of perNry one of the fallowing declameoe,
❑ IhneeanJxIli;n.unuun.a Ccn;reumol Consent s elf-Insure lm Wader's Compcn- DRAINS-FLOOR,ROUT,,AREA,COND S'ICHIPS TYPE CONSTRUCT ION
ton,a, evind c]tar by Sedum 370()of the Lthor Code,for the performane,of lit-
xur nwh;ch tots Tied eennwed, I IIiX'I UkES-1'ER'I RAP
have and will maintain Worker's Compcnxa ton Insurance,as ea,mord by Section
3700nf the Labor Cdc,Wrtle,,fiormarecol Oo work for w T¢Tthnlwunn is lamed GAS-F:A.SYS PENT I INC.J IdffLIH I S OCC GROUT' APN
My Wnde' C ompen.9tion ln�.9 < rant PVT Id, arc.
Caner.J��fl•t .Policy Nu fOeK-1903.5.9 GAS-tins S)'ti'IFNI.O\'lilt J IIiAI OF COMPENSATION INSURANCI?ORKERS GREASIIINDUS'I'RL WAS'I'17 IN]ERCFP`H)R
('ITn..mnn need not he completed.the Mpmns fora..hundr.ddollan($Ilpl - BIIILUINC DIVISION FEES
m less l GREASE'I RAT' PLANCHECK FEE
Icerofy'thatmthe M,Smmamcofmr,o,k fm,1a,h thisperm:,emee.Ldall SEWER-SANI'T'ARY-STITEM IA 200 F1'
not employ any Noun;myrummer+na+to hcenme oh,ce,none WndeM Compen- ENERGY FEE
z O .Tom Lo s of Cnidomm Oat^ WATER HEATER W/VENT/ELIT
GRADING FEE
fry NOFICH TO APPLICAN'P 11,utter owning ton Cemtimte ant Ex.mpuon,Yun sM1OUTA WATER Sl'STEhf/rHliAl ING
F" ; M1nam.a:njcn m lee N'arker+Cnmlwmaunn pmvwnm of the I,aM1Or Cnle,Ynu nntq SOILS(Fai
forthwith comply wuh such pronvnn+ur this permit shall he deemed naok.d, WATIiR SERVICE
Lam. z CONSTRUCTION
on,l Land NGAGBNCY NEW RESIDENfIAi.I'LNBi SQ.Fl (PAID
U0 IhercbY alone lhm them;+aenngmcnnn LnJing agency Gnnhe)xrformnnn,u. Date Itceclptu
The xod for which this jrcmru n,s,mrd(See 3097,Co,C)
Q ULender.Non- - 'I OIAI� �
Lenders Add,-, T(YfAi_
y that I have rend this nPPhcatinn•mil xwte That the alone infornnauon BUILDING FEE.
I cond,
N correct Iagtemocmnply wnhall city and countyordm:mres and woe lawudating u' QTY. MECHANICAL PERMIT' FEE
U Z bmldmg,cmdo him.and hereby authanu reprowmatiusof This city to enlnupon The SHISh11C FIRE
aN)vc-mentioned propene for Inspection purposes
(N's)agree m save,mdemmfy and keep hamdn+the Ory of Culsmm�agan,, I'I?HMI'1'ISSUANCE 111,F.CITIIG IIiE
liabdau,ludgmm.inurwl,and espen+owh,,h maym any way accrue against said City ALTUR OR ADO TO MUCH.
to comepucnce of the granting of lhts petmn PLUMBING hEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOIN I' I AIR HANDLING UNIT(TO 10,001 CENT MECHANICAL PER
SOURCE REGULCI'IONS
AIR HANDLING UNIT(OVER 10,0011 CFNU CONST HUCrION'TAX
Slgnamre of Apphc.nt/Comrunul Date EXHAUST 110011 WIUUCr I I HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
WdlihcapphcautorminebuiWmgoccupantstatearhandleha+anlnw m:venal I HEATING UNI I'1'101110.010 R'1 TH
m defined by the Ca,mnn Moo meal Cale,Chapmr 9 12,and the Print,and Safety
Code.Set ^-55321x)1 HEAT ING UNIT(OVER 11)(000 II'1 UI
p Yes El No VUN I'HAIION FAN(SINGLE RIiSID) PAT[)
. . Date Retttplp
N'dl he applicant or furore budding occupant y A ea Air Qu or devmex chino
rot M1;v:nean.mr enlnanunana.n.JdineJ hY the R:ry Area An Qnalily Nlandgemenl Ii011.1i12-C(1MI'(3111'(1R 11)BdN111 B'1'UI I '1 GTAL:
De ncf!
❑YIN ❑Nn Ii011.liit-GDNiP 1D\'lilt llXI,IIINI IITII;
AIR CINDI'I IONI'H
I M1lth mud WO h ode.Sections 55 5,B53 and 255 C1 mid rshod the Ceh - ISSUANCE.DAr �
b Id Health n.Safety Cale.Sections 3505, "11y and oom 1 undemand that tithe NI?W HIiSIDIiNI'IAI.NIF.CII. SQ IT.
hulldm etmemo rm IlllWy hay.a emoldmmi a 1.my re+pnm;uny m ref Occ nccapam l/Y�•
of the teyulmmenta uoich must M met poor m nwanre nl a Cendcmc of Uccupan y
Owne,moolmeeedagcnl Date TOTAL: ISSUE[)BY: 04 r
OFFICE