B 0423 APPLICANT TO FILL IN INFORMATION WITHIN RED LINE USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL FEESu r NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NECIIAMI'AL S���l ,Q0423
HUILDING PROJECT IDENOFICATIOS
BUILDING ADDRESS'. SANITARVNO. APPLE ATION SUBM .DATE
O NIn '$iAM I3: PHONE: CONTRACTOR'S NAME'. LIC Nkl: IT
1 ^ n _ NIC CUNTRIII,N
OnoC IIIlliCllEN(11NE R L6917 31,1 OkIEA
IC NU, ADDRESS:/ /_L` PJJVJ-10 A-(�
N ❑
COTACT: PHONE �4 BUILDING PERMIT INFO
❑ Consultand Fecg Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1:1 El Id ❑
LICINSED CONTRACIT)R'S DECLARATION QT-Y, ELECTRIC PERMIT FEE
I herebym mum littered under prrvirn oor Chc per 9lco� rcin
rnea JOB DESCRIPTION
qwZ th Satinn7NX))nfDivisio 3oftlm Businca P it ions Cr .a myliatueis RFSI_. DEN'TIAL.
F O in full forte en PERN1CISSUANCE
41- ❑Sil)WI. ❑KITCHEN REMODEL
st �)ae Cluxr III I_ CcVleoo
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGREPIPE
IFnOy ARCHILECT'S DECI,ARA'IION PANELS ❑MULTI-UNU' ❑STRUCTURAL
Z O o Z 1 underswd my Plans shill be ural.Public tcctrds MODIFICATION
OZ12- UI'T0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Liamcd FTofcssiorN ?nal-ItXMtAMPS IMPROVENIENTY E]SWIMMING POOLS
QQ IIWNI!R-BUILDER DECLARATION OVER IL'RB AMPS ❑RATA REMODEL.REPAIR DEMOLITION
6 1 hereby aRrm bar 1 un exempt from the Contractor's License Isw for the, ae.rfCn
K O 1 L) TMlrwing tcdnon Eirction 7031.5.Busit�s aM Pndccsions Code Any city w c amy SIGNS 17LEM RICA. ❑ fER IRS� �CJL 16 t
413 LL{� which require a Examen m construct,alt.,improve.demolish,or reform-Y srrutuae /I/Q �y=��
ESO;! Prior to its issuance,act a,mri the appli.mfor xuch Permit o Gk a signed siaicurenti SPF.CIALCIRCUR/A11SC. .50 'i&kAxw 61,4!
�Qf dark is licenwl qusuatumthe Provuiau M the Commetals Beam.lnw(chapter 9COMMERCIAL.:
4100 (..in,with Sai70�ll ofDivision J ofthc Basins and Ptofnvns Coal m TEMP.METER OR PULE?INST
L d C that he is esempr dortfmm mal the,bmis for to alkgm.emptmn.Any vlo taimi of ❑NEW BLDGIADDITION ❑DEMOLCLON
Seemm]BI IS by any aPgicent box.permit whjccts the applicant to a civil Permhy of POWER DI?VIC-S ❑TENANT ❑FOQD SERVICE
n more IM1an ice hutdreJ dollar\(SNIL
F Z Y IMPROVFMINT
< ❑I.uwm of do ptoPcnYor mY cmq"Ynwimwugcsemrir Wcrnmptearian. SWIM1IMINC I'OOLELECIRIC
WLwill domc o",.dthostrt m,inn. oradnlmnRcmJ farime(Sa.9tW,Huxinx:a ❑OTHER
3 F and Profess or�Cola:lbe CmmwctmS License Iiw docs mar apply to in exi of OUTLETS-SWITCHES-Fl ES
itt. pmI'eny who builds tx improve,materia,and no does such work himself on IAnmpli 7319
his own annE,eea,govdal mm such uniaeormat us ve Mt imerWed or offered for
NEW RISIUIlJ'I'IAL EIFCfR SQ
sal,If,bowcer,the heikling tr immoAt ent is sold wahinonc Ycmuftoo,leion,the SQ.I )OR ARE
rcrbuiltkr will harc me bonder ofpmvine div Fe did ria build Lrimpro.cfupun f� L1
Toxic of W c.). L/I
❑1.ai owner of the Property,un excluvvely coturacting with licent cwtr-ecmi In 1
construct me Irojest(Ser.](IW,Business anal Professions C—)IM Contrt rolN li- I I
ti i roes nxvpdy In ennwncrof pryetty wlo builds or impairs.IMcun.mad QTy- PLUMBING PERMIT E JUN 2 8 199
who antan lu arch projaa with v tontrxtar(s)littoral pursuant to the Contruroh
I.Ic I e,aarm Lexexempt
PERMIT ISSUANCE
❑I un.emq tmJer Sec. .B&P C for mis msson ✓
ALTER-DRAIN ac V ENT-WAFER(EA)
Owrcr lMtc l]
WORKURSCOMIVNSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 IhctchY.farm umkr RnaHY of Perjury mo Mile follwin6 JecDrvrion..
{]n, mol wilFnnimain aCertinanc of Cnnscm mmlf-Insutu Rx W�xkor'NCoinpcn- DRAINS-FI.WH,ROOIIARI?A.GOND. STORIES 'fYPI!CONSIAUCFION
�n a provided!or by Section J]IlU of Jc Iahm CUJe.fon the prrformarce of tk
xk to,which miv Pcnnn is issued FlK"R1RPS-PER THAI'
harc W will mrnorm Worker.ComPrra4iun Inwmante,.«gamed by Section
orfakUracly�r�hOo�rylC�tyd{c�,�ff(wtthcyPcryrBrm mufthcwoAforwhichthi.p itisimuM, GAS-P.A.SYSTEM-I INC,COl1T1-I?r5 OCC.GROUP AI'N
Cyarriac. `4(N'Cl�Y IJQ IJP 1'"YNoryNM/1yu tarn GAS-EA SYSTEM OVER i(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE INfERC[PfOR
COMPENSATION INSURANCE, BUILDING DIVISION FEIiS
(This union road err hetontplalm if We Permit is for.hutWrN JnIWs(s 100) GRF1 Ei TRAP
m Ica)OEM,
PER
lermifythul in thepedonwmeofinework forwhwh miNPennit it NsuN,I 4m11 SEWER-SANITARY-STORM E1.31M117.
tax employ my part in any ttvwor sub.to I3Lrmc3Wli�i to the Workers;Caroni ENERGY FF.I:
z amine la f CaIiIi,/,Di m fC Of 97 WATER HEATER WNENf?lCCTR
zO Applic •`�rI T�A"-14�'a-z t 'A\V GRADING FlE
h NOTICE TO APPLICANT.If,after nmking Ihin Cenifeateof Hxanginn,youayi WATER SYSIItAVIREATING
F' Eocotrc subjat to do Workei s Crxnpeneimm provisima of the labor Crile.You must SOLS FEE
W - forthwith coot `^thsueh fo,isions ur this Permit shall be deemed tevok.ed. WATER SERVICE
1 CONSTRUCTION LENDING AGENCY NEW RIiSIDENl1Al.PL-MR. SQ.FT PAID
= Z (hereby Grim that that is acvwtutdon letaling rKmey for mm
a perfomnce of Dr Racipti
V he wad:f«which this permit is 9swN(Sce.309].Cie.C.)
I-ender's Name TOTAL
V LerM's Arun, T 1=
�+ wBUILDI G F P
[.. I terrify he I have tem min alroheamm vd serer IMI the also,IOf—i'n n
h terrify cartcLlaRree ro a�mgy wine all dtY std ewnry mmaanaa and state lir..+«latinem QTY. MECHANICAL PERN11T FEF.
C..) ,Z haildingmnswaMmPummes
ion.and hereby amxizc etivufmiaehy to enterupm the SHISMIC FE
r Wove meruimcd lnupcn)'fee inspection Forpr . PERMIT ISSUANCli
(We1:Lyrtc toSaor.iocknmdyxm keep homil—the City of C11,111 aguinm EIP.CIWC J3
IiahlBtie.jmlfina a sudexp m�r hiehmay ina Yw'ayaclmeagaier dClry ALTER OR ADD TO MECH.
in tnnNe9actrcufm morin lhiN Ptmtit. PLUMBING i
APPLICANT U 'RS AND;LR COMP 'N'I'fH ALL NON NINT AIR HANDLING UNIT(TO I0F000CPM)
SOURCE !G ,\ S. MECHANICAL FLIT
QAIR HANDLING UNCIOVER 10,000CFM) CONSTRUCTION TAX
Sign n APplicanVConttixmT-� Dau EXHAUST GOOD(WA)UC`G HOUSING M11rrIGAi ITE
HAY�ARDOUS MATERIALS DISCLOSURE
Will Nc uPplicant or Tomer W ilding�ecupum scum or hamlc haranMxu itwmnal BEATING UNIT GO 10i II'IV)
w Gafrcd by me Cupenim Municipal Code,Chegee 9.12,and me H.lm and Sirl
Come.Saban 255.12(u)? HEATING UNIT(OVER❑MILAN)BTU)
Ye XNo
Q VENTILATION FAN SINGLE HFSID) PAID Uatc RcaigN
Will the epfllicant or fmure building ocalerm use"Emem an Mites which BOILER-COMP(711P OR 100,010)H'fID
It met hammaws air eomamh nN inanmmmd by the Ray Arca Air Quality Manmtn
agel
weR
Dye, �No BOILER-COMP(OVER 100,000 BTU)
i
I hart tend_ hour ttotmirms rryuiterrcni ua Chapter rate Cali- AIR MNDITMONER Issun=eli DATE.
hxmo Ilam 6 S y �u ,25s? am 25538,l utdcas4nl mW if tlr NEW RISIDLNIIAL MECH. SQ.FT. /A^ ) O 4
huildine does IY "e atererlt bility to raxifY the aTupant W Go
of the v hich ua cola Cmifowe of(kvu
zm ager fAtc TOTAL: ISSUED BY: L "�
OFFICE _