S 2664' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-P.LEC'FRIC\L PERMIT NO.
BUILDING DIVISION APPLICNFIONA'ERMITIhUMBING-MECHANICAL S 2664
BUILDING PROJECT IDENIYYICATIIIN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
E� 3-Z 4
QWNERS NA E I'HONI_ CONfIL\CTOR'S NA 1C: LICNO:
4msO NIC CONNOLN
-*Q
RCIII'I ECWTINGINEER: I.IC NO: ?3� ADUHESS: ❑
O, O
CONTACT PHONE: BUILDING PERMIT INFO
I✓ 15i0h1J T4-C�5 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PMECII
"1 - 37
1:1 'E:1 LUMI ❑
ICHNSHI)CONURACIOR'S DIiCLARATION QTY IiLECTRIC PERMIT "E
I Wreby arhrm,Wt l am nand amka r .n 9(corrm,crrcing JOB DESCRIPTION
O�Z clh S¢I.un 7000dyf Divininn ani Husineu ar,d my li RESIDENTIAL:
�� % PERMIT ISSUANCE
F nfull Gaa wW eRea, �I ❑Slim. ❑KIT CHIN REMODEL
a U F Liccn>u CCcry CMZ / Lic N
6'Z U APPWANCIS-RF"_SIDF,N'IN. ❑AUDITION ❑I'LUA1I{INC kI.PIP13
vF Oa. Dole�-}^ TS DECL
FOy ARCIIfI1iCT5 DECLARATION PANELS ❑MUCfI-UFR C-]STRUCTURAL
ZpmZ 1other.,.. my,lens shall Wused.PuhfcremtLs MODIFICATION
UPTO
pZ-� 200AMIS ❑INTERIOR
F csn ❑ IMIAIN
W LicmN lvofcinnal :rl-IgpnM1gIMPROVEMENT SWIMMING PV
N�N_4 OWNER-BUILDER DICCIARA'110N OVER IIgXIAAtI'S ❑HAITI RIiAfOOIH/kl?PAIR ❑DEMOLITION
C sc I lwrchy aflim,Ihal 1 am cxornpt hoot the Ctsnmclnia License Law for IM1c
X 6 U folio mg aumn.(Srnwm 70315.Busimxr and Pinde mam Coat Any city or coonly SIGNS ELECTRICAL ❑OfHIDt
3 WO F which ors im If pcoomi In c,xuwct.ahn,inyxn.e,dcmM vh.or reptir any loci !�
tl=y•yrng prioro,,cI..,alv,«quires thce*icvnl for weltPem,it In hlee.gml.,fO.d SPECIALCIRCUITAIISC. y
u�6� that he islkenned Pursm a
raunW pnrvurunsof the Con,racwe lJttmNc LawlLlwpa9
Wy00 frnnnnemulg wishSCCliun 91XX1)nf Drvlsmn3 of lhcllunineu-mW lToftxNi utnCwc)or 'rEMI'.MEILRORPOLEINSK COMMERCIAL:
OL d e that W I.cxcmq therefron,a,d the haxis torr 1W alleged exanpfitm Any violation of ❑N12W BLUG/ADDITION 0 DEMOLITION
Xm Satim7I3I.5 byany.,Oicanl fora Permit wb)mN the vpPlianunaclvil prmhy of POWER DEVICES ❑TESANT ❑FOODSERVICE
W vm mac Nan five hmatred dollars IS50i
F-'LY DIPROVE\IFIJf -
Q O Lottie- of the Pmsoo.ho, a intended whhwagea.P their SBf,ii,m, SWIMMING PIX)L E1EC11tIC
will J r wtsk,amt e I b, m o.of,Li,ef,c 1,a oc,oot a(Sc,,1,1,71W.n..... r it ❑OTHER
a3 ww rmmadnn..c«k:'rrw ctm,mcnNs Lmcn.c Law d'.r n«appy m an^wrier mD(m.LTs-swlTnuts-FIx'rukE3
.. PoSeny whit Wih1 IN nlpmocv Ihcrrnn,ars]who docs wvh work h,mwlf or through
his own ero boyea pry idol 1ha,wch iWrovememx are not intemled or filtered far NEW RESIDENTIAL ELECIR SQ IT.
One.If.howcver,not boiling or impmvemrnt it void within one Y•"of<vmplc,ion,,M SQ.FT.FLOCR AREA USE,FT.
mrWilJcr will lave the M1tmkn M proving Itut W did not Wild m imPTnvc for pm-
pnc^f Salo,I,
❑ 1,os owner of rhe'o,",ant caclmively anntmcling Weh hecnrN comma^,to
ons.,Rha P,,ja,(.Sce.](XU,Bmio.fist IhIfIlions Code.)The Comrvemr'S LI-
law hcN ro,yrNy,nvnnwmrM prnpcny who,baildr«imlamc.thcrmv.and QTY. PLUMBING PERMIT FHE
who
ho ttmhaccr for,ceh prulat with.ennaxtxld licc,ed Forwent to the Conhx,ers
LxTnSe law. PERMIT ISSUANCE
I ant exempt tower Sce. .H&P C for this,amn
ALI FR-DRAIN&VIINU-WA'T'ER CA) VALUATION
(Downer Doe
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I haa')'y whim under penally of Perjury ane of Inc fflk ing declvati^ns:
Q I have and will maintain aC nifiamnf Cof. nt to selLinsum for Wofi,rn CoffPen- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPECONSTRUCHON
.'-fl sr,ox pnwwal for by Salion 3100 of 1 W Iyhw C«k.Ls the per orti n,fof the
wmk Lu whmh thie parodl it ssU. FIXTURES-PER TRAP
❑ 1 have amt will rounlnin Wnrkrr'r Compenwtim Imururec,as required by Station
37gIM,W Mbar Cod,,.fcr the perfamam'e of the with for mhich,hi,Permit is issued. GAS-EA.SYSTEM-I INC.i OUTLETS OCC,GROUP APN
NO,N' -ye Vyio&uranccc- cr ars]Patr)W �,,p
Carrie he,M.:VAair GAS-FA.SYSIIJd OVB_
CERITIICALE OF PXEMPI'ION FROM WORKERS' '`
CO)MPENSA'I'ION INSURANCE GRIASILINDUS' RL -INTER lR3)
BUILDING DIVISION MPIlIg
CUnisy
N.ection nl tart W compinal Rye, ,rout is Its one hunJryd dollim(SIM)
m ku.l GREASL IRAI' III 11914 NCI IECK FFP
Ianify thm in Urc perfamurcc oOhe work la which this permit iS iawcJ.I JuII SEWER-SANITARY- Ad TA 1J
net employ any pawn in any manar w as 1a become whjem m are Worker;ComPen. 1SERGY FEC
0 ,Z cation Liwe of Califom'm.Date WATER HIAF,IRR WNiLECIR tRADING ITG
Z O Applicant ' _
1.. [ , NOI'ICE'DO APPLICANT:IL after making this Ccnificmc of IhcsiTion,yw should WATER SYSTiSM ING
F ^ bm wtryen,o dr Wmleh Conycnwtilan lrvoitouns tY the Labor Ctwc,you must OILS PER
� ftMwilh ctmlRY will cacti pmvisimsorthinpmnit skull be deemed m-u1.eJ. w,\TER SIJtVICF,
4
.u. Z CfNSTRUCTONLENDING oiCY NEW RESIDENTIALINTIA,MMN. Cl PAID 77—
u
,
L0IWrchyOmhul liac i.nctm.tmcliunlrshn,ig14lM1e aat R- , 0
the wtsk for which thin s i,IS owed(lsV.30Nl.Ci,C.)
C) F' Ler's endN. TOTAL:
G Lcrnkr'a Address TOTAL: BUILDING F'
I eenlfy t1R,I have mad thio appticmitn and vme Ilial the Mbove infor im ix
H N correct.I agncm comply with all city utw toot,urdinti and!ewm lawn relming to QTY. MECHANICAL PERMIT FEE
UZ Wildingennvlweli^n,vs]hereby amyYic rcPrcwnlai,o of this city menterurynlhe SCISMIC hili
above-mentioned pmPcnY rix impectinn purryre PERMIT ISSUANCE
(wO agm m wa,iNcmnirY rid kax un^ *0,c City MCupcnino agaivt FJJ;CI'RIC FE
Iiabilitics.jWgmcnt. ousaN ca f
eY in any way xcncagaina,NaW City AI.THR OR ADD TO MECH.
nnrcyurncc of ,Cron 6^ I' PLUMBING FEE
APPLICANT U )CNS NI OOMPLY WITH AhL NON-IroINT AIR HANDLING UNIT(11)I0,0F)CHM)
SOURCER ,Alit S. AICCIIANICAL I'CL
AIR HANDLING UNIT(OVER I0.WO CFA) CONSTRUCTION TAX
Signal cit ban✓Cnm ,m � Dec EXHAUST HOOD DVIDUMI HOUSINGMITIGAIION FEE
IIA%ARDOUS MATIRUAI5 DISCLOSURE
WII dwopplic:O, tY Roore holdingrY'almm ctnc-Wndlche'mrdnuematerial HCATINO UNIT TD l M,Md it IV)
as dclinnl by the Cupcninn MuniciPel Gak,Chapter 9,IP,and the Health caw SACIY
Code Scat.255320al° IIL'ATING UNLL(OVER 100,000 BTU)
❑Ya n
�JY"i VLNTIAT1oN SW(SINGLE NISID) PAID
W,II da:a luno or name buddin 1 eve t-tkvicd which Dmc Receipt A
gx'ctpan v,IAir n BOILER-GQMP(3HP OR 100.000 P'IU)
mi,M1:vnnluux vir umlarninwne as JoOrcJ by,M1c Hey Art-u Air Quality Alwwgenum
ll ITA I:
DkiIal? BOILER-COMP(OVER IM,nM BTU)
❑Yes
I have rad hvar6u ruplim rower Cantata 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Luno IIcuh qy Cts]q e 505,^, _aM 25531.I u«kNaM slut if We NFW RESIDI:NTL\L MECII. SQ,FT 3-
"o"
� ^ Q Q
bnilAiug.k m"mly ealrn .thus' r�.Prruibi yo,n«ifyl c-occeDrnl
of swhi' t oft iticmc of fkcurynry.
Dare TOTAL ISSUED HY'
OFFICE