31044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITND31044
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECFIANICAL
BUILDING PROJECT IDENTIFICATION
BU LDINGADDRE S I SANITARY NO. APPLICATION/
C(lS✓U�BMMITITL DAIS
vov
.RS @ ` '4 NA 1 - _- J� PJC NO: ��
T\ NIC
LLI 9 CO
N
TROLX
C mADDRESS: 11_�^`
It : PHONE BUILDING PERMIT INFO
� ❑ Consultant Fm Paid by Applimust(Initial) PLUMBMECH
LICEsISEDCONUMACTMIDMEARATONQTY ELECTRIC PERMIT FEE
o C Z I hembr affirm tont I an,r.c.wd under provhiams or Coal (rnmnrcin
teg JOB DESCRIPTION
'0 with Section]OD0)of Dilision 3 a We Bud.and Pmfe.u' C an my Name is
I,,,"'O in full forte and eR W56- PERMIT ISSUANCE. RESIDENTIAL
�F.�U�j Licarm Clasr Lic.X ❑ WL RESIDENTIAL-
El REMODELV Z, Dae Cmnractor APPLIANCES-RFSIDFNTIAL DWMION ❑PLUMBING RE-PTPE
Fly ARCIU'IECPS DECLARATION ❑MIILTLUNIT ❑SfRUCNRAL
OZt2Z I uodcrsmal my plansdull beurm as'his,rtcords PANELS
MODIFICATION
UPTO YIp AMPS ❑INTERIOR ❑CHIMNEY REPAIR
���� Licensed Pmlccsnmal ±01-1000AMPS IMPROVEMENT'
Y f j Oat I am exempt
fr DECLARATION
y IX�6 I hereby afnrm that I am exempt tomb the Contractor'.Liccnm Lew Oahe OVER I(IOf1AMP5 ❑BATH RENODEf/REPAIR ❑DEMOLITION
x 3 L FUL.. following tenon.(Section 7831.5,Bui,mes,ud Ihafessions Cak:Any city«ceumY SIGNS ELECTRICAL ❑OTHER
F^la.O y which requires a Permit m mmaacl,alter,improve,dcosmod,,or rtpa,r my suuctum
pdrmlu ixamnoc,ulw reyuirta tx:applicant Er mcM1 Mrmit to flee agramatatement SPECIALCIRCUODMISC.
E y tut be,is liceruM tto the D D
Oil pursu.n provisions ofth Cavrxtola Liceme law(Cheper9 ('.GMMERCI
��QO (mmmerrcing with Section](100)nf Divisinn3 u(te Buxinw.anJ Profcrviam COJc)ar TEMP.METER OR POLE]NST.
6 e
that he u escnrpt Ihcref e.and do,basis foe the ellegN esemprion.Any Anita.of
ONE O DEMOLITION
Secdoo]031.5 by any Wiam fu atom,sub)ena Ne eppliam m•ciO pc.try of POWER DEVICESAp_ A1ppQp7
y
nor mor,On.five hundred dollam($5fat ❑TI'� N VFOOD SERVICE
=Q ❑ I,u..of the progeny,«ny employees with wages as thrix sok cwrWvuatiou. SWIMMING POOL.FJPCIRIC IM ENT
F will do the work,ud the vmctum is rd manded-.ffmM for sole(Sc.]BM,Budneu ❑Ol}IER Ur IXUf tYII
u]3 end I'mfcvionr Ccm,:'Doc Contmclof,Lice.Law rbcs na apply to w.of OUTLETS-SWITCHES-FOCNRFS ��Xa 1 INU
L longi who WiM,or imps ffie,.,Oct who docs such work hirmelf or through
his own employax,provided Nat such improvements are not intended or offered for. NEW RPSIDEMIAL ELECUR SQ 14.
sale If.however,the building or impmvrn a is sold within one ycaorcornpaian,tc SQ.FE FLOOR AREA 55Q.rm
iter-bwlder will hove the burden of Paining that k did rwr build or inrpmsc for par-
of
❑Fl 1 asowne
,do, Mtu S,,r. .am .insane mrfesimrg CoJeO T,Com.,m's Ito
caoumm rte project(Sec.'I[an Business anecry or I.bur,d;or The Cnntrvcmr's I.i-
wiWcoawd,nnotvpply uaanownerof Propcny whowildsor omimv,,Cornn.am QTY. BINE PERMIT FEE
who cuotrru for such pmjecs with•contremor(a7licmseJ pmstunt to the Cwtrawots
License law. PERMIT]I-
I em exempt umer See. ,B k P C for do,easan
ALTER-DRAINR -WA NEA) VALUATION
Owrcr Dam -
WORKER'S COMPENSATION DECLARATION. BACK FLOW PRO ICE .
IherthyallmrwJer perwlty cate.frjuryone self.iOc ollawio,Wml r'iC
❑ Ilwve and will maintains Ccnif tc ofCmocntmself�lnswc for Worker's ComprnDRAINS-FLOOR,RIX) RFA OND. STORIE TYPE CONSTRUCTION
aarion,ss pmvidm for by S«ion 3780 of the L.awr Code,for the perfonn.nc of the
work for which this peron,k issued. FTX'I'GOES-PER TRAP
❑1 have aria win m amain Worl Comper omoon Insurerre,u resuirM by Scm;an
37W of0e Labor Code,for dro prfomiance oftlic work for which thin Permit is i.uuec. GAS_EA.SYSTEM-1 INC.d OMH.FT5 OCC.GROUP ANN
GAS-FA.SY
My Works r m eruveon Imuw,ce terrier em Policy num TTPM-OVER 4(EA)
Carrier Policy No.: Q
CF.RTI CNEOF SATIO INSURANCE
WORKERS'
COMPIiNSATI-N WSURANCE GIiEA.SFRNDUSTRL WASTE INTERCEPTOR BF
(Ihia«nion Decd now hecompinmi ftc brim is frescos,hundred dollars(SI80) 11 r ]VISION m.c
«Its.) GRPASF.'DtAP PLANC%C �.
Isentry that in the perfunioth,work forwhich this permdt is iasmf,I"I SEWER-SANITARY-SPURN IA.3IXI PT.
.ort employ anyp or in any mum,er.ow mbsnna subject to me Wraken'c(s",.- PNERO
,Z sudor laws of"ifomia.Dam
7�O ApplicantWATER HEATER WNFM/EIPCfR GRAD].
G N NOTICE TO APPLICANT:IL attar Diking Nir Cmificuc of liernptiun,yw should WATER SY,TTEM?REATING -
becone wbjcct to the Workers CosoNmuion Provisions of the lCode,you must SOILS FEF.
forthwith comply with such Pmvisiams canthi,Permit shall he decmcd revoked. WATER SERVICE
0
CONSTRUCTION LENDING NGAGPJ9CY NEW RFSIDCNTIAI.PLN B. SQ.FL PAID
d
UOI for Which red thschcra ecol(See.onlmding agu,eY iiathe perfomrenuxrd Date X
the work for Which this permit u iuum(Sm.309].Civ.C.) -
Q F' Lea e Name IlLy
-TAI:
V IsNn,' Adlrcss T
0. 1 cenlfY that 1 have read this application and orae that Ne above inforrmtran is BUILDING Ig
to mse<t.1 agree m rnmply win ell dry em cwnry oNimnc.-s wJ wore lows rduing m QTY, MECHANICAL PERMIT FEE
V Z wilding comtrvedon,end bcchy autaciu raxesenutivn M this city to center upon tc SEISMICFEB ostw Its,
abbs'e-rtemlmm pmperty fm in pmkma W rry,scs. PERMIT ISSUANCTi
(We)ai to save,indemnity and kce,harmless tw city orcownico igam. ELECTRIC FEV NJ/y
IiabiBtles,jodgnents.costa errd upem<swhich rmyin any way acerveageiw sdJ Ciry ALTER OR ADD TO MECH.
APPLICANT
rce of UNDERSTANDS
this pe WI P PLUMPING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO 10.1](10 CFM)
SOURCE REGIIIAllONS, ` � MHCHAMCALFl
&-(e—? TRU
AIR HANDLING UNIT(OVER 10,(W CFM) CONSCTIONTAK
Sagwure ofApptianVCwtr.nor a! Dade EXHAUST Ht(M(WIDUC) HOUSING MITIGATION FEEI IASARDOUS MATERIALS DISCLOSURE,
Will thespplicsmor fmmc wiling occupant sae or handle hvurlous otueriN HEATING UNIT(TO I DBEDE BTU)
u refined by be,Cupcnino Mmricilul Code.Chapter 9.13,and the Health sod Safety
Code,Smtian 21533(.1' HEATING UNIT(OVER IB(I,WO BTU)
❑Ya ON. VENTILATION FAN(SINGLE RES ID) PAID
One R
I WJI the air cormofats a building by Joe Buy
Air Quality
BOILER-COMP OHP OR HANX)BTU) M
[l mit hvadwu air contamiwnLL v Jcfinm by to Buy Area Aa Quality Mnr,eBcnent
U'alncf' TOTAL
❑Ya ❑No BOILER-COMP(OVER 100,000 BTU/
I have rend the bemrdna,�Ls re,mmincros under Ctupter 695 of its,Cali- AIRCONDUDONER ISSUANCE DATE
Near.Heald,R Safny Cale,Secia rix 25505,25533 ad 21534,1 miderscanst do,if the NEW RESIDENTIAL MECH. SQ.Irl'.
,ml,ing does rax vvrremly hive a trnam,taw It is my m,,m ihil ity to notify Ile occupant
of tlr rcquucmaan which rest be,rrct prior to usuwce ref.Cadfiate of(kcvpvryVle.
Owner or aulhodrd ogmt Due ISSUED BY:
OFFICE