S1853 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL IIIHg IT NO.
BUILDING DIVISION APPLICATION/PERMIT PI.UMRING.MF.CHANICAL v 1853
BUILDING PROJECT II wrIFICATION
HUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIS.
OW'NER'S NAME: PHONE CONTRACTOR'S NAME: LIC NO:
NIC CONfROLN
• ARCHITEC`U`EN'GINEHR: LIC NO: ADDRESS: ❑
CON'T'ACT: PHONE. BUILDING PE IT INFO
❑ Cansallanl Fees Paid by Applicant(initial) PLUMB ELECT' PLUMB AIECH
❑ ❑ ❑
LICIiNSIiD CON'I'HACIORS DECLAHAI'ION QTY ELECTRIC F'F--KNITFEE
1 Emrcby nTr m my 1001 uctraseJ po+ m
Inwec Ixo.noo,of cnt9(cotncrcine JOB DESCRIPTION
0Q »im Ncaion911J0)oflT.;aion]orudt,aasircssedd Pmka.itvt crude.tad no,1'.,e<i. RESIDENTIAL
rERKIIT Issunncl:
Tull force and cRcn. ❑SIIJWI, ❑KffCHIiN RFJAODEI.
MC U IJccn.m Clu.0 Lic.x
F�WE bat, Cwammr APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
NG2 ARCHITECTS DECLARATION ❑MULTFUNIT ❑SfRUCUIRAL
m PANE)S MODIFICATION
ZO'"Z Iutroorud my'Ear,Jwll M toad u publicocutJs
IJLN—a Ur TO 200AMIK ❑INTEJUOR ❑CHIMNEY REPAIR
F ti+FW Ucroscl Don,tiotul 301-1000AMPS IMPROVEMENT 0SWINIMINGEOOIS
OWNER BUILDER DECLARATIONOVER 100DAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
pC W Q I hcrchy ofOmd Thal 1 in cxnnlg from Ibt,Codmcets Licensc law tar IM1C
U Edluwing a-apw.(Sculiun 7011.5,ji—tross and Podcxviuns Cork:Any city or edwlY SIGNS ELECTRICAL ❑(TTEIER
u+3 LL y which equim. mi
a pert n r—t,mate,idc-1114,rr^Ve,de11,T4 of st w,ic any Iwrc
F'1='�� ry'uxm it icoar.,Wm aquae Um vpplicenl for such pemtil to Ell,a siprcdsumncN SPECIAL CIRCUITIMLSC.
� ¢� Ihnl ria i.IlccnmJ pursaannntEe prnoi0lonsonnectnlmwnra Lacon.0law(cn.o19
W nO (enmm^wmg with SccJmt9lFgp of DinstoudofJm lfuamd utd Pruf+annz Gdqur '1'EMP.MIFIliROHIOLEINS'I'. 1
Ho=ax o z that he L.ancon,thisml m and Ik bad•for the alkgW esempuon.Any vloletion of ❑NEN'BLI%'i/ADDH'ION ❑DEh10LTfION
n=l` Section 7031.5 by any eppliaad fa s pemut suhjals not tip HI-1to a civil pcmldy of POWER DEVICES El TENANT ❑
TANT FOODSERVICE.
F.ZY ds bore than tivc hado'd dodlus(35UU). IMFrBOVI?ME'NT
=Q ❑ L as oul If the loony,or myumpinycs with wagcs:ulhelr solo"In'envalmn, SWIMM INE POOL IJ,BCi'RIC
p- will Jo We wol nod de I.I.is n+ineoJcd«MTcrwl W ulc(Scc.70,kI.Businec ❑OTHER
W—� and Profecsisen Code:The Contrstuft Urt.law drcs on.a'l'ly to an aw.,of OUTLI:1'S-SWITCHES-FDTURES
C�'.. prnpcoy wixo Molds or improves theme,and wIII does xueh work hinoxif or through
hit own couruyucs,provided Ibe stch Impnrvene^t ort Ixx inlctdecl ur oRclaT 1 NEW RI!SIDEN'HAIL HLL'CCR S
sak.If,hever.tldc lwidinp or in-Mvednent is old within tee year of corropmhe.Ihc SQ.17.ILWR,\RFA i'gO.FC
ow
nor-builder wdl Nas<thc boom of pnn'ing thud he did nv IuiM w imfmns for pur-
qom M'sak),
n I,w usurer of O¢pb,,r,wau
u cluskoly eomrxling with Iiccnxcd Lonlmxs cnat 'Tf
lb.,IN,projm(Sec 9041.Buxincaa ad1 Prat"om CWe:)Inc Conlmclt✓a Li-
cmsa law lines nd epply tow owdcrof ptoPco,wh^hoilJs or knot flacon.and QTY. PLUMBING PERMIT it.
who,.aoscnfne... pmjmlx wishom^vamnAel lireuvdIcusua^nnT ho C—u.1Iue's
1-icnsc law. I'CHMI'1'ISSUANCE❑ Inncaamdudder See. ,B&PC for thisrcasun
ALTI'A-DRAIN tiVENT-WATER(IA) VAhUAT1ON
Uw r Dam
•
WOR
nsk"S comnatty pinaryNs 0N UECIARA I IONlowin, BACK FLOW PR(il'IECT.DENIER
ihaeby dr ansa reodty tcofConoxn of theiorturvivy Wook,,wion.:
❑IM1mr and will maiaaina Ccnificae of Comenunsdf-inuae fo orona Cunycm DRAINS-II-(JON.HllU4 ARE,'.COND. SI'ORIF_S. TYPE CONSfRUCfION
swian,as hick no,
o fm by Scdion 1. of iM IaNx Code,fnr IM pedormanre of dk
work forwhich ill permitix order IEKTUHILS-1`ER'I'NAP
❑I brise vrW will maintain won:er's Compwsatian Insurance,a dryuirN by Section
J91X1 of tk labor Code.bm No pofornarl oftle work fa which that E[mdl i.isstx`d. GAS-EA.SYSTFEXF I INC.i OUTLETS (xC GROUP APN
My Wnher's Cnmpcnalion Insumncc carrier add PuYv numhcr arc:
Conice. VolicyNo,: GAS-iCs.SYS1N OW iflAl
CERTIFICATE OF EXEMPTION FROM WORKERSGREASHMNDU.WR1.WAg'1'17 INT � OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This smite vein nv heor
cnplumlrN d lflhc,cmrit is hoose hutxdotlars($HXB GREASE'I'NAP J
or Icnc) PLANCIIECK hili
Icc,dynoduathepert^mantic ofthework forwhich Jdxpermit ui.vacd,I dull
not employ tiny person in tiny mamcc sou to Issi udbjcl to do Wuskai Coxnpen- SEWER-Sr\NffARY-ST G.- 'rT. ENERGY FEE
ZZ t:ninn Laws of Califomim Dwc WAIL?R IRiAI1iRw a.I;cl'Py'J GRADING FEE
O ,\Emlicwl
y NOl'ICE'DO APPLICANT:U,ruder nuking this Ccr ifin¢ul E arynkn.you should WATER 5\'STEM/IRP TING J`
F` bl, x subject to doe W'o'k.+.Compensition'nrcisitwx of tic lalw Code,you nest SOILS FEE
at ti forth.ido n�ndply Isith.u,h foto,Hour—runs pcoull Hml l ho ccroc,l os o4'd WAD!R SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RI!SIDEYHAI.YLhIB. SQ,FL PAID Uwc RcdlgN
UO 1hctcby eR flow there isito unucm scoll'cow,far lhcl��enl'cnf
IN-work fin which Nix foemd 6 iC ubd[Sec 31199.Civ,C.) TOTAL
Q U Lctdnrs Nand, '1 OfAl:
} Il] lcndcfs Aokhas. o
Q. I cnify that I hoot,mad This applicra n wd start Ila dldt,aUwc informviw is NUIIDING J3
Z) .xecl.I agr.c m t,onply»rim all city rd woody txJinwe.s^od.Too lows obutiog m QTY. MECHANICAL 1'F,RMIT FTai
U Z building conNdixtion.and hereby adhuro' mprcmnrbvesofIdx city to cher afoot die SEISMIC IEP7
dnveddentkxeJ ptopcny for impclion pu9u', PERMIT ISSUANCE
(WO ager to sa".indemnify and km haamlcu tie City of CoPadim against ELECTRICIl?.
Iiabilllic.,juJgmcnn,cmisaM expcnut whicM1 may in tiny why accrue against seiJ Clly ACTERORADD'DIMECH. PLUMBING iii
In
APPLICANT
NDE STAN S ANpermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10.000 CFM) MECHANICAL E
SOURCE REGULATIONS.
AIR IIANULINC UNI'1'(OVIEH III,I100CIM) CIINSTHUCI'ION
Si,.ofA,Iic.lYC..ocr Dwe E%HAUST FOOD(WIDUCE, HOUSING MMIGATIA FEE
IIA%ARDOUS MATERIALS DISCLOSURE
WII tlo a,hoodon comm,huildingoccapnnlseranr handle hvnrJwsmaterial ABATING UNH(11)100.000 It IU)
as detitcJ by the CuNnino Municipal Ctak.CTwprer 9.13,and IM`Hcnito and S:dJly
CuJc.Satitn 15531(a)'1 HE VUNG UNIT(OVER 100,000 BTU)
OYcs ON. VIENTII.AFION PAN[SINGLE:RFSID) PAID IJam HmcilxA
WJE Ileo ltppllcunl m fudre building rccupan al cyui'nenl.r J.ry Rxx whicM1 BOILER-COMP CUP OR 100,n)BT Or
eon baaenlous sur codvnitwt,r dwint,d by the Bay Arca Air Quality Marugetnen TOT y J O
District' BOILIER-COMP(OV ER IBLODU BTU)
❑Ycs 0N
I hast,and Ute M1waNmas tnweddsocc,dwnews uNcr Chapter 6.95 N the Cdi AIR CONDITIONER �k ISSUANCE DATE
futn'v Hdth&Safam
y Code.Sitvu SNI".25533 and 8511.I undedsmld Ihw FNO
if tf NEW R1SIDAh MECH. SQ.IT. /
buildingdnc,not cuncody N�vt,a,courb shut it isnny tesrymsihdin sonny the ocvpwl [ SP O
of the taquircnen,whichu .d Mbel Citnmluwuxx oda Cmtifxvtoof(kv'upmay.
T
Owrcrorwthnriud agcm Ila¢ TOTAL: ISSUED BY.
OFFICE