31417 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 31417
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTI'CATION
BUILDING ADDRISS> SANITARY NO. APPLICATION SUBMITTAL DATE
- 9A0 h�L CRS� 161 1
OWN NAM1 PH CONr R'S NAM LIEU D
I� NIC - CONTROL
ik sRCH /ENGIN E NO/ A q 590 / /_^ �1,�� ❑
CONTA PHONE II'Y✓tel /// ✓�gl (may I,L BUILUING PERMIT INFO
�� ❑ CollsultenE Fees Paid by Appliconl(Initial) BLDCs/ ELECT' PLUMB MECH
Iff
LICENSED CONGA R;S DECLARATION Q'T'Y ELECTRIC PERMIT FEE !,'�—`{l`
t2 x
1 hereby nr Nm 1 em IiansN rode povision,of Chaleer 9(commercing JOB DESCRIPTION
,0,00 with Secfbn TrlW)ofDwision 3afJe Bisim.s and Professions Code,nail my license is RESIDENTIAL
�� p I'ERMITISSUANC�'
W-, iiecoac uc and effect. _ ❑SFDWL ❑KITCHEN REMODEL
NQU Licmac Clan Cm am APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE•PIPE
Vi 24444.y ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑SfRUCTURAI•
zgnn E I uMnmoninJ my plamhall be used m,public rands PANELS MODIFICATION
OZ-O _ UPTON)o AMPS 'may ❑INTERIOR ❑CHIMNEY REPAIR
F�lqq" Uccnscd Profexsiowl 2ul-IOIfIAMPS IMPROVEMENT
�y2 OWNER-BUILDER DECARAHON OVER I(IW AMPS [I BALL REMODEI/RFPAIR ❑DEMOLIfION
of 1 hc,,by amp.Nu 1 am exempt from tic,Contracture Liccme Law for Ne
d U f Alowine reason.(.Semon ID313.Busim,cs arta Rofesen,C«k:Any city or count) SIGNS 1?LEC'fRICAL El OTHER
LLlx+46 y which require a lermil to nxtiweH aheq improve,demolish,«rtpm,any q.1m,
I. Priormiu iuunrcx.also rryuim that,ap,licom fm h,.t to fkesi'"malcmcol SPECIAL CIRCUUUMISC.
f } fbu Inc is licmncd pwuumt to the rovisi«u dthe Connectors License Law(Clolnus9
a,1 00 (`cmrrcncinp with Section T(XX))dDivision 3ofthe Husire.amld Professions Axle)or TEMP.MISTER OR IDLE INS'P, COMMERCIAL
1 a a o rfim he is csmnpt Ihertfrom and the basis for the o11,ccl cscmplio t.Any vioWior of ❑NC}�j BLDG/ADDITION ❑DEMOLITION
+Settim]03 13 by any app5amll for-Pcmlir suhjecrs the aMicaer to o ci%il perialty of POWER DEVICES - PTPNAN' ❑FOODSERVICE
I-,�y f fWn hvc humtrM Oillvn($NXT. IMPROVEMENT
�o�ol,anwrcrof pmpnY.«mYcmPloY swiNxvg kmmp rim. SWIMMINGPOOLELECIRIC a QO M
will cde owml;, A Ne shwnme e,um immi er.Baal fm sak(Sac.T01C,Business
�I arld Prof..Code:This Commiclnr'a License Law does nor apply to sn owner of OUTLETS-SWITCHES'-PE TURF
�' pmpmy won Wilds nr impmvca Nome,and who docs wch work hlm¢If or Through
hu own empbym,pmvidd Jur s«h improvcmeou ue ror inretvlal«oRcrtd f« NEW RESIDENTIAL EIPCfR SQ FT.
smk.l(.however.Nc WrMing«improvcmcm is sdd withinom yearof camPMion,Ne SQ.FT FLUOR AREA S/SQ.FT
c
on -butterwm
illhcTchrodenoficimetlb,t Ahuildarimprorelirpur- PAID
'
w
- pwe of sale.). -
I.a owr of toe IaopcnY.am ecluuvcly canuacting with lianxd com ano,to TOTAL_
m
conuroet the pmjcn(Sie.7044,Busineu moil Pnde.+ions Code'.)The Connwvds LI-
x UwdmlaWlymnownnnfmpwywhobilap.orimmvehortmrvnn.wd QT . PLUMBING PERMIT FEEJAN a
C'
who conuncu f« uchpojcetwith•comicanoJa)IiccmNummnr to the Cm's 0
uccnsc l,tw. PERISSUANCE
IUt. ulameryvu rSerlEHI
ALTER-DRAINA VPI.] A IFA) ^VALUATI�OfN..a
rRSS OMPINSATIf I CLARATION BACK FLOW PROTECT DEVICE /Tr/B
:.r I by fir ou penilty of perjury me d me following dec V
❑ 1 secma naCcrrificvcofCwlunuosell-inose(m wbrkKa C«srycn- DRAINS-FLUOR.ROOF,AREA 'OND. STORIES TYPBCONSfRUCDON
satiric,as provided for by Section 3]1X1 of the l,dN CWc,for Nc perunctrcs,of Ne
work for which this lentil ut iswed. FIXTURES-PER TRAP
I have and will maintain Workers Conrpcmaricn Irtstm .u se4a�by Serino
3lWdthe laharCNe,f«the performarce ofJew«k(«which this pernril is iuucd. GAS-CA.SYSIt1A-I INC.J OUTLETS OCC,GROUP APN
My Workers Cam scmuium Insuruncc tourer and Palley mond c,sic:
Grrim. PdiNy RO
OAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE.UESUONIEXEMPTION FROM WORKERS'
COMPENSATIGNINSUHANCI? GRPASI%INUUSTkh WASTE INTERCEPTOR
BUILDING DIVISION
1'1louscdon mission,WrnrrglctN BJe prrodt isf«mrchutxlmltldlon(5100) GRGSETRAP
«ins.) PLANCHECK FEE a
rectifyfhmt in my menace
dformcwhich thio hot, ilrarer,Conifer- SEWER-SANITARY-STORM G.NXI HT.
not empby say person in any.throe,so as to became.objet to Ito Wuheti Crmrpcn- ENERGY FEE
0Z aaka Liwa of Cahf.i..Due WATER HGTER WNNT/ELECIR GRADING EEE
Q ApPlicanl
NOTICE TO APPLICANT:Jr,eller making this Cenificmo of Eacmptiun,you dhould WAITER SYSTEM/SREATING
SOILS FEE
Iecorrc o comp m it WMern Compcor this pmvivam of Ne Lads Cock,you rrmu
fmhwiN comPlYwithwch providms«Nupvnrif shall WdemN rcvokM, WATER SERVICE
Y A
7 z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.FT PAID R i
IheeebY aR thu Jereu h.aemsm swnioo leMiog aprncy fm fk PcrfmnomrcT of (g
LU4O drowork for which this permit is ismer](.Sce.3N7.Civ,C.) vTOTAL: / a
H Mcr's Norm
� IU1<
1J a hcrder'm AMkh¢m TOTAL
1 ennify thin 1 have read In,aPplicamor end nate that dsc uborc information is BUILDING FEE 0-
Ln
1p ameci I agree m comply with.11 city and county on ineme and else Iewa retains m QTY. MECHANICAL PERMIT FEE
C.2 Z Wilding c«nwcamer.a ad hertby mmMriee reprrnlurivc.(chis city w inioruPal de SEISMICITE
prapcny for imPcnion purposes. PERMIT ISSUANCE
(We)agrm In save indemnify mul keep ham l^ the City of Cupertino ageiml ELECTRIC Pili
Iiabthoor,judgmc«s•coca,mal cspcmeawhich may in any way ecnueepaiosr said City ALTER ORADDTOMECH,
in vomcquc«e of Je emnling of Gds permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CfM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER H."CFM) CONSfRUCIONTA%
Signamreof Applic.uCamm,,or Dome EXHAUS'THOOD(W/DUCI) HOUSING MEDGATIO.
IIAZ RDOUSMATERIALSDISCLOSURE
Will the,aMlicwor futum building meo,enl sane or hmalle harac a.material I]RATING UNIT GO I Wfna BTU)
m defined by the Cupenhxs Mmosipol Oxle.Cb,i,cr 9.12,and the Hwlth nml Smcly
Cock,Section 2553200? I HEATING UNIT(OVER IWMI,BTU)
❑Yes []No VENTILATION EAN(SINGLE RESID) PAID
me Ra
Will the eaplicr or future Wilding«cupunl A equips u il Devices which _
emit bamvtbsearussearmuitm
miomu uderoM
nhby Ne.Bey Ates Air Quhfmugcmmr BOILER-COMP(JIiPOR IW.000 BTU) �.
Wirier? HOILER-COMPIOVER Ig1.IXUBU)
E3 ye, E]No
these read Je harmdtum mevn'ils rcquirnrcnsuMn Clupm 693 of Ne Cilie AIR CONDITIONER ISSUANCEDATE
furor.11ea11h A Sefcly Coco,Sections 255115.15,533 mod 23534.1 undmxtmnd Nut if the NEW RESIDENUGAL MECI I. SQ.14.
Wilding ilea rwl aurcalY haveatewu,Nm it is my respswihilirymmdfY Je mcupmn
dile rryw+eneou which thou be rrer prior ro iasmge of a Cenihale of tkculmrcy.
(hxocr ar vurhmizd aged Dam TOTAL: ISSUED HY:
OFFICE