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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB.DfNG - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
tlUILDIN'f. PROJECT I IIENTIFIG'HON
PERMrT No.
�a G I]
J J
BUILDING ADDRF_SS
SANITARY NU.
APPIACAI'ION SURMI'TIALDA'I'E
Iggo!5Tic, -TREE Cr
3.27--5F�
OyaB"LH;SNAME: �PH(INLn�
In/•L�NI 741
TR NA NO
(:OI.n�Cr_% �UH � slsa
1L
NIC
❑
CONIBULM
ARCHITECT/ENGINEER: LIC NO:
j —
,+{) DRI.SS
Y.oik), (d/yi, SANT lisp [A 4575.
CONTACT; PHONE:
BUILDING PERMIT INFO
a�G R�ori S 97/-�7 0
❑ ConlUltent Fees Paid by Applicnnt(Inilizl)
BLDG, ELECT PLUMB NUICH
❑ ❑ ❑
LICENSED CONTRACTOR ;S DECIARAHGN
I nerchy affirm that am lkcn¢t1 antler providon. m Cllnpor 9 (,ommcncing
QTY ELECTRIC PERMIT FEE
JOB D17SCRIPTION
wimSmr;on pq>tgol mvid.m3d'me 8-m—and P ved my lkenm i.
in lnn Rra and et �Q
iS� I J'9
PERMTIasuANCE
RESIDENTIAL:
❑siroWL ❑KI'fCHENREIs10DE1.
APPLIANCES- RESIDENTIAL
Licenu:C . Lkp
Date Cnnm� 11
ARCHirEC1'S DECLARATION
un ntY plan•Jmll .•p,�yll luhlic Tyw4
El ADDITION El PLUMBING RIi-PIPE
❑MULTI -UNIT ❑SI'RUCI'URAL
MODIFICATION
PANELS
UPT0200AMPS
[_1 INTERIOR [I CHIMNEY R1711AIR
IMPROVEMENT [J SWIMMING PWLS
hicenud l'n oinn:d
201-IWOAMUS
OWNER -BUILDER DECLARATION C.... ON
o for the
1 M:mhy 0(800 het not aeon fo-ni the Caolmeto/n Licence city rc
ISnitt ]IDliraeusineaamt Profession•Cnk::Arty
which
❑RAIH RFNIODIiU EPA1R ❑DHMOIJ PION
❑OfHFR
OVER ENTRE AMPS
SIGNS ELHCTIUCAI.
rgaicua an
paircclsltn.mm
which itnum
imma Teton)tit cnnamn,alta,improv,h
$PF.CLLL CIRCUIT/MESE.
pril Permit t fire
in, i.awmta,almrtquhcc,owi,i the Lrvuch Permit
her, rat. Liikuo-iglw(Cb ocr i)
10111[ol Disixio
(larhee mewed
'IP.MI'. ME[ ER OR DOLE INST.
COMMERCIAL:
Sell a Sol icBm—and Pollaw(Chepler4
(cununcncing with Semitm 9akpnl Uiviainn3 oldc Bmirxisund l'nnassinns Corlc)tr
Bm le is cannel IhereOom and the basis Im the elkged caemption. Any violmion of
❑ NEW BI,DG/ADDITION ❑ DEMOLITION
Srclinn 9031.5 by any;,plicr for a Penuit mhjmN the npplieanun v eiiil penalty of
e mon live hmed drtMdlars ($500L
m man1'M1_''f
or wogo'vn their cmtpcn.vtioo,
-1 1. ere trwrrr of me Pmpcny, or my o,
will doled wof�, and the no lucm e. tmcnktltroQmcd for .1c(.See. 90N. Ha,me,,.
%)WLR DEVICES❑
NANT FGODSHRVICF,
YROV
QT
SWIMMING POOLJBSCRIC
urd Proft imeri Cock: The Cmmex,%ota Licence Ltiw tk.n not apply In an twrcr of
OUII.ETS-SwRCIlE1-FlXTURFJ
prolf wed Mllldn nr ihnpruvi tMmoht, and wLu Uwti socb work onocif or thnwgh
his nun cmpkyce , pnwickd Thal wch imPrnvcmcnu are net inerMl or offered for
role If, heevc,the holdif,ee mer.occroem it cold within ane year in"IeTill-e.Ile
NEW RFSIDENMAL ELECIR SQ FE
SQ. FL IIJR)R AREA
ESQ. IT.
(tit p
tweic,lhaileerwill Ofthe burden n( Prov nQ NL ordid not build or improvew-
0 of role of be Profa acaeively c trrnie,or, wish Ilccn.wd c mtruemn to
I
'1IAL
t:
nvinto thc`Pm1Rt (Scc_ 7041, Bwiresa arid Prufnutxu Cade:) The CtmlPetar'a Li-
xLaw, tkc.not .,,, loon nwm+nf prgteny maedi Or ild• or impeor, tern.h. and
QTY PLUMBING PERMIT FEE
who common formach project•with accmume ov,) lice Act! punuent mrbc Contracloh
I'IRVB r ISSUANCE
Lkcnsc law'
sm cacmpl umkr See ,B&I'Cfor Ni•w,—
ALTU R-DRAIN&VENT - OVATE R(1A)
Cot or, Dim,I
VALUATION
WORKERS COMPENSATION DECLARATION
HACK FLOW PROTECT. DEVICE;
1 Mmhy aNnn uNvr penalty or 'It., con..f del "Hensing tkclumtions:
DRAINS -FLUOR, R00F,AREA.COND.
Iluve.rrd will mdmuiru CeniOcwed Cowenno wlFimmmErwnter'x Ccm,n-
tylion. es prwidcd far by Seellna 37W of the LaLoT Cole, for the Pcntxmamc of Tire
SH)RII'_S
TYPE CONSTRUCTION
work for which This Kinno in i.aued.
ITXTUKES - PER TRAP
❑ 1 hove net will maintain Worl er's Ctrnpeuwlon Incomes es tryuireJ by Section
Tlglof Ne lsMr Code. for the peofnmtvuzofih, work Gr which hi, cnoil,, bwactl.
GAS - EA. SYSTM.I INC. 401111CFS
DEC. GROUP
APN
At, Worlc:s Ctsmpen•u0on Inumence cenier arW Policy number ere:
C.nln. Poliuy No:
GAS - PA. SYSTEM OVER 4 (M)
CERH%CSfli 01; EXENWHON FROM WORKERS'
COMPENSATION INSURANCE
GREASPIINDUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION IBES
1'I1his:cnlun reN not lccanplcted 11 Ncpcmtit ix lnru¢hwdrtrl dolWrs (i1111q
or les..)
GREASE 'MAP
- — -
%ANCI{ECK PER.
SI7WER-SANITARY-STORM EA.2W lT.
Lcnily thu1i3111n prhrmii oflhc work for which M,,cr it it,,nul l Wwll
rot employ any'imm in an, manryl y_ yyyyryue wbjecl to the wertrrV Cwnpen-
ENERGY PER
WATER HE[I LR WIVENfl11.ECIR
cation Taws _ r 1�I :�rfZSL�/�
A,li., 1 nA/Lc SAO
GRADING FTE
NlT1ICGT0 A�P ACANT�iIf. after making this CI iftnm of f mr Tion, yin MtmW
bavntw sehjcet m the Worker's Cnnj,cmmio a pnwlsinm of the I�Ixc Code. you must
WATER SYSfI?M/IREO ING
SOILS IRE
form,iN complywith inch Pnu'ivms or this permit shall he deemeJ revoked.
NATER SERVICE
CONS] 'KUC9'ION LENDING AGENCY
I hereby af0ml thatthereka mmurectitm lrnding agency limlepcltmmarcc of
NEW RESIDENTIAL %\1H. SQ. FT
PAID
Uwe JA #I
din work lar which Nis Permen is Iswed (.Sec. YN]. Ci, C.)
Isrdeh Name
TOTAL:
Icwlcrs Amalie,
'I A
O
1 certify door I wve rid Nis applicuiwt arid ..,Milk fi sx Informa ion is
BUILDING 1'
Q'l-Y MECHANICAL. PERMIT' PEE
SEISMIC FE
corocc, 1 a,,- m comply with all a, amt county onliwnccs a1u1 clow Inman rduting m
hulking coesuuetion, artd hers rathetDc a m,,cnlmivc• of Of city to enter ninon the
19eRMl'I' ISSUANCE
ELECTRIC F
thin, me tioncd P9cnY fm rose¢lion Purposes,
(We) agree to rwve. indemnity and keep barntkss the City of Cupenioo.gait U
ALTER OR A DD TO MECI I.
PLUMBING I iL
fiehilitics,jtdgments.c.nu aml eaten¢+ ultich may in any uay mane egurul aid City
io ntmc,plcmc 0 the gmotlug of this pcmhi 1,
AIR HANDLING UNIT (TO IBIXIO CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOLI r IR♦;L.LLGLIATIUNS
AIR HANDLING UNIT (l1VPJt It1,lY1(CFM11)
CO NSTNI ONT
COTS fIt ON TAX
S,mnorof A,kano'(omenclr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST DOOD(WMUCI)
HOUSING NI GnTON FlJ!
HEATING UNI1'(10 IIU,(XX) B'1lb
Will m., apMicam or fumro huiliinghccupain tore orhaelle lmuNom 3 -renal
u tkfined by the Cupcnino Sfunici W Cock. ObitNer 9.12vet the HcaIN and Safety
Cole, Seetinn M5J2(e)'I�N,/(''
Fj Yes [Qa�o
h+rxrtlous Areal% Qmilo, Mater,cm h'tch
JclirleJ by N< Bay Area Air UualilY Mlvwgcrrcm
Ic Will lho.%tlleamomm. building by If
HEA ING UNIT (OVER 1NI,11(X) It H1)
PAID
Elute Rr,iptN
VENTIATION PAN (SINGLE RISHH
NOILER- COMP(JIIPOR IW.gXI RTU)
con air cauwtirunlx m
Di.erin?
El yet YNu
OIAI
BOILER - COMP (OVER BOOM) X'fU)
AIR CONDITIONER
I have read led h:vo keut minerals res irtvteet, unkr Chaeta 6,93 of the Cali-
ISSUAR DATE
NIiW' HI!SIDI:NI'IAI. MF.CI I. Sp. Icl'.
Tama TWIN At Safety Corse, Scerioca 15505, 25533 and 25534. I urderslmd Chas if the
buildingd",not,uncndy ha".¢tutm. Of it is nhy rcsghasihility lonl'i, Nc.rruhwu
q
rcbcM
of, uVn1 •uhic'h m.Y il1[tic of Qcupvey.
���-� /
y
ISSUED BY: 1
TOTAL:
Owter or iuifarteed .sent Date
OFFICE