S 1650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ID CUPI:RTINO BUILDING-ELF.CI'RICAL PE IT No
RIIII, ING
I'll VISION AI'PI,ICATION/1'ERMIT PF.umnmc-mecxnNICAF' 1650
BUILDING PROJECT IFIENTIFICATION
BUILDING ADDRESS: SANITARY No, APPLICATION SUBMITTAL DATE
/ q b WooO d�
OWNER'S NA ': PIIONI CONTRACI'lIR'S AMG D - LICNO'.
s S NIC C(IpTROLI
• ARCI I ITT.CTHFNGINEIFR: LIC ISS: ED
IL9.1;(IV 5... 9617" 191/0
CON'rACP PIIONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B EFIJ!C_ PLUMB V MECH
LICINSEDCONTNACfOR'S Of CLARATION QTY ELECTRIC PERMIT FEE
I wreby afEroar ar 1 am Iice milrov
er Iiospml
x s of Chett 9(c mencing JOB DFSCRIPI'ION
O�Z w,In Sttaiou 90f80ofDivisian Sol lK Basmarlurd l'ndminm Codc.md my hart—is RESIDENTIAL:
4:O O PERMIT ISSUANCIi
N� in full LreeanA ellen. ❑SIV WI. ITCIIEN RCMODEI.
NQL V�Class Cormmnm APPLIANCES-RESI DEN'TIAL ❑ADDITION I UMHING BE PIPE
FDN ARCHITECTS DECLARATION PAN'IiIS U.
-UNIT ❑STHUCTU WAL
Z O n Z 1 unoksmnd my plunaa,.Il W to d m public mrntd+ MODIFICATION
OZ—_ UP'fO2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F E!11,_'W Licensed Prafcxsiowl I 211MM)AMPS IMPROVEMENT 0 SWIMMING I'O(IIS
YES
OWNSR-BUILDER DECLARATION oVIiR 1018)AMPS ❑BATH RIL\fOD11JREPAIR DEMOLITION
XC Q I ac, affinnS...Elul I um crentpt from me Contmcmos a:Aa,,Law for tM
d O Bdlowi nguims a (Secti7031-1,us Iluaircx.end oc,dnninrtc Code:Any oily m coumy SIGNS CTJFCIRICAI. ❑QTHFR
LLLL1l 0 when rtyuirts a pnmil is[ma tha alacr.'IN i t for so dalwli,1.m a r'ir any vwcwrc
FSO prim "I isaurcgal.wrcyuirca thcapplinnt for CommOsiuutnc Law ochs'narg tiP13C1AL CBNI'1'IMISC.
f�} dua he ix lianscl parsuantmdre pmsis'wm oftW G(ntm[INslittma Lew(LTeptt9
Wao0 (axon,ncing with Se,kno70AB or Dwimm 3n11ha Baainea.an Prafirssra.Cufa)tt EMP.MITER OR IDLE INST. COMMERCIAL:
15' for pt Ih
ha is exempt en
rrt d the Fast,l.n the;,111,d u:umpmr iAny violuliuo of ❑NEW BI.DG/ADDITION El DEMOLITION
Sacrosn]0315 by any applicam fm a Pam a salrcas the applieml to a civil parully of LOWER DEVICES
atom five M1urdred dollaa(5500). ❑I ❑IiX)D SERVICEZi n't M14 IMMPROVPROV EMENT
Q SWIMMING IOOI.F.I£CfRIC
�O willhtlhcwurk, orl the oocmmo
rc ie,..io [dorolfcmd fur sale(Sm.70W.Berax
ait ' ❑OTHER
3 anal pmfcoiors Cron:Tin Coma r'x liana Lw dr.:.rxr apply ,,an owmr or olrrurrs-SWI rcIES-F1x _
popttty who W id.or tmposxs ffi .m,arta who dre_a...h work nimalf,m m
hi.s own[mphryeca,provided mut weh m,i semeda arc not imerstkM m offered for NEW RESIDENTIAL I:LECTR
sale.If.howo'cr.tire building orimprovemcnt is aid within or¢yaarMatmpletiw,dm SQ.FT FLOOR AREA 5dSQ.Fr.
rcnhu I&-r will havu me bunlen of pmviug mm he did oot W lld or improve for,no, p
Pmc of sal.A. P N 1 D
I.v oaancr of tk pnrprny,am cxdurivdy cwxxting wish licrn'J comranon m TOTAh.
xuwd t W project(Sea.IDI.Btrsae,ao Pr..fe..6rw Coca T 'Cmtru[m/a IJ-
[ 'Law ck.n..1.'ly to w owns if ri who huilm k Fmpns"mcmtn,em QTY, PLUMBING PERMIT FEE AIA
Iq JIV � �
wlm'macaw for...h pmrho Hca
j"l «xnmcur(s) vwd p,rxuunua IW Coal.t A'x 1�IM1 AIMan
IJccmc Law. PIRMI'I ISSUANCE �M W
❑I am exempt under See. .B&P C for this rtsxan 11f
N.TER-DRAIN&VENT-WATER(HA)
owner DataNNIyATION
• WORKER'S COMPENSATION DECLARATION1 HACK HOW PROTECT.DEVICE? fl/I�r
I hrebRmn
syarm dry+mlty d perjury Inc ofma tamvwing okclualinns: n L�rs 6
ET lluveund will meinrdnv CeniO[meodCm+entm¢Ir-Invert fur W'onkera Compco- DRAINS-II.00R,ROOF,AREA.COND. STORIES TYPE.CONYFRUCTION
action,v povidN for by S tmar 3700 of dm I,r r Coe,far me psu fomwme of the
work tur which this,rodl In is'cd, FIXTURES-IT,
'rRAP
❑1 hate aril..It mainum Workers Cnmry:naminn hon arra,u.rtyuimd by Scnkn
37M.tnate le fCo .fm me pert of the work for which bit permit to isawd GAS-G.SYNTFM-L INC.4 OUTLET S (ICC.GROUP APN
My W(Akcr' M yp�qr� and Arlicy nu �a
/Carrier. w rV Policy Nov:��� GAS-G.SYST-G1OVER d(PA)
CERTIFICAT OFUNEMNION FROM WOHKE S'
COMPENSATION INSURANCE, GRP.ASIONDUSfRL WASTE INTERCEPTOR
BUILDING DIVISION S
1'Ihi.re��.nein not becanti it the Pamot is faar a huulred dollars t$]M) GRIFASETRAP
.,r 1,,) p1ANCl{ICK 1113
I[enifymalaa meperfrmmat uOhcwrrk for wh is h mix pamtiG in and l sbullSEWER-SANITARY-SfORh11iA._2()(1 PI'.
na employ any parsml in any noomer so m m buonr.ahl[ct m thv Workcrd Cn,nry:n_ ENERGY ElS
oz cation l.wrorcdFornie.Ina WAIIFR HEATER WNENI/EI£CIR GRADING IS
z O Applewt
fn NOI'ICIi TO APPLICANT:11:after nuking mix Cenilicme of Eacmpion,you mmuld WATER S)'STE Vo RILMING
a ; become soh' m the Worker's Com eon 1 W la,how cr.k.you nmu SOILS IT£
JeCI prnr pmoximwo
� fanM1x'im cmnMY wim wch pruvaiauamix lermit mullhdccrrcd rcvo,lo i. WATERSERVICE
Q
CONSI'RUM ION LIFNUING AGENCY NIiW'RESIDF Vf1Ah P1.MR. SQ.Ff. PAID
U O Ivor hi,h his
Tor d,a pnemnlm,a ar Date Rc[dpt«
P+ 1"' the vena,for which mi.p+mn is nwrd lsec.JIMA,Cie.CJ TOTAL
IcnW's Name
y� L) Icrxlcr'a AJdres TOTAL:
yI ity mol I hove test mix vgdlalkv anasome Nut me above inrormmimt is BUILDING FEE
t� m anrccLl mm[on,pl wim ell city anA[aunty oNinwcu.mxl slva Wwc rdatingm QTY. MECHANICAL PERMIT FEE
U z WiWne n tinnVY
v M1crthy vulMMvc rapeanmtivasoflhi,chyn, .I-apart mm SEISMIC FEE
vW.r- tit lfe8.xdun paEMad IRMIFISSUANCE,irtrmndyenJle City of Cupertino•µIna1?LF,CIRIC IEIidandCspo,. swayaa'rvenrtALTfiR pH AOD Tn S1EC11. PLUMBING FEE
nlingoflM1spcnnAPPLIrANDS AND WILL COMPLYWITH AI. NON. DINT AIR HANDLING UNIT(TO IILOq)CFM)SOURS. �/ MECHANICALITE
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
igwtmc of App manVCanvxtm Uac E—IIAUS1IIODD(WIDUCI) HOUSINGMTIGATION FEIF
HA"LARDOUS MATERIALS DISCLOSURE
Will me.,krnt ur I.,.Widin8 w'ca,oml stvc w h Ic bsslua mstamal HEATING UNIT(TO Iff,Of1(1 BTU)
ax dcfn H by IW C.,umo MuniciWl Cok Chap¢r 9.12 anal ma Hod111 and Sufcty —11
Coc.S Linn 25532(a)' HEATING UNIT(OVER 10)(1c0 If FU)
❑1'ca MN. G'IRAID
VENTILATION SINGLE Dato Rcccipl0
. W It UN applicant or from building u uwf ua ryuipmcN or Mna iwhich
mit vunlous ar a uraunde0md awBtt
lx v by 0,Buy Ara Air Quality Mocnt ILOILIiR-CONI'(11IP OR IULgO B'IL)
C hmm
Dissret9 'IT)TAL:
OYc ON. BOILER-COMP(OVER I000)(0 RTU)
I lmve mml Jr luvsnb ,malcrials m hrcnrenu urder Chyxvf(.95 of the Cab- AI R COND I'1'ONE ISSUANCE DATE
fm,in Hreilh&Safdy CnP,Sr Porro 25505,25533urd 25514.1 undustvld mut Ute NEW RESIDENTIAL MECH SQ.Fr.
Wilding olrcs not cmrcnlly Mac n¢wit,m:v a may n.ry,mibility e,notify roto owxvpam
d me rtyuimmcnts,hub moa W ori mora.issusrc of a C tlifeate ut(kcv)nn y.
Owner ar amhariud agent Dem TOTAL: ISSUED BY:
OFFICE