B 0354 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL 50001 AC 10354
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. - SANITARY NO, APPLICATION SUBMITTAL DATE
4 a nan -10
OWNERS NAME: PIONF.: CONTRACTOR'S NAMEi LIC NO'
�e0 COA11' 'k33 Nrc coNrgOLe
ARCHITECT/ENGINEER: LIC NO: ADDRECO OS C/ I�� + ❑ -,/r
~ /
CONfnCI': �nN PHONE: BUILDING PERMIT INFO
l(l o6 - /6 O ❑ Consultant Fees Paid by Applimnt(Initial) HI.I ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 newhy dnnm dun 1 an Ean co ameT pmdaionv of Cnappm 9(eomnleneing JOB DESCRIPTION
O�Z with Section 7")of Divi:ion 3 to Bmi.and Pmfcssican Code,amt my liana is R CI1F 1 ENTIAL:
�0� Licen¢in full face end clfeaq 'Is PERMIT ISSUANCE
�j 'Ia Lica �Jl
32 q
U ❑SEDWL C1 KITCHEN REMODEL6Z1D Due�lkt gn_y4 Cana p APPLIANCES-RESIDENIAL C3 ADDITION El PLUMBING REPIPE
Q 6 ��r +SNC
Don ANCHIITiCTS DECLARATION ❑MULSTRUCTURALNIT STRUCTURAL
ZOmZ kra
I untlmd an,plansahaLl he,mot aan publn1'ANIiI S ic
xrxds MODIFICATION
O Z--'� UPT0200 AMPS ❑INTERIOR 0,w5INEY REPAIR
MHayl", Greased Professional 201-EXCAMPS IMPROVEMENT CSWIMMING POOLS
� OWNER-BUILDER DECLARATION OVER EW AMTS ❑BATH NFSMODEI/REPAIR ❑DFLtOLTT10N
C 6 1 Hereby alErm tMt 1 am exempt fmm the Conlracial",Lileme Law fa the
OdU followingmaven.(Section]091.5,Bminewaal Pm(e.uinm Old,Any city-aunty SIGNS ELECTRICAL ❑OTTTER
3 te• whilh rcyuin,a permit to cl000—t,-Ire,ilmnrve.Jemalish,a rtpuil any si—Ime
F'u•{�{nn Siam ouisuaauc.0-tostaires Oen Been,faauch permit to flcaugl 1stotco l SPECIAL.CIRCUTOMISC.
9yyg IMl b.-islkenwol Puauam In lh:pmvisions of the Gntructa".I,icrnwlywtCTluN
?� (conlmcmine with 5alion]LXNB of Divinion?o(Ihc Nusinccs ualJ Pofdaiau Co.k)a TEAMMEIENDRPOLEINST COMMERCIAL
Thu he is exemp therefrom W me,Monis fa the alkk.l euraiman.Any vb0n d^ of ❑NEN'BLEKMADDrnON C3DEMOLITION
uXl Ssctitm 7011..1 hyeny.,liom fora rymlit subjects lac applmunt In.JIB pewlry Of POWER DEVICES ❑TENANT' ❑FOOD SERVICE
terarQ
F-ZN t e than five huaheJ dollan(S500), IMPROVEMENT
❑I,mownorof lhC ryopctsy.amYcmplgceswilh wage asthe'u auk romprnsvlion. SWIMMING POOL ELECTRIC
will d^Inc work,end thenmewte is not inlealcd or oReml for solo(S=e.]INT Basilex
3 tend Profies'.Code:The Cunlncmr's Liccmc Taw aloes MI apply In an..of OUTLETS-SwffCHP-ti-Fl%TURFS
his owns o'n wM Milds m impmv,s Iheteal,and wM duex such work himwlf a fhmagh
hemployees,pmwidcd tMl such impmvemcnln mu not imcMnl a 10Ci fur NEW RP_S]DEMIAL BLP.CTR SQ Pf.
sale lf.lwever,the builJingaimpmvemenlusold wiminae ybrofcaalpMim.Orc Q.MA-QO@t AREA1999 Q.F1'.
owarcr-WiMlm wJl hove the MudenMProving tote MJW nes huiW aimpmse fa lN- Y 1 U
rync of selcJ.
❑1,as ovnor of the propcny,am enclusisxly contracting with IicemW cemaeclaa to TOTAL:
conunlcl the Projm(tier.]6W,Buuaan and Profeuiom Codc:l The Cmrnl-s t;-
c xWwdoe,mwopplymanowrcrofµ aywo,huiUsailnprnvcxlhecon,wd QTY, PLUMBING PERMIT PEE By
who conuau Its such ProjecB wish o conancux(s)licensed pllrwann m the Caumn«s
Lice se PERMIT ISSUANCE
L] I am exompl under Sm. .B&P C O.this reason
Owmr ALTER-DRAIN&VENT-WAIER(PA) VALUATION
Dale 3 o e
WORKERS COMPENSATION Dthm ANON HACK(LOW PROTECT'.DEVICE
1 he"he"affirm order,Penalty of pttjury one offthe fo0uwing hclmuiau:
I Mae mr.si Lal in,
eCenihcvwof duoonuo Cod,ww(a effoo sCnmpm- DRAINS-FLUOR.RWI'.APPA,CDND' TYPE CONSTH CI'ION
❑wtiun,r Providal for by$scfial 37()Oof the labor Gila for the peAmvmc of the STORIES 4
wast Tawhich Oda permit is Worker' PXTURFS-PER TRAP N1
E]1 Mee vd will maintainWalera Cumpe wion Inwrane,x myuiml by Section
?]INlof the l.ah+Gde.for llle perfunnwaut tnexM for xhi,h lois
.it ix iuuW. (lAS-IA.SVS'IIiM-I INC.Y(lU'I'LETS OCIC.GROUP 69A1t�
My Work, Can mmnn .. cad Peliq myQlprpyc_gq GAS-EA.SYSTEM-OVER H1G LY
Carrico OPTIOpolbN Nn.: WOR U q .
CEKI'IIRCATE PE ' TION ON FROM WORKERS' aJ
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This rection malt ml h:complclM feral ^e dr
if the is faohured dollars($10(1) BUILDING DIVISION TEES
a w s) CREASE PIANCHECK FEE
I lenity that in thcperRrmlmwc oflhewak forsvhich thispearm is isulmL l shall SEWER-SANITARY-STORM F.A.200 FT
na employ any penoa in anyn,amrcm hn
r so as erosmji .,he Workers C,—,.- ENERGY IEE
O Z Baia Laws of Col;omits Usti, WATER HEATER WIVEN'DIELECTIR
2 Afflko GRADING FEE
Z
I,i NOTICE TO APPLICANT IL after making this Ceruliut¢of luempion,you Juuld WATER SYSIIJN/IRPATING
hecome subject m as,WOrl Compensation Provisions of the Tabor Cale,you must SOILS FEE
� ? foMwith comply with such frovisions or thu pemul shall be deemed revoked. WATER SERVICE
7 Z CONSTRUCTION
aecasa ENDINGAGpNCY NEW RESIDFMIAL PLh1H. SQ.FT. PAID Rccff,0
UO llI., ch111t1NIJIReueld(St,liamkmCis,agealry Tarn,pvfammcc of
w HIbe work for wnicn thin 1K[illil is isxucJ(Sa.JII9],Cis,C) TOTAL:
I.ntler's Name
U Itmk(s AolJms • TOTAL
T a I certify that l havcrced lo-,licalion and.lam tnallM: 1infmnminn ie BUILD
I^ V1 comrs,Iaeon,an comply won all city and county adiroi wl slue cox:reainew QTY_ MECHANICAL PERMIT FEE
U Z buiWo,commuclion.adhertiveof by authaire relce,emalob city m enter aryn O e SEISMIC I'
ahrvrmcnlio Jpmµny fa -I tion purlaws. I'ERMfI'ISSUANCE
(We)uyree m arc,iakmndy east keep hanmkas Bre City of Cuperd^o agaiml E'LECT'RIC
Iiabililmjudgmi coo aM expenrn which may in any way accrue agavow,said CityAITFR OR ADD TO MECH,
n yooneu oflhc,,mingoflhis pemsil. PLUMBING FF.P\
APPLICANT UNDER NUS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000CFM)
MECHANICAL FIFE
S NCE REGULITIO S
AIR HANDLING UNIT(OVER IO.000 CIM) CONSTRUCTION TAX
C _
S-
Sigmlaeo AWlicanoUcamctor Dale E%HAU,SI'HOOD( MUCD HOUSING MITIGATION FEE
I LAZARI%lUS MA 1:RIA(S DISCLOSURE
Will thtippliesum a for.With g cecupmawae a lvadk M1navdvus mmcaial HEATING UNIT(TO 100,000 BTU)
as dcfred by IM Captain Mtin
mpal Code.Channel 9.12.and'be Hmlth lotSafcry
Goa Sen,mn 255321a1'rHEATINGUNIT(OVIR IOBBXIBTU)
E3 Y. IX. VENTTLATTON FAN(SINGLE RESIDE PND --
Date aciplM
Will Inc upplicmm or fulum Wilding mcoIa l use ehimpaxot or Jcviecs xhich
emit bmJorua a r celmand lwu u defiled by the Bay Arta Air Qlulily Mawgmnl
eeBOILER-COMP(?HP OR 100,000 BTU7
Diuril^
❑Y No I N — BOILER-COMP(OVER W.akBTU)
AIR CONDHIONU
1 have road tnc hvmJous rmlcrimis nquirtmrnu made,Chapter h 95 of the Cdi- �-. ISSUANCE;DATE
fomiu Death&SW'cty Cole. 25 . 25511 and 25531.1 unikalwd than If IM NEW RESIDENTIAL MECH. SQ.F1'.
buiMlimg docs not carremly is rely resplmibilay to notify Oe ottmllmn d
AjLc mquir,ncnu ankh I to-Oanc ofa Certificate of Us," Ory.
-s agcn J I)JncT TOTAL ISSUED BY:
OFFICE