S1064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY
CITY OF CUPERTINO t BUU,DING-ELKS RICA pyy "NO. 1064
BUILDING DIVISION APPLICATIONIPERMITPLUMBING.MECHANICAL
BUILDING PROJECT IDEW11I(AITON
SANTI'ANY NO. APPLICAflONSUBMITEALDATIF
BUILDING ADDRESS
OWNER'S AM11L: CONTRACT R'S NAME: LIC NO: NIC CONTROL#
ARCHITP / Ul P LIC N �^ ADDRESS: D
G -Z
CQpfpgR; PHONE: BUILDING PERMIT INFO
d liR64�-e �q����/7 ❑ Consul an[Fee Paid by Appli ant Qn I al) BLIT eC n.uM1lx i MECH
LICIENSED CONTRACTOR'S DECLAKATION (4�1 QTY ELECIRICTERMIT FEE LSmC/JOB DESCRI IVPr]ONN
1 Wmby affirm IMI I.,It Ilanwl under i r--roan of r]tnpmr 9(commaralmg
QOZ winoGa'tunlmBafuivisian 3af the Husinasend mdc..innn Coic,, dolyl'tccriw i. RESIDENTIAL:
PIENMIT ISSUANCIi
KGF In full force roof cRat ❑SIV WI. ❑KUCHIN REMODEL
GUuu Lice.Class LkAPPLIANCES F_S-RESIDENTIAL ❑ADDfTION ❑%.UA1fl LNG RE-PIPE
�i a a nam C.or
ARCIRfECTS DECLARATION
PANELS ❑MULTI-DNR ❑STRUCTURAL
/1,�,,t/,a'(I-. ^' bl sry MODIFICATION
OZ-'� �L uPTO'-OO AMPS El INTERIOR ❑CIIIM1INI:Y REPAIR
r4 t', Uc win Rofew t- 2IM-1000AMPS IMPROVIJ ES7 L]SWIMMINGPOOIS
�1
OWNER-BUILDER DECLARATIONUVIiµ10 )AMI'g ❑RAM REM1IOD%BEPAIR ElDIAOLITION
a Q I hereby elEnn thin I an'eactnm boor the Cnnlnclollti Urease Li-Tor tW
O y V following Trema(Sen Mn o(G 5,Husircce wd Ihtfcavions Ctvk:Any city tx nwmY SIGNS ELECTRICAL ❑Of HER
u]�+tt.raction, m et aIle
which action,a Permh curlsw ,impmvc,d,roolidi,or Ieluir any mclare
a
friar to it,iasurroo,. otNiias the applicant farmch Permit In file n signed german SPECIAL CIRCUITMISC,
f r�jy that he is lirmd lWtwant to the fravi.innwof Ne Contractor.Licroo Law(Chapter 9 COMMERCIAL
(y�0C Boar.ing wish Section yxi4 Divivon3 of the Busine,o,and Profeaaiana Code)ar TEMP.METER OR POLE INST
tL a e a thw be B caavpt therefrom anij the bei,fu IM alNgd eactrtftian.Any virbiion of
❑NLW AUDRION ❑UEh101.ITI0N
�y Seetitm 70316 by any.,Fb,.f«a pemlir wbjms UeaPflicanl ma d.il penalty of POWER DEVICE'S ANT [I FOOD SERVICE
Z y m Ione Nw five toodrevl dulka,(5500). IMPROVEMENT
�pQ ❑ 1,aew rofibe"ity,m mycmployc withuapes.4 lheirvoh,cwnfenwtim, SWIMMING POOI,ELECTRIC
will do tW crit,andtnc suucmrc is notlmrn ,,roRcred farm In XL,71] .Brii7- ❑OTHIiN
anal Ihtfa'ainns Codc:'Thu Conlmnnr'v Lsccnw law it,,not apply m on owner nr OUTI.HI'S-SWT-CI 1RS-FIXTURES
tL Proli who builds nr impmven,Merron,and will,dues each work himwtf or thntagh
his own milloy.,pavidd Ina such imM,cu.ntr am not inamcod or otllsd to, NEW RESIDENTIAL ELECTR SQ IT. SQ IT.FLOOR AREA ESQ.Ff.
-R.If,buvice c,the huildine n improvement La cold within one year ,of rnmpinitm,the
ow, -huiNv will have Inc holden of proving that ho did ort W Old m improtw for par-o L
sale.). OTAI: / , C
ltowrcl a(the papmy,am exclltusxly cunning with Bern.i contractor,an IY_J �-Il
ettnumct the polo ISn.70TL Haiti..and Pmfessinu Collet The Canitx'hr'e Li-
QTY. PLUMBING PERMIT FEE
who mmmcls for such prajms with a mmrslarts)liccnmd furwant w the Cantmcutr's
Lkanse U.. PERMIT ISSUANCE
Ea
tnto mpr
ALTER-DRAIN A VONT-WAFER(EAI VALUATION
Gw 11, - Date -t-
'AY( 3o 0
RKER'S Mi: ON L'GtdIATION BACK FLOW'PROITCI'.DEVICE!
1 yaffirm udtt Penalty Mlcrjury flM fnounagdcclmmina:
❑Flare end will mainlainaCrnificate NCaeotuoulf-irtstm for Workers Cnmprn- DRAINS-FLOOR,BOOK AREA.COND. ST RI TYPE CONSTRUCTION
.,anion,Is poll for by Seoivt 37M of the labor Code,for the Pcrformati of the 19 7
work for which Nis{cant,ix mucid. PIN URNS-PERTRAP
Fl 1 hese ad will maintain Wnkers CamPewlion la,uomce.an,nyu'val by Section
3700of1hcldbm Cask.fnrtM perfomutttce of the wart far wh'mn lhta pnmit is iewed. GAS-EA.SYSTEM-1 INC."OUTLETS OCC G IDP APN
My Wnkcr'a Cnmtrenwdat lnutmtcr eemmonl Yaliry numAr arc GAS-EA,.SYSITM-OVINa IIIA)
Currin Policy tb,
CERTIFICAl H OF EXEMPTION FROM WORKERSORCASFIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING OIVISIUN FEES
(Thiseeetioo md,oth compleadifdtepemut infaune hurWell dolWn(SIIMII GRFASETRAP
a lea.) PIANCIRiCK FEE
IcenifyBan in the lt.nolaa.or die wolk for xTichlhispmmit is itu ,Isball SEWER-SANITARI'-STORM FA,200 PT. 3 , O
rw,al any p+Twn in any manttcr.1,as to becmte wto th
njecn e Wtn4n'Cmmmt- ENERGY ETI:
Z mtionlaxsof C"Ii(unot [)me W'AfERHFATERWNFNT/ELECTR GRADING FTI!
O A,licanl
NOTICE TO APPLICANT':IL ofler muting Ihia Ccnificale of EecmNion,you dstad WATER SYS?:MfTR A'I'ING SONES IPE
F bumn,,eanja,us the Wnkcrs Cmnpenwnion ookiaaear dor WI"v Code,Yw mast
ai GMwith comply win...IP^rvision,-Nis fermi'vbrIl W thmtd¢vote. WATER SERVICE
LL A
CONSI'µUCT10N hENDING AGENCY NEW RESIDENI'IAh PLMB. SQ.FT. PAID
I herebyiffimt lhtonumumamy,for the'fucgntc of
lf e a cction leeding"rD. RcaipM
U O the work for which Nis Permit is itwd(Sa.3 7.Civ.C.)
Keens N. T AL:
C V I<t.krs Ahhcm TOTAL "
} 1 I ratify than I have mud this efplic.im ad sora that the above iafnrmetim is BUILDING IIJ?
V)7 cmract.l agrecm comply with all tiny ltd county oldintotca andgatc laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC 11717,U G Wilding crtnattuctlon,and homily atnhanrc mprcwcnlalkes prink city to enter upxt Nc
uWvc-rrcneond fnritcoy for Iml.alion Porto— 117RMIJ ISSUANCE ELECTRIC IIJ?` O
ALTORADDTOMECIL
((We)egreo to wvc,hvlemnily atm keep hannlcwa the City or C.FicNnt allain:N q �1 0
li"Whlies.lodgmrnts.msts"W esPenses xhkh nmY inmY way ttc<me agvn.a sad Cily ERV PLUMBING IPE
In canegaener of thr granllaa of toil pmoin.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO In"CFM) MECHANICAL IEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OV IJt to."CF]I) CONSTRUCTION TAX
Sigaama of A,,bcvnl/Ctmwentr Date PXHAuST FOOD(WNUCI) HOUSING MI'I'IGATION FIJI
LA% RUOUS MATERIALS DISCLOSURE
Willtheapplicanto,future Wilio"occop"m son:n handle halla oasmmtial DEALING UNIT(in Biloxi RN)
as define by the Cale tint Municipal Coda.Chapter 9.12,and tW Health and Satcty HEATING UNIT OVER IM.000 BTU)
Cut.Section 255320)!
❑Ye 0 N VENTILATION FAN(SINGLE RF_SID) PAID Data R.q.#
Will the epflirnt m furore Wilding omrfam um citaiPnem of Jnim which BOILER-COMP(3HP OR I00.IXp BTU)
emit heaardaus air emtamittvtu a de fired by the Bey Area Air Quality Manallerrcnl TOTA f
Di.6,1? BOILER-COMP(OVER I(b,(aa)BTU) _
❑Yes E3 No
AIR CONDITIONCR ISSUANCIi DATE
1 twru rc.J the Cojc, a io,o;1a 5. rancor,,unl51 Gutptn 6.95 ofthc Cali /
hanw HcUN&Scfcyrome Glc,c.tm,o 13505.'3537 mrd IISH.I utdcamtd that if nM NEW RFSIDIiNI'L\I.MECH. SQ.tell \ g� n ,�7 D
WikEng vita<uwhich Mvroawn600rtdoor.'.'.e"fitcellty utmeiry UtcxcvPom t,/ V /�I
SKr xhmnm x�,prwrmt«rnra��a ga GRa�y. 0
oll lig-
(Tamer«" 'xed earn, Dare AL: ISSUM BY:
OFFICE