S 1428 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL DING.ELECTRICAL PEI nN
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BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL J 1428
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: }{rr-��/[� AA�T �`� SANITARY No APPLICAMON SUBMITTAL
D�rkA'I'It
541
OW "N,AME: A�. ,` ( NO
PHONE: Cp}y'IfAM�AMD"� �I.IC�U57, NIC CON I'R(lL#
'IARC HIi'LENGINEEk: (l �!'-i,N1!lhA/ICy~N�`O: AIYD�� �I L � �`•�� ❑
cONTAC I``�,. �)�•yP.HONNET:f �✓�2_ 1'` HUILDINO PF,RMIT INFO'
�A t'nIG KIKu��( O -l�/V)�, ❑
Camordtant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MRCH
Llc6rvsBD coNTRncTOR's DECLARATION qTY. „ELECTRIC PERMIT PEE
l hereby afthm thnlo�n liren.pJ anadr p.visinns.,r chapter 9.(cnmmendng JOB DESCR I PTION
WAWteZ with Seals 9000),d Dter men3efde Business ens Pmfice,ram Chda.mdmy licarld i. RESIDENTIAL:
k-1_ in full force and effect. PERMIT ISSUANCE _ ❑SPDWI, ❑KITCHEN REMODEL
�U$V License Cl... Lica - pppL1ANCE5-RESIDEN'I'IAI. El ADDITION El PLUMBING RE-PIPE
F d W Date Contractor
m ek ❑MULTI-UNIT El STRUCTURAL
ARCHITECT'S DECLARATION
(.❑rte PANF.1,5 MODIFICATION
Z z y Z0. l undcrswnd in,.Ienx shall he used as public rewma
OZi,,,Q UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
F-F� Licensed Prafcssimul 201-I000AMPS IMPROVEMENT SWIMMING POOLS
F Ind I in thea. I DECLARATION OVER 1000 AMPS ❑BATA REMODEUREPAIR ❑DEMOLITION
p� tt��U ,heavy amrm nim am enempe from me Cs,ior,r.Cleanse Law ear me w
iC dU which
re eamon.(Sermon 9fo sr t,alter, and improve,
Any city nramnrY SIGNS ELECTRICAL F1 OTHER i✓��
wNM1 y parent l construct, ❑ P demolish, repair, Y;t marc
Error r t .. . I. q lh Intl' II 1 p m fl g d.t to neat SPECIAL CIRCUI'PIMISC.
ad",ti moth dpursuant t t p .a n [th ( t tel L (Chapter9
COMMERCIAL
(an he is ngwith Seman91N10)of basisf Nce .tacos Il ,An, is Codcl ter TEMP MI3'fP.R OR POLE INS'('.
mm he is exempt mcre[mm and he basis roc he alleged exemption.Any violation of [INEW NLUC/ADDITION ❑DPMOLITION
W m Sermon 90315 M1y uny appllwmfmapermn.uhjw¢ahcupplim,mmudvil penalfy.f POWER DEVICES ❑TENANT El FOOD SERVICE
net more than five hundred dollars($500).
I � E] m Las owner of the propeny,or my employees with wages asmirs
eolecompirmande, SWIMMING POOL ELECTRIC IMPROVEMENT
will Jn the work,end the s0nnuoe is not imanded...ffcrml foreold(Sec 9044,Business. ❑OTI TER
W 3 w and Professions Code:The Comparators hfceme Law does not apply m an owner of '('LETS_SWITCHES-IIXfURP,S T A I w
property who builds of improves Income,and who docs such work himself or through
his own employees,provided that such impmven ems aro not intended or oBeead for NEW RESIDENTIAL ELEC'1'R SQ PT.
sale.If.hearer,the brilmngorlmprovementiasdd wharone yearofcompletlon.the SQ.EI'.FLOOR AREA $/SQ.FT.
er-vuilderwill haverhe M1uNua or proving thmhedld muvulld or improve forpar- MAR 27 AN(1D
pos� f. ) {{�7
L] 1. fthe p,(,Perry,aaeclue lycontractingwith 'licensed rmrlmam 'TOT .:
ant uth p jedt(S 7044Business' dProfession,Cedi-Tire Characters Li
dense1 I mapplyl property fin builds or improvest mon,and QTY - PLU -PERMIT NEE — CtIUNU
who contracts da,auh papers when chmoamr(s)licensed pursuant 1.the G,mmetods
Fire...Law. pi312MIT ISSUA
❑I am prompt under Seo. .R&P C for this rcvmn
ALTER-DkAIN&VF,NT ATF. A) VALUATION
Owner Dale -
1 WORKER'SCOMPENSATIONDECI.ARATION BACK FLOW PRO'T'ECT.PEVI .
II I herehy.firm under penohy of perjury ane of the following dedarnnon,:
(] Ihave and will chromum a Certificate of C.nsenlmsulf-imeu.for Worker's Compete- DRAINS-FLOOR,ROOF, �A,CON STORIES TYPE CONSTRUCTION
sad.m m provided for by Section 3900 of the LavorCode,for the performance of me
work lar which this permit is is.ucJ. PIXTURBS-PEIi T'ItAIt
❑ 1 have and will maintain Worker's Compensation Invanmde,as required by Sudden
3900.fthe Lubar Code,fnrthdpddmmanaxufine .,it Bvwhiet this permit is issued. GAS-EA.SYSTEM-I INC.4 OU,FFE.PS OCC GROUP APN
Camra p"'chatpepmsi t__Fgr•m Rday NoPolicy��� GAS-EA.SYSTEM-OVER 4(EA)
FI--(� CF.RRTIFICATEOFEEXF...MPTIONfRUMWORKEeR S'
COMPENSATION INSURANCE GRF:ASFIINDIIS'TRI.WASTE INTERCEPTOR
BUILL GNIVI. MFIiP,S
(This aemi.n need not hemmplered ifihepermit is for one hundred dollars($I W) GREASE'I'RAP
it,less.) PLANCHECK FEE NU
Iratio,thatintheperfurchari the work for which this permit is issued,[small SEWER-SANITARY-STORM EA.200111'.
nor employ any person in any manner m,as In om
bece srbjeer to the Workers'Compete_ ENERGY PEE
Zr sa.on inve,of GErornia.Dart WATER HEATER WIVENTEFF.CTR
Applicant 1 GRADINGS
.rh
NOTICE 10 APPLICANT:IL.her making this Cenifaleof Exemption,you should WATER SYS TENUTREATING SOH,
bwome suhjwm t the Worker's Compensation provisions of the FaMrCbdc,you must
q m�•a forthwith cmnply with such provisions or this p......hall he deemed mvnked. WATER SERVICE
W Q
CONSTRUCTION LENDING AGENCY N EW RESIUF:NIIAL PLMB SQ.FT PAID
Datc Receipt
1 herehy.f0ma mu
ehcrc is u construction lending agency for me perfonnonce.f
U he wed for which die permit Mother](Sed.30)7,Civ.Cr)
u' Le ler'sName 'f0'TAL:
O U Lenders Address TO FAL -77
I o try that l have read this application d mm shot thh t i 'x -" , BUILD( GFEE
�+ m
correct. g t ply with all city and county ourfirproto and state laws filming in ,QTY. - MECHANICAL PERMIT •FEE
U Zbuild g onsnretnn and hcrehymthorze representatives,t this city to ether tenth. SF,ISMICFFe
uhovd-mmnimared propeny for Inepeation....nnes PERMIT ISSUANCE
(We).gran m savq Indemnify and keep hanmees the City of Criterion.against LIEU('RIC THE
Iiahilihe mdmremv,c.sts and uxpeases which may tee any way accrue against said City ALTER OR ADD IT)MECHr
an singe
me of the granting. Thi: emir. - PLUMBING PEE
APPLI(7 1 1NUL+RSTAN A WILL,C( YWI'1'H ALL NON-POINT AIR HANDLING UNIT(1010,000 CFM)
SOUR E 1 IONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTION TAX
Signmu.en' FrdiDCmmra..or Da EXHAUSTHOOD(WIDUCT) HOUSING MITIGATION PER
AZARDOUS MATERIALS DISCLOSURE
WiB de.pplicanr or tutus building mci pant stoic or handle hamrdou.material I EATING UNIT CIO 100,000 RTU)
as defined by the CiTedua.Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532fup HEATING UNIT(OVER 100,000 BTU)
❑Yes - ❑No VENTILATION PAN(SINGLE kESID) PAID
Dale Receipt
Will the implicate,at fair.building occupant use eynipn.cm m devices which
emit,ezamous air conmminama as di by the Boy Artie Air Quality Management 1301LER-COMP(3HP OR 100,fp11 B'I'U) TOTAL'
Dismal BOILER-COMP(OVER 100.001 BTU)
❑Yes ❑No
I have opal the humorous mmddafs reclearacns r dm Chapter 6,95 of rhe Cali- AIR CONDITIONER ISSUANCE DATE
forma Heuldi&Safely Code,Sections 25505,25533 and 25534.1 understand that The NEW RESIDENTIAL MEC I. SQ.FT.
buildingdoes molcmrendy have a lmmntpant it'¢mym,,v sihiliry ria notify theoceupam
or and thi imnrce.whieb mrsr banal prior s lssvunce of a Cerifiwm rf 0....utecy"
Owner or authorized agent Data TOTAL: ISSUED BY
OFFICE