NO PERMIT NUMBER APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-N,LECTRICAL PERMI T NO.
BUIL DIVISION APPLICATIONIPERMIT PLUMBING-MRCHANICAL 7
F. ItUI1,DIN(i PROJECT IDF-N'1'IF'ICATION -!
BUILDING ADDREISS
b W/w/� F SANITARY NO. API'I•(IC�ATION SIyr:Nl'PI'AL DATIi
tionft
OWNERE:'S NAMR� PHONE: CONTRACTORS NAME: Y LIC NO[:/'// /N/ ?9
NIC
(•�� V� ' N/C CONTROL#
A RCHITFC'UENGINI3ER: LIC NO'. ADDRESS:
o e s7k Ess-z�
CONTACT: PHONE: vi CA �'BUILUINGTERMIT INFO
CunsRllunt Fees Paid by Applicant(Initial) BLLDD�G/ ELE
C
T
PLUMB MFC1II
_ L7 LT LJ L'J
LICFNSPD[ONTRACIY)RS DI'ChARAI ION QTY (- ( ELLGTRIG PERMIT: t �FIw
C z Z I Imreny aPrr a to t I licensed under providon,of Ch pt 9(commencing - 1013 DESCRIPTION
W xllh Smlatt](HPo)ofD - I fthe Husmessandltolessions C:de,and ntyfcenee" RFSIDENTIAI:
F�� full fomeadd effect.l!�� II''p PERMIT ISSUANCE;
QUU Limo,Class 1> Li,.# ��u l ❑SFDWL ❑KII'CHU'N REMODEL
N<W Date Cnmmctor � APPLIANCES-RESIDF"NTIAL ❑ADDITION
❑STRUC INR R'17-PIPE
F+7y
As shall ECPS IIf:C 1die me O s PANELS ❑MUI:I'FUNIT ❑STRUCTURgI.
oo z 4 I understand my pleas shill heumd as public me us _ MODIFICATION
UP'DO 200 AMPS ❑INTIiN10R L1 CHIMNEY RIiPAIR -
<F4 F W Lmeased Itolcsmonal 201-10(NIAMPS mI�MP TENT
S W OWNER-BUILD17R DIiCLARATION LL#'IM ❑SWIMMING POOI S
C d I hereby affirm that I ant caentpt from the Commetm'z Licenxe Law home OVHH I(Xq AMPS III RI?MODIiI./REPAIR ❑DEMGLIIIGN
4O following mason(Section 9031.5,Becone,and Professions Gula:Any city or county ❑LOT]II?R
•3 LL F SIGNS eLIiC'fRICAh
F-=OrQn which req ' permit a t alter brain,donnish, p anY ztmnurc
qyw N..1 Priori M: qih pylic if hp¢ a PI -g Ismmmem "RNSlDp,W1ALELE�R
Cl RCUI'1/MISC.
2C� thati t nr )
{�1..60�0 (°nm n ) fl B6(tJ n� fER OR I'OLF.INS'1'. COMMI3RCIA1:
L6o p( thin he g Q _ J)t f n Ipeula fp.rlliVICHS
tea' Section 9n3L5 pl ) PP\\WW..ssll++ \CC�R��CVV�JYYri'�#^"1))111.. / BLDG/AUIlIT10N ❑DF.h10LITION
not mom tit five hmtdom dolk-($500 F AN)� ❑FOODSERVICIi[]1,as cwrer Uf Bet Myst ty he POOL IILECI'RICdoscworkandt a Ccm m d�'I-��]dc}e��,tlWl l9enanA Prolmeinns Cnd oa 'nL' c, ItWlt�'.,,dlhi -SWITCIIES-MIXTURESprr, wbn hoilds t fs!(his own nulla rovided shot s MUM
is atn nor inmnded or ollcmd f rDENTIAL"ELEC R SQ FT.
sale.If
hnwcv r, d y p SO T.ITOOR AREA
er-huilAur h �r'1L1, S/SQ.FTryKUfsulc.) thw,wM
F1 1,a,earn the li d TOTAL
constructm pj ,(S c.'IW4 nosinessdPr f..' n-Cb )ThContractor's Li -
,eL 1 tapplrt fp 1 q e 1 QTY.; , + l PLUMBINGPIiRMIT # +'i`. FF:G
who Law for Nchp je t.wthaeontru t (,)Lunzed par. .tet to ths.Ctmra tors
License Ww.
❑ I am erempt under Ser. ,H&P C In,thismason PERMITISSUANCH
OwnerALTER-DRAIN&V ENT-WATER(IIA)
Dare VALUA'f10�'
WORKERS Cdy of rimy ou Dl t e ollowi g I{qCK 14f)W PROf1;LT.DEVICE
1 hereby w ll ono door:.penalty of perjury nae of the at....Ing declarations: O 1,
].Ihdve and will far
Section l immnf the Cra,ca"No
Code.for
Worturi Cnmf the DIEAINS-FLOOR,HIIUM.AI11iA,CON 1), V
salinn,as provided fnr M1y Section 32W ofthe LaMn Code.for the Mrfonnana of the STORIES TYPE CONSTRUCTION
,fork for whichthe,p.if n I. IlX711RCS PER TRAP
E:l I hoorand willonainnain W kr:Ctnrp ' ane, q ' Iby S¢Cfot
3)00 lith I h Code,l th pert a nlithr k lo,hichlti penui,is irteuad, GAS HA.SVSTFM-I INC.4OUT LE15 OCC GRfllli'
My Workar yvylt�p I�nv�r� artier and Policy n �b�ay f� 6�J
Camee f' YLf�kY Jtccc Polity No.: .19=1lu.— GAS-fiA.SYSTHM.OVER J(EA) dtl O
CP"IG 117ICATE LIZ EXEMPTION FROM WORKHRS'
COMPI;NSAI'ION INSURANCE GREASIJINDUS IRL WASIt INTERC1711I OR
(This section need not be completnd if me pe.,at is Intone hundred dollars(Slap BUILDING DIVISION ITHS
nr lesc) GREASE'I'RAP PLANCHFCK FEE
ccrany[herrn mn p,rmmncer ofO twmkfor which thin perlWorsers'Colsmell
not employ anypenon inenymannermrw to Mmmcwhjedmthe Wnrkcr�Com en- SIiWER-SAN)'I'ARV-STORM F;A.200 1.7
0Z s.ti.n Law,of California.Date p 13NIiRCY ITE
Applicant ) WATER EHIAILR WNEN1/EILEC1O
(TRADING I'HE
ar�•i NOHCE TO APPLICANT' e,Idler making rt p Cen Himte of Iia nor on,you n cars, WRIER SYS'I'P.MII'HPA'TINO
, Mcnme,uhjea m the Workers Gnnpemmion provisions of the Labor Cale,you mnM SIIIESMEI`"-'� -
[IJ forthwith comply with such pnrvtzinns or this Cit.hull b¢demnnl revuAaA. WATERSIiRVICF:
CONSTRUCI ION LENDING AGENCY
zNP:W RI3SIDENTIAh PLM13. .SQ.FT. 1 II)
L)Q Iherchy alrnn that them isecon,tmetinn lending for performance of J� Date n nR
the work mrwhich this permit ix rued(Sri 3097,Civ,C.) -IIJJ UU
C) yLender's Name V 1 w
lenders Arabic,, 'IUFAL' v 'TOTAL: i
y. I certify that 1 have mad this applic:nion and state that thu aMrve in(omtaion is 1 r LUNG FEE
.r
N conaA Ia,rum loindy wirhall dty andenrnty mmnanees.....laQ
loam laws relating ' TY ' + MECHANICAL PERMIT'
bidding cncorreinn,and hani crchy hornempi'exenunive"m firs city to enmr upon the ) • - 'i "FEEx
above-mentioned mo,my for inspection putptme,. PPRMI'I'ISSUANCE;
(We)agree nt lave,inchaninfy and Amp hannlms rhe City of Cupertino against HLECI'RIC FF.E�
liabilities,jud,namb,costs and eapensea which may in any way name agaiacm,aid City AI:rLR OR ADD TO MECH.
in comeyneneeol rhe - pcno. PLUMBING FEE
APPLICAN . I:RSTAI, ',ND WILL COMPI Y WIIH ALI.NON-POINT AIR HANDLING UNITITO 10,000 CFM)
SOUR . EGULAI' MT:CHANECAL P[li
AIN HANDLING IINI'1'(OVEI110,WO(7FM) CONSTRUCHONI'AX
lam of Applican onCnor to EXHAUST HOLD(W/DUCTP
HAZARDOUS MM HRIALS DISCLOSURR HOUSING MITIGATION FEE
W111 the a,lo cant or brute,Inm1ding oecupmn store nr handle hazardous material I HEATING UNIT(I()I(,iN),I,H)
as defined by the Cupertino Municipal Cafe,Chapter 9.12,and he Health and Safety
Code,Second 25532(x)? HEATING UNIT(OVHR 100.000 RTU)
❑Yes '6bo TATO _.
VIiNT11.A'1'1(IN PAN fSINNJti
i l?SIDT Det, Remipl#
Will d the applicant or ants a defined by the B y A a Air a or Mara which
lemv hazarroua air contaminants as defined by the boy Area Air Quality Mdnugemanl BOILER-COMP CHP OR IaI,IgO p'TU) '
jni,rdeH
❑Ycv TAI No HOILHR-COMP(OVHR 100.00011TU)
I neve orm,hc hlmur O mamnaL,na,mmment,under Chapterb95of the Cali. AIR CONOI'1'I ONPR I$SUANCP DATE
Lrniia HurllM1&JIS Inrp We niuns255 and 255J4.l undenlnnd tiro ifthc ryHWRFS1DLNTIA1,M1.CH. SQ,FT, r "r 2U •� .G�.1
hnilabing d:raxlroif ,P nsihiliry etnaify the nim am 1%
of the mere up y.
nerrm t an. xge I D i 'TOTAL: •/�
ISSUED HY"+
OFFICE