31157 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATTON 31157
UILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10171 A �30�
) OWN[k'S NAME NE CO CfORS NAME LIC NO:
A 2 L 3 NIC CONIROLN
'WCHITEC`1'iENGINEE . IAC NO: ADDRESS: ,J ❑
{0l 13M Wntiff-5—
CONTACT: PHONE: - BUILDING PERMIT INFO
/^ —�- L�� 78a S�3 ❑ Coluvltant Fees Paid by Applicant(Initial) pLDG ELECT plB MECH
ra LICENSED CONTRACTOR S DECLARATION
QTY ELECTRIC PER MIT FEE /kcal /pa`
L hmeby afr that I am ficemw andm pntdsiun.nr emaptm 9 faanvnevam¢ JOB DESCRIPTION
07. wtm Section Dlvistun 3ot'deB.st.aril Pmfnrai^ru Cds,m,dmy loo.is RESIDENTIAfL
O in fdl force,and effcn. PERMIT LSSUANCE
aU� Li..Clans Lic.N ❑SFDWL D KITCHEN REMODEL
APPI IANCEN-RESIDENTIAL
FF W Date Gntrxtm ADDITION [I PLUMBING RE-PIPE
i-O:)on ARCHITECTS DECLARATION PANELS ❑MULTI-UNR El STRUCTURAL
'ZOE2'Z I uMmiatW my pluo shall is used as public rxsxds MODIFICATION
OZ UP TO L- AMPS
I-4 F'M L iccOed Pmfesaioml El INTERIOR El CHIMNEY REPAIR
OWNER-13MLOER DECLARATION '-OI IOp0AMP5 PRT
1 hereby affirm ata m 1 aexempt home the Cmilm,htCs License Law for the OVER iM)AMPS �TH REMOVEMODFhEI/RfiPAIR D DEMOLITION'
K O�U followin¢..(Section 703 1.5,Ban.tariff Pmfew.C^de:Any city or county SIGNS ELECTRICAL. [[��OTHER
Y_1 LLOra which olemrea s Pamir to mnstnes,Wer,tmpmve,demolish,or repair any smrt¢,am
hJ prior to int is.uemc.also requires be,applicant fur such pmmit to fk•tinned Alarmism SPECIAL CIRCUITMISC.
Qthat u Licensed censed Pursuantro
unt to the pdwm siof its,Cmtracmnse r's LiceLAW(Ch.IXa9
WRO0 (mmtncocin,with Section]OW)uf Dwision Sof the Had.sal l4OfmLxLs CMB)nr TEM 1'.M MT R OR POLE INST. ' COMMERCIAL
L d that he is cscm l thcmfmm end the firms fix the alkgeJ ese.,fion Any viol.i.of ❑NEW BLDGIADDITION ❑DEMOLITION
Sscsion 703121 by my applicant fora pernu "
tsae
jthe applicant to.civil pealtyof POWER DEVICES
Z yN., mmore Dun five hundred dllan($500), ❑TENANT ❑FOOD SERVICE
C .M 0 L,as nwmrnf the mnTenX ar my cmpinyxs wish wagesmtheir wle svmpensaswn, SWIMMING POOL ELECTRIC IMPROVEMENT
T
will d^dew^rk,and the stricture is Oe intend i m MTcrcd for sale(S .]Ow,Busineu DOTHER
W— and Profusions COde:TM Cmtmrmcl l.iame law don not apply t^an owner of OUT1FfS-SWITCHES-Fl%TURNS
n'3 pfupasy wbo huilda oc mpovu thurmn,turd who d«s such work himself m Omagh
his own employec4 PmvidN that such irrrprovemenu are mrd imeMN m off d fu NEW RESIDENTIAL ELECTR SQ
sale.If,M1owevcq the huilding^rimprnvamcmm won within meYcar Ofcompledon,the 14RDEA 5/SQ,FT.
wmelmilmr will nave ho hooffcn Of proving tktt he did not build n-improve far pun
Prese of sale.). �f.�f[�1.'�(1
[11,u Owner Of the poo,ct am exclusively comoicting with licensed em osctoa to T APR s 0 IY.fl�
comtrun We pmjat(Sac.91161,Burtnese and Pmfeow TJe�slCode:) Contnnofa L.
cense Lew does rotrtwya.an..f progeny wba Wirth re improve decreer,aril QT'y, PLUMBING PERMIT FEE
whOcammcri fmr h l.^;en,wish a�,I.tm,)licvroad ussuant�^�e Gra�tm�tm. CITY lir wrEHiiNO
licen'u Lw. PERMIT ISSUANCE
D lammempturde-Sec. ,B&PCfvthis Troon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owncr Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby air m
under-piliy Ofperjury ore of the rnllo,mg declarations:
D 1rescard will'--Win n Cerilicnc.f C.'lo If-Inure fsx%Acis Compen- DRAINS-FLODR,ROOF.AREA,COND.
auioo,as gashed for by Section 3700 of de IAM1Or Coder,for tier perfmnunce a th, STORIES TYPE CONSTRUCTION
Work fo which this peon is ius Oc. FIXTURES-PER TRAP -
❑I have and will maintain Wmkcrs Contpcmmiim Inmrercc m rtyuireJ by ativn
J]00af tier lAhrt Codc.fv the perforrturce of the Work fon which Uma permit' GAS-Fon.SYSTEM-I INC.(OUTLETS OCC GROUP APN
My Worke rMlGtn lasuntte terrier end Policy M
/' m. - Y Policy No.. 7 F GAS-EA.gYSfEM.OVERi(EA)
/ taut CERTIFICATE OF EXFJ.IPOON FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
ecBaol CLhia!n'titm rrcN nix be,compkned if dopermit is for ore hurnLel doff I-1S 1011 GREASETRAP
PIANCHECK FEE
ty Nuin[be mmnc stwM fix which this mt is issued, ell SEWER-SANITARY-STORM EA
non employ any vn in any murcr w as w tecane subjmuo theWua'Cmn,,en- 2lX)FT
ENERGY FEE
Z ,sf.Uwaof C.Iifmnia.One
O MATER HEATER W'NPM/EL[CfR
� 2 NOTICE GRADING PEE
y bees.idhi1.thec 11) OteOermekln¢thls Ccnihcutf Off E titre,Ole, Mould WATER SYS'IE_WTREATING
F't — baome s onor,y the Workees CsxnpeOf thi n Pm it sha of the IAbor code,yon muu SOILS IEE
W ti fmshWith mmply with such Pmviaiana or thispmnit shall be deemed uvdW. WATER SERVICE
as
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,Fr. PAID
U O (hereby aff than theme is.cmr 1iunIcimg.gcncy fon Nee perfomumce Of Ihtca
h. n. the W.A for which Nis permit to issued(Sc,.309].Civ.C.) Lit_
O U Lendcfs Name TOTAL
1 l-[rdCtl AddressTtA C;0
I comfy Tat I have read this application aril sat that the above inhxnulion is BUILDING
h camel I agree to comply with 41 city and ccomy Winarcu and swc laws relating to QTY, MECHANICAL PERMIT FEE
UZ buikfingoosonation,and hereby suthoron rtprnematives^fihis city toenmr upoa the SEISMICFEE
alnve memiured Pmpeny fins insµtion purryucs. PERMIT ISSUANCE
(We)egrte ns.ve.indemnify and keep hmmlea the City of Cu,mno agaiml ELECfRICFEE
Iiohllitia,ju ts..a art capcnsm which may many way aamcegainu said City AIAEEk OR ADO TO MECH.
rnnsryu t the granting^ ix pemmFEE
APPLLC NT NO ST' S I WILLPLYWLTH LNON-POINTAIR HANDLING UNIT(f010,(pO CFM(
lei
SOURf U MECHANICA EE ,
/0 � AIR HANDLING UNIT(OVER 10.hCFM10.01M CONSfRUCII
Sigrut enfAWlicanu'Cun nor Date EXHAUST HOOD(WIDUCn HOUSING MRIGATVF�
HAZ=S MA ALS DI.SCLOSUkEWOWeri'licentahuaebulldin int uort mM1aMkM1aaaAwarrurenel HEATING UNIT(TO 100.000 BTU)
u mrd by to Cumtinn Municial Cale.ChWer 9,11,W the Health aml SdnyCodc,Seds255.121.1! HEATING UNIT(OVER IW,B011 BTU)
❑Yes ❑NO
VENTILATION FAN(SINGLE RBSID) PAIDDate'
Will the applicant tx future building rueupant ass equipment(,r devirns whim BOILER OR 100,000 BN
mit hmurLma au co^rArrdmmus m detirud by Ibc Bay Arne Air Quality Mana¢mean )
DisWn2 OTAL
D YO, 7N BOILCR-COMP(OVER 1)11,(X.01 BTU)
I have read to hautmd is materials CTuper AIR CONDITIONER ISSUANCE DATE
rtquitarcms urda fi93nftheGli-
hmia Health&Safety Cock.Seetitaa 25505,2553]and 25531.1 analcnmmd dont ifthe NEW RESIDENTIAL MECH,
building docs rat cunmUy havea imams,rM1an it is my re,rac ty to noddy de reculwn
of do rcquimmnans Which maq be Tru Prwsr m i.suascc of.Comricatc of(kcuparcy.
Owrerm.udenael.gax Dane T 1 ISSUED BY
OFFICE