31503 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 5 JO
UIDINGADDRPS5: SANITARY NO. APPLICATION SUBMITTAL DAD
117o3 oRo-r1� Auld F Wh Cv G 'r,'J✓v k1 13-9,6
M_may/ R C� PHON%` CONTNACIO '5 NAME LIC NO: NAC (/%��
�R�HECTVG#/EER. !V LIC N(1: ADDRESS: V I LI
CONTACT: IF PHONE BUILDING PERMIT INFO
Rey„/, L F V ❑ Consultant Fees Paid by Applicant(Initial) BDG ELECT PwMMn MECH
LICENSED CONTRACTOR'S DECLARATIONQTy ELECTRIC PERMIT' FEE ICS
1 ha Rhy nlltm,that lam Eeenwd ander pro,mons of CTulne 9(cmtate«ins JOB DESCRIPTION
WC
S in fulifaceerdcRU Beat. PERMIT ISSUANCE ENIIAL
pf FWL ❑KITCHEN REMODEL
auZu License a.. Llc.x
�6RJ DateCorr.mm APPLIANCES-RESIDENTIAL ❑ADDrrioN ❑PLUMBING RE-PIPE
N LA
Z852
ARCHITECTS DECLARATION PANELS ❑MULTI.UNTf ❑STRUCILRAL
y v5^ I uNenuxl my p4m 001 he used u public record, MODIFICATION
OZ^pppq UPTD200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r=2L Li«nsed Pmfeuiowl 301-110(OAMPS IMPROVEMENT
C S OWNER-BUILDER DECLARATION
y Q I hereby affirm 0.1 1 am exempt from the Cantrucrors License Lnw fur the OVER 1000AMPS ❑BATH REMODD/REPtJ{R p DEMOLITION'
qxx L U following muton.(Scei«]0313,Budnoas and Pmfnsiva Cask:Any coy or aunty SIGNS ELECTRICAL 0OTHER A RVT
I++LL LLO F which myuima.permit[to eeaWne4.Ilea,improve,damlish,m repah=y strtrcmm
y pnmm its iaau.noe,also myuims the npplic.nt her such pcmut to file a.rgred"emcnt SPECIALCIRCUI'17MISC.
thet M is licceseu pursuant torM1em.,istms of be Connor anr'a Liana Law(Ch,o,,9
apo (mmanncin,wild Seed.700(yof DlvWem J of Ue Bush nac)Pmfnsiom Code)on MIR METER OR POLE INST. COMMERCIAL:' '�
6 C aw he is exempa rMefmm mJ the h.sis for the alleged cscmgirm.Any violation of ❑NF.WfADDI Ok j
N ❑DEMOLITION
Y• Smtion703L1 by any applicantfArraroom,wbja4r theapplicam mncivil penalty of POWER DEVICES Vry/1� f,
..y a more Nan Ave hundred doll.rs(S510). ❑TENANT kxUN`�F DSERVICE
~=G T.uownerol Ole propeny.mmy crmdoYce+witb xageutheir nk mmprnrnion. SWIMMINGPOULELECTRIC OTHER EAIFM V
ill Sr the work,eed the strvnure is not i nended In offcm0 far We(Sc.7a ,Husine,, OTHER
s W Pntreskm Cede:The Craven«'.Licosa I aw don nor apply to.n..of 011'ILLTS-SWITCHES-FI%TllRES
pmPetY who builds or impo,xs dexmn,.he who don auelb wart himselror through
hie own employe',pmviJod that ouch im,no con nH art mal imeNN or ofaed for NEW RESIDENTIAL Fr I= SQ
sale.If,huwavegll love tlimgur ren of
is an be did mtne build rTampktfor poo ^� 0 _` SO.�( A
Dover-builder will hav<thc huNat of moNng thathedid wt build«ingxove for Eur- S 5 llC../VVV�LI
dvkJ.
ex owe oftha pmpmty,nm I,chatively crmtmning with Iiaem N contractors to
arm
cea
mre Tonw Use act pplyBusinoss eM Roreviau'code:)The Cmarutnrc,s V- QTy, PLUMBING PERMIT FEE
wcamuIfter M1proj«PwRh mom's
Lncease mow' -R PERMIT ISSUANCE
Iwex
fT r int ALTER-DRAIN&VI I-WATER( ) VALUAI]ON
WORKEN'S CO PPN'SATION DECLARATION BACK FLOW PROTECT.D ICE � , o �—
Ihacbyalluma Ape Yaf perlmY ore Mthe fMloeing daWuiom `fit/
❑IMvcaml will nuinmi eC i0n¢afGxurntmwlGin umfnr Wrrtkcr's CnmPcn- DRAINS-FLOOR.POOP,A A, D. STORES TYPE CONS'TEUCI'ION
utiasr,u provided f«by on 3]1X1 of de l:Whm Cuk,f«the prrformana of the
oust fm which Uri.pcneil u issued. FIXTURES-PFJt TRAP
1 hoot.b will maintain Wmkds Comp<wlim inwnna.m nalpuN by Section
37W.fd.:lab«Ci.le,for the perfanumccofthe work f«which this permilin i.wN. OAS-EA.SYSTHM-IINC.40I311E7S OCC.GROUP APN
My Warka'a Comperrwion Inwm«a c-Wner.nd Policy number.rt:
Curia: Policy No.: GAS-EA.SYSTEM OVER 41FA) '
CERTIFICATE OF EXEMFHON MOM WORKERS' Avi
COMPENSATION INSURANCE GREASEnNDUSTRL WASTE IMERCEPIUH
(Thu a:timn recd na hecompkud ifde pnmit is f«we haNtN dollen(S 100) B IL 'IS FEES
ak¢) CREASETRAP PI.kNC1lE(X ' r
Ianify0utinlleperfmnwrec orlhcwmkfm.sun tothe orkeuaN.l shall
«1c^W1oY•nYPeaon io enY nmm�rcrwumbamrc subjmrothe W«km'Canprn- SEWER-SANITARY-STORM EA,30)FT. ENERGY AU 49 �.
O ,Z amen Iowa of Cdiront Dem WATER HEATER W/VEN7PELECTR
Z O Appliam GRADINOFEE
h NOTICE TO APPLICANT.IL.fie matin,did,Certificate of Exempia4 you ah,rM WATER SYSTEMOREUING
rFrr� ^ barye aubjecr m the Worl Comrpernsta.pnaviti.M Ue hila.Code.Y.mon SOILS FEE
p ❑v0with comply with wchp,00kl«s or this pmnit shall be decmcdmcudod. WATER SERVICE
ww Q
UU0CONSTRUCTION LENDING AGENCY NT:W RESIDENTIALPLM B. SQ.FT PAID
O Ihertby.fErm detthemis ecraetmcdn kr.ling.genry r«IM1e perrarmtance nor Dore x
Ne work hr which Ihie permit i.ia.ued LSa.309],Civ.C.)
C) U T.aldara Nene AL
W Leader.Addrevs
y 1 certify da I have most this rMl lade and nate Ion Ue atone infomwlino in BUILDING LYE QS
N ct t,lgm tocw lywith.IldtyaNcountyrnd'aurcoerduuelaw mimigro QTY MECHANICAL PERMIT FEE
U Z Muldno'comvuctirm,amdbercby.MOuire mprcacarives of oris city menta upon to SEISMICFF.F,
.Mvementaxed propecy for lmpclion puryows. I'ERMH'ISSUANCE
(We)agree to rove iNm
enify.hl trop M1artnkv Caperton City of Cuperdagain ELECTRIC
FA
Johi,, mddnc .N cxpmms whkh may ln.ny x,y rcruc.,•imts.W City
locrosequence Ne ting of Nie i4 ALTER OR ADD TO MECH. PLUMBING
APPLICANT NUT ST DSA ' LL COMPLY WITH ALI NON- NT AIR HANDLING UNITITO 101"CFM) MECHANICAL FEE 1 IL
SOURCE RE' ION
AIR HANDLING UNIT(OVER IIth"CFM)
p- CONSTRUCTION T17
S aurum or Applicvnl/Con ux D EXHAUST HOOD(WTDUCI) HOUSING MITIGA NFFE
HAZA 13MATERIALS DISCLOSURE
Will the aMlicamororo building occupant More or handle W—dons mineral HEATING UNIT(TO 100,00p BTIH
ex defined by the Cupcni nicipel Cede.Chapter 9.13,eN the Ilcallh arta Seray
Cnde,Seodvt 25533007 HEATING UNIT(OVER Ell BTU)
❑Yn ON. VINHAI'[ON FAN(SINGLE RPSID) PAID
[)We
Raei
Will the applkun«fWum Wifined«agnuse egJlir ent Crudity
Micnwreem BOILER-COW(311P OR I BE"BTU)
Omit Iwvdous.ir conurmmma u dJrtal by the Nay Am Air Quality Muugcnear TOTAL:
Di u n]
0Y ON. BOILER-COW(OVER 100,000 BTU)
I leve rad to hstrami s metcrida requirrnmt.tr Chepa 6.95 of be Cdi- AIR CONDITIONER ISSUANCE DATE
fmnin Heath&Safay Code.Saaima 25105,25533 and 2 534.1 uNcrsurd bo tithe NEW RESIDENTIAL MECH, SQ.FT.
buidig do —aly lon...4 Net it is mynm notify dre recall
ofthe whit must he nopriorm ivaf.aCadficiac
of OnNlsaeY.
Owneror.Mthminedagent Dale k ISSUED BY:
OFFICE