S 0760 *"APPLiCANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECFRICAL PE5IT NO O 1 VO
IUII,DIIiG Dn'ISION APPLICATION/PERMIT PLUMBING-MECHANICAL VJ
BUILDING PROJECF IDENTIFICATION
PBELDING ADDRESS: SANITARY NO. API'hICAfIONs
t.✓ a✓c _1r_ 1 ;-
NER'SNAME: I'HO P.: CO AOOR'S NAME' I.ICNU:
V-e A NIC OM1tOl.tl
tCHT:CI'/ENGINEER: LIC NO: ADD S. ❑
o All
COM'AC. PHONE: BUILDING PERMI'r INFO
❑ Consultant Fee Paid by Applicant(Initial) BI. ELECT PLUMB h1ECH
❑ ❑ ❑
LICENSED CONTRACTOR'S D% LARATION QTY ELECTRIC PERMIT FEE
1 I I�bY affirm men 1 Ira Hamm mslar provision,or Clol+a 9 anmmercmg JOB DESCRIPTION
In sun&m varo)efuiviJ„nJnnk Bu.ircu eeJ l'n,res.'im.n Cr.I�.,,w my Ycenx ix RESIDENTIAL:
a:O PERMIT ISSUANCE
�WO nifullf«a and eIT / ❑SPOWL ❑KITCHEN REMODEL
az 4cem'e- %J 1j,It APPLIANCILS-R151UGNI'IAh L1 ADDITION ❑I'LUh1BING RE-PIPE
I Q1 Uatc Cmuvcno 0MUI.TI-UNIT 0MUCIURAL
shall
b .wi DECL li,roc
F ONZ+ 1 unJeruenA my plvnr shall he u.1 vx puhlic roc d' PANEL, MODIIICA'1'ION
OZ-O UPT0200AMPS []INTERIOR OCHIMNEY REPAIR
p.4Fu1 Lccns,d Rnfcssicrol 201-100K)AMIS IMPROVI:MFNI' OSWIMM ING POOLS
•.1
OWNER-BUR-DER DECLARN'ION "
I
OVER AMPS El BATH RILLODELIREPAIR CIDEh101.IllON.
Q I hoi affirm at mI am e,engst from me Ca «araena Ii rat Law for me 1)
1 O d U follwving reason.Section 7031.5,Buvmesn vel Proc dm,Core:An t tt.m f
Any air�n r 5lclvs BuscrRlcnl. OOT'E 'a
u 3 LL y warn rtyw�a p[rmin m ranamcn,eller.impmva,demuli,h,ar Ryair am,lNenare fJVi /LJ�YL
F�OQ hammslic edwrwortyuiree nneapplicenn fm Conlratoi nufleaai aw(M car' SPECIAL CIRCUR/MISC.
�ji•.1 purwnn prov�.�a..o pm' �a�Mb .�I�
nM1vt he lv limmdl na me (Jlc Conlrwus lion,lnwlOw J
W1'a� (comntercin�wim Sttnim 7010)M'UiviumJofine Puwrces aNl PmfevimsOdc)o TEMP.MEIHR OR POLE(NST -OMS h1ESA
L y—y O, Jun he is esompl mcrtWm nd he burs for tlr alkgM eaompnim.Any violation of ❑NF,W BhIX1IADDff10N []DEMOLITION
JCRa' S,-atom 70315 by any appliennn rr a limit cmjocls lM aWlieann to u civil tonally of POWER DEVICES ElTFNANT 01'OOD SIRVICE
J'm rat rams Jew Eva hurdrnl dollva 15500).
tZY I ROVINENT
=OOLns wtcrn(mepmpeny.mmY emPliryro winM1 wage,vvhcirwlcnxnlrn.wlim. SWIMMING PIX)LIJ.ECTRIC R
21111"''1.. toi arots.i k.and me ni cnoeixrwtinmMedor o.coo,a notaLSce.71 an Nuxineaa
4] � sal Nofcssimu Colic:The Caurecmra I.iccnx law docs not apply m an mvrx+af OIIfLCTS-SK'RCHFS-p1A"IlIRF_S
pmpcnY who mild,or mtpmvcs mama,nnJ who tk,R'wen wad nimmlf or mawgh
hu own cn riloyuPei a,Pe that such imI^o"mrcu am ria nimcrdm or oBcmt for NEW RESIDENTIAL.EL ECTR SQ FT.
sale.If.howc,,r.me Wifine or inlpmvrncnt is sold within orc y.rof compleliae,meI
. CU AREA SISQ.FT
wncr-lwilrer will Mac the buNcnof Paving mal the Jld.build or mpmvc fmpm- �1
pose of salt.).
O L as ownof the wo,, ,am culueivdy ennlracutt,with licemcrl amt tm" TOTAL:
er
_sato tM Project Iso.TW.Huaimcxe and Ptofcs can Cale)Tha CtxNscmlx D- DEC 18 •��
c"w law does non apply_an wcr nof pmprny wle,huikls or impmva nllOm
e .mal QTY, PLUMBING PERMIT FEE
who connm[nx for such projects with a Gann aramx)licensed 11uAYvalla ma Connanaf s
LJccnx uw. PERNUTISSUANC. TTY ur uurthf INU
lora c,crin ra k Scc. ,B&P C for Hi,..'a
ALTER-DRAIN&VENT-WATER WA) VALUATION— _
)wncr Dac
WORK17R'S COM PFNS ATION DEORATION HACK MOW PROTECT DEVICE /��k�
I Icrchy affirm utticr penally of perjury on,of the f Wlwwing dcehraims: �/LJw si
Q IM1a,c and villrwmvn aCrniBcac MC,nsrntno!cif-rano_fa WwkcY,Canteen- DRAINS-FLOOR.ROOF, M IEEE& STORIES 'TYPE CONSTRUCHON
_lion,u Provided fm by Se nial37(X1 of the L.I,r Crde,for The,_minnnna of the
work fat which mis pandit ie issued. IHXTURFS-PER TRAP
Am I I-
0 1 have and will maintain worker,Crcrlpen_tien huamtre.a,reyairm by vara_
3710of Je labor Ode.for the perhrmatue of the work Lw which this pcmnl ie meat_. GAS-IiA.SYs'fEJN�I IN 1 OCC.GROUT' APN
MYW % m Emanates,earn and Poliry call a
Crtriq�Jd/.a6e1LM/ ,OlacSa.Fallo y Nla:CL YG/ 7777 GAS-BA.SVSTEM OVHNi(EA)
CEiRTER ATEOPEXEMMON FROM WORKERS' GRGSF/INDUSTRI.WASIY.INTERCEPTOR COMPENSATION INSURANCE BUILDING DI VISIT,N FEES
Mmc. im nem lox Na avnplemJ 11 the perm
mit ix fore hmAnd,k4Iars IS 100) GRBASETRA'a la,.) PLANCIIECK FEE
Ianifyman in Jc performanaoOM1ework fllayr wniecn�l6�1ep1peem�'n,�s isoum,l%hell SEWIR-SANITARY-STORM EA.21X1 IT
rvmanlpinyanypctx,N in any nunlcrw as In bn L-In ' `t; 7 i oo".- El.'eNUV FF.E
O Z sedan Leh of Celia.Date WATER HEATER WIVENTA:LECTR GRADING ITE
/.- NOTICE TO APPLE .1,o mr mvkice mis Cenifcmc of lacmp!n,Yeu,Mold WATIiK SYSTEMITREATING SOILS Hifi
bacon wh*t to me wooer'Compcmatian provi.d me Lano Cada.'no mist
furmwfin cmnply winnscalb pmnxiar,tr l his Proof 4el l be recover!rtvokm. WATER SERVICE
D
a CONSTRULTION LENDING AGENCY NEW N131DIiNf1Al.PIJOH. SQ.17 PAID
U QIbench,aRrm mwmert is u cvsM.1ml rdic,.Qercy for me perfmmnceM Dom RneitrX
me wrak for which this permit is issued(Sec.3097.Co.C.)
{t. (~ lender's Nvmc 7O'PAL:
m
0 Lekr,AJmes, TOTAL
f... 1 smify that I have mad Oak epplieatim and sate ohm the eM,r information is BUILDING FEEL
F. Vai camel laprmmntmply wish tll Illy oral cranny otJinancc,oral score law,mlwingm QTY, MECHANICAL PERMIT FEE
Q Z building cnnsuuction,and brachy orthosis repaxnnaivO of this dry to ens upon dse SEISMICHM
abate-contra socc!pmpeny far inspccnion pmPi PERMIT ISSUANCE
(We)agm m vevakmmly Imunit keep bvrmlea the Ciy of Cul,amim againn IJ.ECI'RIC FEIi
IiaBililiu Pd{mcNn.( %ad ctpcmex is Inch may In any way accrue against Lid City iALTER OR ADD TO MECH.
in nn,e9ucna of ane grunting of thin email. I'I.UMHING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT LAIR HANDLING UNITRO 10.000 CFSD
SOURCE REGIIIATI0.�'II MECWSNICAI.FEE
,AIR HANDLING UNIT(OVER IU.aMI CPM( CONSTRUCTION TAX
$11;^awmo pp r 6G Lddd— l Dam/T (EXHAUST HOOD(W/DUCTI I IOUSING MI'I DATION ITT!
HAZARDOUS MATERIALS DISCLOSURE?
Will dr applicant or fumm building tccupaN nae n,henvlk hvvtbus macoal HEATING UNIT(TO 1 W.WO HTO)
ss dd nm by nhc Cupeni no Municipal Corl CTuptm 9,13,and lM Health and Safety
Cni Section 255321a1^. HEATING UNIT(OVER 101.000 BE
OYn ONo PAID
VENTILATION FAN(SINGLE RESID) Dae Rceeipntl
1
Will us eau in Totem bu,fica pr(B hl device,whim
appli 6aauhrN me.qui HOILBK-C(lMP(IIIPOR IIMI,ODII PTU)
l mit hwvdae air nmtentinantt e,def rcJ by nM1e Pvy Arca Air f7ueliy Muugcmrnn TOTAL'.
II UrnicRBOICEB-COMP(OVEA IW,00o BTU)
GY E]No
.l I Mac nod me barankws marmots ngmucts ga avkr Cle ncr1,95 of no,Ui- AIR CON PIT IONF,R ISSUANCE DATE
fonin Heel_&Safciy Cola.Secrimu 25505,25531 ao125511.I udmuN mat if no NEW RESIDENTIAL MECH. SQ,FT.
Naddingd.not cutter Jy have.oral.mol in i' y m'rynsihi iy l n myily JY`oeupom
ofiner ircnnluwhich rm Prmt. f iy nflOtoyparcyy,]
Owncroau gent TOTAL: ISSUED BY:
OFFICE