S 3347 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI, IsT NO. 3347
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL CJ
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NOAPPLICATION SUBMITTAL DArF
l,�oo q
IWN`'RO/�'S NAMI!: I'IIONI!: CON'INACIUH:S NAME: LIC NO'.
NIC CONTROL 0
ARCIHO'UC/TTANOINEERLIC No ADDRESS ❑
CONIACr �yis(N_ //� _ BUILDING PERMIT INFO
I�S.�S Y a a/ ❑ Conwltant Fees Paid by Applicant(Initial) a lil.l!Cr PLUMB MECn
/gyp/S E�So Y
LICIiNSED CONTRACTORS DECLARATION
QTY ELECTRIC PERMIT FEE
I Iefehy mflrm Brit 1 our aL<nwd uncle,pmviJrva ul Cnvrmr 9(so rnisc cing JOB DESCRIPTION
ma'z wuffi5 yim?()00) RESIDENTIAL:
1- - o full force and effect.n. PERMIT ISSUANCE
'W ❑SEDW L ❑KITCHEN REMODEL.
QUV Licenses Clan Lic.g APPLIANCES-RESIDENTIAL DDTMON ❑PLUMBING RE-PIPE
F'Q,6 Date ContrXnn
f� ARCHITECTS DECL\RA'I'[ON 1'ANI:IS ❑MULTIUNIT ❑STRUCTURAL
F 5 H
Zpy7_ IuNcwud my plana shall bre,roar!npublic records MODIFlCA'Tl(lN
pZL,� uP TD NXInMI'S
Fw ❑INTERIOR ❑CHIMNEYREPAIR
[-n!1Liecosad Prufeueenal 20I-1000ASIM IMPROVEMENT OSWIMMINGIOOIS
CSS; OWNI!R-BUILDER DECLARATION OVER IaOAMPS ❑BATH RL'MODEVRI!i'AIR ❑DIMOLH'KCI
C�Q I hereby aRlml Nal I am mcmq fnnn the Cnmracmr's hicens lor In
w for K p,U following mnma(Spoon 70315.Business,end Pmfcadmn Curie:Any city ii cranny SIGNS ELECTRICAL ❑CYBER
3 p-� which reymrta v permit e,construct,cher,improv,denlnl itch,or«far any,aualure _
F�DQ prior to its iewatt<.alwrryulrn lW ar,A.,fof.web parboil In GleueigrcJ sucrcnl SPECIALCIRCUITAIISC. J QI
teiy� that the is hceni pumuam m be pruvii,ions nr Ile Cnmraetws UL r-I.w lCnvgery
t$CQ Iemnncneing w 11 h Section AXXI of Di serum Ld the llmi ncxrund%W onion,Cutest or 'll!MII METER OR POIF INST. COMMERCIAL_ �r
6 X o Nat he u cure t tMefnm vW the bank fa Inc alleged eaemgion.Any violation of ❑NEW BLDGIADDRION ❑DFMOLITION
Section 70)1.5 h affliction for a f subjects the applicant m a civil renally of IOWP,R DEVICES
by 00). ❑TENAM' ❑FOODSERVICE
nx neon than live hurv4N dollen ISAXO.
F'L> IMPROVEMENT
FD6 1] dothe ornflhe the ony,mmyemggcea weNwred for aleircde (m.Husnim. SWIMMING POOL EI-ECIRIC
will N,ncrirrk.and Ncnmcmraesnot It Licrud IN alfudJs rilei asan.Hurc,of ❑O'I'LIER
3 wW Pmfc pons Co or inc ove,denser L pill w Law olocc w apply to an earner a( CIIILEfS-SN'ITCIIFS-FIKTU F_
gnpcny who Ni or iiffi Ncmrn,eM who de,such rind huncued ts,car Nud for
IN
h5.awn employee,prnvhntl Nw,inch empmvc wild
ton mn imemlW or oldrW the NEW RPSIIII'N[IAI.ELEC!R
aale.IL hmanrr.Orc Willingaimpms'cmrntia told within one yen Mrnmgeaun,IW SQ.FT.FLOOR AR lb 5/SQ.W'.
Wn
cr-huildr,will love n he Wodenofpraving nnat hedid no hi empmvo for pus
pLee or,ale.z
❑T.a,owner of NC pnrpeny,am rod—scly cona.ling wim lemoned commcmn to T(TfAI.:
eonnmcl nM project(Sec,711JJ,Bmr—and Ymfessiona L—,.11 CMlfaCla1Ii-
cen+a Law Joey nmappy,m en mvnnnf gnpeny wW build,,improve,IM1ncmL anal QTY. PLUMBING PERMIT FEE
wMrcmares Rrrico pmjmu wint,oplmtnr(vl Ii... pus neon lu Nc Cnnvatur's
License Law. PERMIT ISSUANCE,
IvmcacmquNr Sec. ,B&PCfmi,i
am 4 19F, ALTER-DRAIN&VENT-WATER( VALUATION
Owner f DUC O
WORKIiN'$COMI'IiNSATION DI!CI,AHA7lON BACK Id.OW I'HOfIiCI'.UI!VICI!
1 herehY vl Brm under IcnallY nl prjury one of Ne following Jccluuiona:
�Inne vrd will maimaineCrnif molCmunnn.wlf-irlwmfur WndRs Compcn-
DRAINS-Fl,fN)R,RIIOF,ARCA.GOND. STORIES 'TYPF CONS I'RUCUQN
Mann.e,
❑warts which rl1 ropermnyhub:ti,nwal nal m Ne IuWr ode,ret the nrHnrnuu,ee er nhe
FIrn7Rls-PER TRAP
face caw will
mai for se der oration lits ,nt ro,perr by seaarn
My Wr IW Igor CuJe.tnr Neurance wrra ollhcavrAlnrrihichlhirpermit uisuud. CAS-li\.SYSTEAII INC.)OIIfI.EIS IJCC.GROUP AI'N
Myrier. Cmtprntvlien Insurance carriraM Polity numnr are:
Carrier. Policy Na: GAS-IU.SYS'ItiMOVER J EA)
CERTIIICATE OI;EXEMPTION FROM WORKIJIS' Sz 5�
BUILDING DIVISION FEES
COMPENSATION INSURANCE GREASIONDUSTRl.WASTE INTEHCITIR R
flllirartionnminnt he cnmplclpl if ale permit ie(Drone humhetl dollvrs($IIXB �S�
or less) i'IANCHECK
Iccvil'ylhvlinl,a an'. narcmrinW wndrri-hyh Ibisenl isi. ffttILw\ R- gARY-STORM IA.NO 14.
rcr employ any pawn in anY nunw w n to beeerne wn)[el n 112 Woderi hcrope, E\'FRGI'hl:l;
oz crinnlawxnf C.11brrha Dan, WATER 111 x'NIK?I-I!C'N
z O Appl'..t 11 ' nrel GRADING FEE
i,,, NOTICE TO AP%JCANT:If,aBr.a ng Nia Cmiticanc M Eieulgian A;6.al&wI WAHmR S 1lIRHATING a SOILS ITL
S hecunae subject to thir:r C
Its,Wlrnmm
pcn,iumm
pvirirns of Inc he&r Carle,you marl
... fordwahrroplywhhsuch proomins m Nu rrmif shall W c6,r6,l revMel. WATERS 1 E
7 Q p PAID
z CONSTRUCTION LENIIING AG1!NC1' L Y NEW RISID• AL YLMB. SQ.FT.
U p Ilmrchy aBiml Nal dlre is a[bnnnrlim lending egrnry or the Dam Reccigg
Nes work lot whech Ihls Icorrt is kored(SLc,YYJ1,Cls.C)
0 F-'L) lode/s carne TOTAL:
LenJcl'a Address TOTAL.:
y BUILDING IIF
I com
comfy that I Use mal this application rid No a That the these in4mmaon riis
N cmI(CL 1 egrcc to comply wiN all coy.rid camty mdimnaa end sum Inws mlvanE m QTY. MECHANICAL PERMIT FEE
hailding mnvrvom.,aM h neb,-11onm relremnmti,cN nl oK,ny to cine(upon the SEISMIC PEC
above-rrcntionwl pnrpeny tic m%p cioso parpo . PERMIT ISSUANCE.
(Wc)apm Ia save,indomnify aml keep hai the City of Cupcnim againn II,ECIRIC Fl]!
iuhilillea.juJgmcmr,moor andongnra which nary inanywuyuccrucugainneAc Ciny ACfERORADUTOMECH.
It
in rruvquerac of Ne Iranian,of Ni, .it.
Il.UAIBING IFF,
A PI'LICANT UNDERSTANDS AND WILL COMPLY WI'IfI ALL NON-}}}`01 IN AIR IIA N IDLING UNI I'ITU 10.(0)
S( - HIiGUI
N
CONS IRG'I'IfINICALF-eE
R HANIILING UNI[IOVEXI H IO,gCFM) CONS'' UN'1'AX
Signature of Alr ' ,m/ConfrYYmDam EXHAUST HOOD(W)DUCT) HOUSING bill IGAI'ION PTE
HAYARDOUS MATT IAIS DISCLOSURE
Will Neseprifcarn or futurt tviltil occupant meso rc handle Ila arcusi nwerial HEATING UNIT TO 110.000 BTU)
as dc0oal by Use Cupcnim Municipal Code Chagcr 9.12,and Ne IIea1N and Safry
Gdu,Setiai 25512(a):' I rEA'1'INo GNU'(OVER Latin B'UJ)
p Yes ON. IINIIAPAID
VT 'DON FAN(SINGI,I!RESIU) Dine Heecio
Will Nes.4 coraalnrfus hueWing by hicB ,mea Air Quality
)Man which
emir hnrudnua au cowndrwn nJenrcJ by ole BvyAm Air Quvliry Afenagemrnl BOILER-COMP(3HP OR 100.0008'N)
IO1j
l,:
Dlanrin9 BOILER-wmp lavEH I Wd10U e'ru)
❑Yes, No
IM1avc marl do M1aauNxx lwtaiaH rtyuimlarnfr udr CM1upfr L95 ori IIs CWi- AIR CONDITIONER ISSUANCE DATE
Retia Hcahh&Safety Cru.Sa none 1!1%5.25533 and)SS}f.1 eraknafvd drat if the NEW RESIDENTIAL MI:CH. SQ.Ef
huiWing Nes....unemly face non,11 1 it o my rcgnsebildy m noidy Ilx ocaurwn V
of DIY mquimrnenn which murk mn pror to i,warce or.Cmilkwi,w Ottvpaery.
Owner a aulborner]ugcnt Dam TUTAL: ISSUED B
OFFICE