31164 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO 31164
BUILDING DIVISION APPLICAT1ON/PERMIT PLUMBING-MECHANICAL -
BUILDING PROJECT IDES INFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL PATI
ER' N PIIONG OR' ME: LIC NO: I J I� •!
cg CAM Ltil"11I
NIC CONTROL
RCHITECT/ENGIN
LIC NO: AD RES. Li
CONTACT. PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MECIy.
46 4r7 IP713' El ❑ IDB�T1
LIC'EN'SEDCONIRACTOR;S DECLARATION QTY ELECTRIC PERMIT FEF.
I hclehy affiml Ihm I all lik",i 1 adv pmvidols of Chuen o(mennendng' JOB DESCRIPTION
W�µ10Z vi,hSalim]IW)ot Divuim3 ofdm Budnevsaal Pn.fies,an.0 for my liceme,is
F W D in full fwcc usun�yy 3�s4(� ��,,//��. PERMIT ISSUANCE - RR SIF DDENTIA1-
eFt UZE License C1. �r C IJc.«_}�✓`cI ❑SFDWI, ❑KITCHEN REMODEL
NQS Duta Conlrnctor^ APPLIANCES-RESIDI]JTIAL ❑ADDITION ❑PLUMBING RE-PIPE
II--��
>y ARCHITECTS DECLARATON ❑MULTI-UNFF ❑STRUCTURAL
Z8! Z I umkrsd m J
umy preWl be uerl m Public record. PANELS
:11 UP'ID 301 AM15 MODIFICATION
�4 E'ua1 t.rcrosd l4ufasiotW DINTERIOR ❑CHIMNEY REPAIR
WCf OWNER-BUILDER DECLARATION 301-1010AMPS IMPROVEMENT
y W�Q 1 hereby eTml IM1aI 1 em emmµfrom the CnnwcuN's Linse
mlaw fm the OVER IIXIEAMPS ❑BATHREh10DP1lREPAIR El DEMOLITION
x 3 a V foliowin{moron.(.Sermon]11315.Business and ItuRssion.Cde:Any city or emmy SIGNS ELECTRICAL ❑OTHER
ul LL O wM1ich repairers.Pe+mil 0 consumer.eller,mmprvrc,demolish orm se it any vruc.
prim to itsisswnce.Asn errant Lha applicsim for such pere tla fide.d{md malement
vW SPECIAL CIRCUITMISC.
vWW11y thrteuli.9 rd SeGis,7").mdsision 3 the ComoseBusi sussor ru icProf.i CCoper9
CpO (camrrcrcing wish Sectim0000)of dvwm3ofthe Bmintessurd Pmfeviom Code)or TEh1P.SfETPR OR POLF.INSf. COMMERCIAL
a
FM
e tY
,d he is scrops therefrom surd be,Ist for the dleged eaemptian.Any viNmion of ❑NEW BLDGIADDTUON ❑DEMOI.TTLON
^„y Suamm?0II5 by any epplmcent Er.Prrmit whjccu th epplicmnn ecivil?rarity of POWER DEVICES TENANT ❑FOODSERVICE
�Zy not rote than five hopdd Jallars($500).
6 Q I,mowmr of rte praµrY�mmY msploycs with w.{nuthcir rokc IMPROVEMENT
ongBusi iaq SWIMMING POOL fir
will dodewmk,Cmot oir, N,C.rimswlimuded m'vv fmorupt side ,,in Business ❑OTHER
13 lord Rofessiuns Cak:The ,.drm e Licerce Inw Ales v rk o es lf nw.er of OIJII.I!TS-SW ITCILEti-FIXTURES
Nslormierry.who builds or imgovm Jeanne surds Jon.loch work himself mitered
Ww{b
Ns awn empbyee,provided thatran sroo imµoveold w art on imm of,m oBcrt l fa NEW RESIDENTIAL ELECTR F7.
safe own,LmiI,mr will
buidingmlen or proem ithathe ithin urycmorcomPlel ion,the - SV FF.Fl,(IOR AREA $ISQ.FT.
a.f.Ider will hove the buNrn oTpravin{tha he did not huilJorilnpmrc for pun- P A ' D
pie of rated.
❑ I m w use
tort rc propmy,.m esclunively cnmrect o w.,dr i)Thv Conmtroctax to TOTAL
trod La Lhaµoyer(Sea,o sun Business oad Py sh. ns Cider)Tho Co dirmenr's Li- rs y 1
nY Lew desrsuelb ytnen nwllm oomemorywremotIdsormmprovudcmm,.nd QTY. PLUMBING PERMIT FEE A READ
wkmdram fm such psojau wth.caeremor(s)Ikmnscdµvsuam to tM1c Coolydrol.
(] LLkense Lew. PERMIT ISSUANCE CITY Ue GUrtHTINU
mcxcmµuadmSa: ,tl&PC GNthiz neaum
Ower Dae ALITR-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPPA.S ATION DECLARATION BACK FLOW PROTECT.DEVICE
1 lent of inn under penalty of perjury ole of the following Jaleretions:
❑Irose our ill meimema•CeNCcmeofCmscmto self-inane for Wmkef.Cmnprn- DRAINS-FLUOR,ROOF AREA.COND.
.It.,a prosidd for by Salmon 3701 of the Iuha Cade,for thepserfmmerce of do STORIES TYPE CONSTRUCTION
Wyort far which IN.permit is iewcd. FIXTURES-PER TRAP
X.of Iadn Cak.forrdieµrfwmencc a de,wml,[in which dims pttmbYs imed. GAS-EA.SYSTEXI-I IN4 OUTLETS
My Wort xCo nation Ewraa tank tad Policyrup�.Tjie:3 1q!1Q J_ ' OAS-BA.SYSTEM-0VFR 4(G) OCCGROUP AEN
Cause Policy No.:, 9 1 �1
CERDFTCATEO (EMITION FROM WORKERS'
COMPENSATION INSURANCE GRHASV'INDUSTRL WASTE INTERCEPTOR
-I—)) BUILDING DIVISION FEES
(Thls meed
section not M compld ml
piftbe peit is for are huldrd lLJlaa 1$110) GREASETRAP
PIANCHF.CK FEE
Loy w,lpimso the smy mm crof lheamtfmwiljectt io pamil isirs C.IsuMll
aN employ en SEWER-SANITARY--STORM EA.3IX1 FT.
y padre in Nny manner.w fir w Meunn subject to dm Workers Cumpen- ENERGY PEE
Z Alimebustmn of CJiromi..Ddc
Z O AppOceot WATER HEATER W'NEM/F.LECTR GRADING FEE
y NOTICE,TO APPLICANT.ILafter routing this Ccrofit of Eacinumn,you should WATER SYSTEhVFREAHNG
F become suhlal
t.1h,,Woiter's Compr ottiol pboo,t r,of de Iibor Cork,you must SOILS FEE
a fanhwid comply vidsuch provisions w IN,pvmil.hell he deemed revoked. WATER SERVICE
a �
Uz CONSTRUCTION isamnia LENDING AGENCY NEW NESIIIIiNTIALPLMB. SG,FT. PAID
UO kernby erishia Adthert isarn (Sce.3097,lendrings,e{ency for the lcrf«memc of Date RaeiµN
� .. bee wat Tar wnkb rah pemJl h Kama(see.309'],tie.c)
O
U I<Ner's N.e Leader's Adlness TOTAL TOTALps I eenlfY Nor I here nr.J this epplkdian surd sole dol the above infamuliw is BUILDING FEE
h comct.l.grt to ttmlply wish eu city surd roomy mdimrcm em slate Hw.rtldiv{to QTY_ MECHANICAL PERMIT FEE
U .Zr buildingi,mum lrniaa.tadloehymborire rtprgcenmtivcsof INN dly to clnruµmlhe SEISMIC FEE
above-mcmilmm propery for inspect pdpmses�. PERh1IT ISSUANCE
(wa)e{rce W.arc,iNcmnify sued keep h.rmkm fine City of Cupnaivo.{airs FfFCIRIC FEE
luhilitieejd{roems.ecuu eM espenmwhicIt may in my way ecemeugaiml said City ALTERORADDTOMECH.
in cmrcqueru of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT SIR HANDLMG UNIT CrO 10,0(X)CFM)
AT
SOURCE REGULIONS. MECHANICAL FCL+
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCHON TAX
Sigmturt of AppBcanUCanor tm Dem EXHAUST HOOD(WIDUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will de supplicant or future building ucupant tore or lumlle heruNnus msterlel HEATING UNIT TO 101.1X10 BTU)
m e crind by the Cupertino Municipal Cock.Clutp er 9.12 and IN,Health surd Safely
Cade,Satiml 25533(.)? HEATING UNIT(OVER 100,01)BTU)
❑Yea Fl No VENTILATION FAN[SINGLE RESID) PAID
Will the affliction or future bwldine acvpant use eglipnea or device Dime RectiµY which BOILER-COMP BHPOR 100.000 BTU
mit hmvJous air cumaminenu as def nlN by the tley Arra Art Quality Menagemenl ( )
DirrKl? TOTAL:
❑Ym nNo BOLLCR-COMP(OVER IOB.JJD BTU)
I have red the bmvdm,mdcrinl n ml vimnar.under CluPtm h.95 of ac Cali- AIR CONDITIONER ISSUANCE DATE
fort Hmlth&Sefely Code,Sstiau 355)5.25533 aad 35534.1 ordsm dd trod if the NEW RESIDENTIAL MECH. SQ.ET.
Willie{doe.rut ancndy bon.lenen4 Jw it is my reyussiMliry to mlify the obbi sm
of BenyuirtmcI.which muN lc met prmorto issuvtcc nfa Cmi Team ld(kap9rcy.
0�,JnYrllareu?IMxdeegrncrsiJdc J� TOTAL ISSUED BY:
OFFICE