99110123 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 01611 /0123
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT In
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL
RUILDENG PROJECT IDEbDIFICATION
tlU1LUIN0 ADUHISS'. _��� ���� �� r SANITARY NO. APPLICATION SUBM�AL UATk
1 _ V
OWNF 1 E: 'F'v/ �1 CON U IC�ity,
'� ` /y �(fI{r�/J'lC//(/n,/. NIC CONIROLM
PCHI'1'IiCIIIiNGINEER: LIC No ADD@P �)AN •^�r D /� �C/r ❑
CONTA�LDY,Jv/`� // PHgvVE�/�� !/ ✓ BUIfDICT PERMITINFOO
3 N �i, ❑ Cousullant Feev Paid by Applicant(Initlel) BLDG ELECT PLUME e ;C
❑ ❑ ❑
LICENSED CONTRACIDR'S DECLARATION ELECTRIC PERMIT FEE
I hereby alfam that led Ikemed mdm pramai,m a<ChnNr 9(ennnnercine Q JOB DESCRIPTION
WOO with Section'/(.)O)of Division 3 of to Busines a ad Pro 'wu tde.udm license i. RESIDENTIAL
FOO -n full force vmkeR ' MRISSUANC�.
--� ❑SFDN1 ❑KITCHEN REMODEL
aUt-u Licrnsc Cl , IJc♦ AP IANCES-RESIDENTIAL ADDITION [I PLUMPING RE-PIPE
md L Ume Commetar
A III'fECTS DI!CI T PANEL ❑MULTI-UNIT ❑STRUCNRAI,
OZyZ I urdcauarrk myplana shall be used es'Nic records MODIFICATION
UP 11U MPS C]INTERIOR ❑CHIMNEYREPAIR
[-�2F'w Lidcrwak Profeeaxrul 2(U-I"AM IMPROVEMENT [:]SWIMMINGPOOTS
x(44} OWNER-0UILDF.H DECLARATION OVER HIO(IAK1 ❑BATH RE.MODEUREPAIR ❑DEMOLITION
y C W Q I herehy afiiml thin I ant escmry(talo the Cmnmelm,Lieense Law roc the
U rnnnwiny rwu,a fStactort 903J s.Business and 1'mrodune Cale:Any say naounrY SIGNS ELECTRICA ❑
which imitates a .it in tomaraCl ehe impm.C,JCrtdiah,M repvr any samemon E Ue Wk•Ci<
F u'O pr nt he
sk,nedJ deo ,1.flea lleapplkanl fie such parwl Li logo luwemrnl SPECIAL CIRCUITINLS
oral M1c is lianscd purvunl rn Ile po.isiwu nolle Cwarsrah I.ittmc I�w lCTnper,9
III C, (rosy a.,with Scl'xn9(W)uf Division Softhe Business aN Nofewides Cordels TEMP.METER OR POLE IN
a q a u Ill.,he i,,exunpl Therefrom and me basis f r the alleged ecminirm.Any vimariun of N BLDG/ADDRION ❑DEMOLITION
LLXl 4• Senlnn 9(131,3 by any e,fc'um fix a pemrit s.bjrels the vpplievnl it,.civil penally of POWER DEVICES AfFT ❑FOOD SP,RVICH
F.Z,}
not macthan five humbled!Jollms($Y"). JMPROVEMFls'f
SR 0I.unwrcrnf the pmpeny.ex my emplMm with wagessstheirsok mmpensatiaa, SWIMMING POOL ELECTRIC 1�-/a`,
E E.� will da de,winand she e uMd
rueum is n,l inte ,roRerad fm M
stile(Sec.TU ,Business THS
RW and Profusions Code:The Cmadrea ,license Lew docs nm apply to an careD
r of OUTLETS
o
4'3 aspeny who tra'Jds or improves thnrea4 nal who Jou such work himself,r through
his own ma,do,ces,pmvitkd that such Impmvenents are no,Inge dend or olf.ml rill NEW RPSIDEN'f.AI I'l DC'fR SQ IN
safe,If.h,I,.,, heW.d'mgori on,meemcnt iawdd withirione, arni nunplainn,the SQ.FT I4.00R AREA ESQ.14.
xf holder will lure the burtleo of pmat thm he did rrol build nor illation,for Par-
0
ar-
I,u awmr of Jon pfc a y,em exclusively convecting with llttmrd oenvocmn to TOTAL
vnslrucl to felt(Ses.7W.Busimess erd 14ofcssisns ColledIleConvxutr'xLi-
enseLecathwsnmapplytonnowmrofpnmenywMbuilrL,xini ruvesthaeon.nM QTY. PLUMBINGPERMIT FE
who c tx for such pmjm s with a coniroutoos)licensed punuvnnn me Contractor s
Us—law' PERMIT ISSUANCE
E]1 em eserryn lower Sec. B&P C far this..
TER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date /�
0
WORKERS COMPENSATION DELLA RATION BAC FLOW PROTECT DEVICE /(LD
1 hinfirm
ereby naknae o
r penally of perjury f the tol6wi ng dedaramovs: V)
F1IWve coil will mei,tninaCervficate of Connem mxlf-insam fur Wbrkn's Compcn- DRAINS FLOOR,POOH AREA,COND. STORIES TYPE CONSTRUCTION
.,lion,as pmvidcd for by Smith 3700 of the labor Code,f«doe pmfamanee of Ile
for whish this Penni,is isll FlXTURFS RTRAP
I has,end will me ddid.Worker's Comperwrion Instwtx,,v requvni by Section
or late Cade,Ion the nerksmance of the work
yfor
ywhich
tm,,pemat is iraued GAS-EASY 'M-I INC.40UTLE`LS OCC GROUP y(� AP14
My Wml�/�Coni uhayl9pa�oauHulll,,Nn Ws^� " 930 OAS-PA.SYSTES )VER4NA) 56 r /
cameo: fJtYI. /11-77 n
CERTIFICATE OP EXINITION IROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRI.W INTERCEPTOR
BUILDING DWISION FEES
(This section need nor he completed! eman is f«wu humored dollars(SIW) GRFASETRAP
or I..) PLANCHECK FEE
Iceody thin in the larfumwmcut the work Lrwhrth In,perm I.O,d roll l shall SEWER-SANITARY-STOR ,]IMI IT
na employ:my prawnmanner
to any so as bmnmwm
a b . bject the Workers Cmopcn- ENERGY FEE
Zz xalioa Laws of C.1h onew Date WATER NATER WNENT2LE
C) Applicator GRADING FEE
(n NOTICE:TO APPLICANT:If,after making this Cenif to M Exc r cion,yon should WATER SYSfEAVDIFATING
.�' become n Ibjttn to die Workers Compensation provisions of Be later Cole,you maul SOILS FEE
fonhwlth cartily web such provisions m Thio pmr l shall he deemed revoked. WATLR SERVICE
� z CONSISUCTION UINDINGAGENCY NEW RESIDEMB
NTIALPL . SQ.
PAID
1 bncbyeffirenWl Oereuam,slrucriun lemlinp agency fmlM perfomua,of ly RSeipl
_
U OIh work for which Lids Permit is oundl(See.3(N7,Civ.C.)
U IcMcr's Nem. rTOT
U Trader',Address TOTAL: 1
T /�-�s\ I
Q. I o,m y ne,1 have rend th!s applemar nod,ate Thal the aWv.imfomamiam F `Ilb ILDING FEE
rp craem...gree m eco ly wish el l dly rndenanty ordinances and ,are laws minlingm QTY. MECHANICAL PERMIT NE
U Z Wilding svnatmctkn nal hereby auth,risc rtpc,muin'cs n(Ihi,city to ever upon Ile �SEIS
above mentioned pral for impection purl•res. A1IT ISSUANCE: I ELECTRIC FEE
(Wel agrtt to,se,isdeamify std kap hermles,the City of Culacnion egainu
liabilities,j,d,—,u,antsmd eapenxu which mayin any way aceme.yine,id City ALTER OR ADD TO MECH.
inn quetwe ofthe gram....otth "tar, Pk. MBING FEE
APPLICANT UNDERSTANDS AND WIC,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IL(gO CITU - t
SOURCE REGULATIONS. MFCHAMCAI, E
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sigrmmre,f A,meenUContmcur Ulm P.XI IAUST,1000(WNUCT)
HAZARDOUS MATERIAI S DISCLOSURE HOUSING MITGATION FEE
WIIIihnapplicant nr rotor,Wildlngcce.,al nor.or hmWle hmarMvr material IIATING UNIT(TO I A)':
)' BTU)
as defined by the Capenima Municipv.Coen.Charter 9.12,sud the Health and Safety
Code.Section 35533(.)? ,/ HIAHNG UNIT(OVER 100,"BTU)
E3 Yea No PAID
vFMItAT10N FAN(SINGLE RESID) Due ReceiN M
Will rd theto, o von or from Wilding acuupa]t u,ea Air nt m JMare which BOILER-COMP(3111'OR IM,gp BTU)
mil M1wurduu,err caalaminanta as slnfired by ahc Ilvy Arra Air(7uvlity Mvnugcancnt T AL
Dtstnn9
Yes BOTER-COMP(OVER IW."BTU)
❑ ,\�'j\No
I Wvc read de hIxaNeu,thamak rtgairemdies tmM Chapel 695 of the Cull- AIR CONDITIONER
ISSUANCIE DATE
form.li,10& ety Care Sol.,2551".25533 ark 2550 k macervand mat irthe NEW RESIDENTIAL MECH. SQ.PT. /I/�
Wlldin.Ands ly have atownh that 11 is Illy Teeomsibilily loami ytheowsvpwl r/ //y �fY/y'
of ale esu can Wmct prior ro iswmxc ofe Cenifeae f
sed I TOTAL ISSUED BY:
OFFICE