S 2941 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMH INo
BUILDING DIVISION APPLICATIONIPERMIT pl'UMRING-MECHANICAL
BUILDING PROJECT IDEN"FIFICATION
RUILDINO AUDRI!SS: SANH'ARYN) A PLICA9IO MI "L .DATE
IZM Du wAs DR, 6'Cr11V( U4 9sd'3`
FRS NAME: PHONE: CONTRACTORSNAMIi: LIC No
S, 3 _ �7 j i' NIC coNraol.g
ARCIII'IFCA/ GINEIR: LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Pald by Applicant(Initial) BLDG ELECT PLUMB
MI CH
❑ ❑ L(� ❑
I.FCENSED CONTRACIUR'S DECLARATION QTy ELECTRIC PERMIT FEE
I W tihy afhmr Than 1 am icen.ed under ptwisions of Chapter 9 ocen omerwing JOB DESCRIPTION
O�Z with Smion 7g0pd D,,kion?of the Haslnessend laolf—r.,Coll amAnry lirenw;is RESIDENTIAL
.100 PERMIT ISSUANCE
FW Li,Ose Cls vrd dicer ❑NFUWh ❑KITCIIIiN REMODEL
NQV �emc Clio Cm Nxt APPIJANCIS-RF'-SIDEYHAL ❑ADDRION ❑PLUMBING RE"PB'li
N ARCHITECT'S DF0,NRATION ❑MULTI-U.N`IT ❑STRUCRIRAL
Mmtmd
ZO$�Z IUmy Mennshall he used mpebloc research, MODIFICATION
MODIFICATION
OZ�O I UI"f02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.Fu; litemcd lrn4csimal 401-IgOAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER HWAMPS ❑BATH RE],IODELTEPAIR ❑DIiMOLITION
4 Q I lmmhy edirm IeI I am atemM from the C.Ornclnr'.v License Law for the
x 3 a U folkrwing rewm.LSn'Icn]Bl 15.Business mW Pmtosions Code-Any city or connnY SIGNS INLECTRICAL ❑OTHER
which rtymrts a p,mT m amdmm,alter,imptrna demolish,or repair nay Nmnure
04 pnor ermana,r to isalso myubn No applicant fa such permit in fit,a srgmdsdinment SPECIALCIRCUTTAHSC.
than be is I wanmdla,mon nodal pro,,ii sor The Ctmman,rs License Few(Ch,pmr9
OOBandeercing with Sntioo 700111 of Do
daiuClm�y aDoi Business
necs aul Prufsiunx Coca) TFMPMEDiR OR
POpE 1NST
COMMERCIA1,
o t h.i. n lml he W,fvlhu all ❑NEWBLUGIAUIX
f10N ODEMOLDHON
ec,im)13lSh)my&Wctfaa twhct% eapownt(oncivilenal,yM POWER DEVIC ❑TENANT ❑IFOODSERVI
CIi
Ila nxxe ohm live huproper iliac y mr,l.
IMPROVEMENT
Q I]hasownerk.the proper,areclamyediphryma with wages anthcirwk cormpeusinin. SWIMMING POOL,ELECTRIC
C � will gabuanons oa,M1che Comierue,mendosluLa.do famle,1,1 anowrolncs El OTHER
LL�5 and Irofe[.b Code:The Conlmeln Bans.law-nes nut apply to if owner oK OlJ1LEf5-SW'RCHLS-R%TURF_S
pmpcny wpm builds oro,c ova,oah ,and who docs aah mo,himself m though
his own owewoecc haddi g that ouch itnpnrvecad w am not intended nr ufkrcd fa NEW RISIDI"NfIAL F.LECIIt SQ Irl'.
sale.E,lmwevxr,the Wilding or intpmve�nt is wW wiWin ono,year ufcumpinimu.the SQ.IT.RWRAREA S/SQ.IT.
ossracry will base the unto of proving thin he did not huild oT imMov,Fir pur-
p"'4vle.)
L I,as ioo of the prnpen%nm esclusisely cunmsting witf licensed«soodo,n,to TOTAL:
cnnorod them)*I(Sit.low.Business urd profession.Ctde:7 The Contractor's U.
Mn
loan,inwdo,,,a.pplyma
mowrofpn,perraprt
y wNo buildsnrnast on,ard QTY. PLUMBING PERMIT FEE ^1�1
ohcaumctx for pmjnu with.cattations)Iicenssvl petauvg In the Cane,
Lir m Law. PERMIT ISSUANCE
❑lam ca uMv Sn. .Bkl'Cfa Nis eserine
AL'TF.R-TRAIN&VENT'-WATER(IA) 'AluA O
to Dae U
WO KERS COMPf onto,ors UINC e Ache ION F BACK RAW PROTECT'.DEVICE
y alOtdi.trier p.mhy of w jury enc of the tollrrwing VArkautiaue:
.a W will for by
on 37mc of C e i to L"N"C '.farther effcma'r Comgm� DRAINS-R.WR.ROOF,AREA.COND. BST(IRIES TYPE CONSfR 6TION
.or,for
M,co for by Scut on l)ql of the IaMx Calc,far IM1e perfunnaen of the 3 O 5y
work fa which duapeinalin iswcd. IIXTURIS-VER'1'RAP S By
—
.or,
ham arra will ode, on wnrAcr's mance 4th,s Irl,for ,huelb ms clor by naaado
MydesCool'de.fm tlelcMmmmex MdtewM fawhicb this penia,i.u+ucA' GAS-I:A.SYSTFSI-f INC.JOITI'LETS O OCC.GROUP AVN
My WnAeLs Cwnpenxaun In.mmm'e nrtio arcl Polity nninhur um:
Canicr: Nrlic)'No.: GAS-FA.SYSTEM-OVER J(EA)
CITIN IICATE OF EXGIPRON FROM WORKERS' I
COMPENSATION INSURANCEGRIA-SIYINDUSTRL WASTE INTERCEPTOR
1
BUILDING DIVISION LEES
(Thin section nadnul WcumpletN ifthrlrerm"t is Fatale hurdreddollan(loint GREASETRAP
a Ins.) IgANCIIIiCK fF.li
I certify that in are perfoomatc.of the work for which this permit is inuN,l hall l SEWER-SANITARY-STORM G.201 FT
not employ any ptrxon in any dimmer rc testatora
as to conc bpm to the Workers'Connote, ENIiHGV ITE
Qz .'tion lawsofcdifumla.Uwe WATER HEATER WNENEI.
TECT)t GRADING R]N
Z Q Applicant
h NOTICE TO APPdCANf:If.atter making this Cenircvte of Esemption,yw shwa WATER SYSTEM/TREATING to FINE
h ore auNI-1 no the Wur1.Ys Compemanxt pro—ion of the[elror Cala,Yom insist
fomhwato compry with with pmvosvn or his pennitslull M Oexmed rerNeaL WATER SERVICE
aQ M
CONSTRUCTION LENDING AGISNCS' NEWRGIDPNTAh RSSB. SQ,FT. PAID
U O Iherebyulrnn lhatthere isa unwmeGoo Lording agemy trona,pc,fonnan,edr f)TRecefit Y
de sea\or which this permit is issued(Sc,3(M.Co,C.)
D.s Ul ode,'x Nan. TOTAL.:
ICWn's Addncws T( `
1}}L... I ear,,y Ilia,I have read This application arse dee tet the those i axam ion Is BUILUWG L
L ria) earn,.I agree it)comply with all my and etmmy ordinances and state low.rAntingm QTY. MHCHANICALPERMI'P FEF.
u Z huilJing cunwauon.ural ertby.udcrim mptemtnaaivn rat thLa city to rnmr upon due SEISMIC FEIN
eWvo-mernmed Pmpeny for inHrccvion purpri PER.M11 ISSUANCE _
(We)'re.n.neve,indemnify arra to harmless,e City of Cup,ld.agnea, ELECTRIC
limbilitw.,jadgnrcros,ensu and exon,wtich may E maty wmymecme"Ilnd said C ly ALTIR OR ADD TO MECH.
in nteque cal of the gaming of Nis pc rel. PLUMBING RNE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-VOINI' AIR HANDLING UNIT 00 IILIM)CFNE
SOURCE R' 1TIONS. MECHANICAL.Rl:
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
Sign of IiemW aivr.chc P Doc PXI IAUSf HOOD(Wffo HOUSING MITIGATION FEE
IIAZARl) AIATERIAI S DISCLOSURE
the npplicantmfutum Wilding oecvpuntumcahvWlc e,aw,us nmtoid HEATINGUNI'T(f0100,g0 NYU)
by,he CuPcnim Munkipd Coo Charter 9.12,and ria:health and Safety
Code.Section 25592(.)? HEATING UNIT(OVER 110.000 B'M
❑1'n r-1 No
i
VFNfILA'fION FAN(SINGLE RESID) PAID
Will are aWbo mt a future Wilding aetpam arc ey lipownt nr dmicca which Date Rmei a Y
omit Iwudous a4 caumnato at defined by the BaY Area Air Q,ulity Man.,., BOILER-CONI'GHP OR 100.000 BTU)
IF4ria;' TO L:
❑Yn ON. HOLLER-CQMP(OVER I00.100 RTU)
AIR CONDITIONER
l have nod,hit hmmdtus rmcdels rgryirtmenb under Charycr fi.95 tate Cali- ISSUANCE,IJATIi
Frmu Ifeath&Safety CNc,Sntioca 2SNI5.25511 arra 251U.1 IurtknVartd tom it N, NEW RESIDENTIAL SIINCH. SQ.ET.
huilJing uxcarrtntlYM1mxatcnaut,autllisinyto{ Nlitymdiiifylhoo ii nl 1
m'tWtidal . sat may he nal prixmiasaanmfa Cmifgac (uthorieod agent tet Defe TOTAL ISSI113D BY: �O
OFFICE