S 1491 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ` BUILDING,.ELECTRICAL PE ITNO
BUILDING DIVISION APPLICATIONq'ERN11T PLUMBING-MECHANICAL J 1491
BUILDING PROJECT IDENTIFICATION'
BUILDING AUUKISS., SANITARY No, APPLICATION SUHMITIAI.[)ATE
OWNER'SN -vS PHONE: CON RA 10 ';NAME?: ' LIC NO;ift
ARCIIfI'ECT/FNGINLER: LIC NO: n1 ❑
1,
CONI PHONIL BUILDING PERMIT INFO
❑ Crarp ullant Fccs Paid by Applicant(Initial) BLDG ELECT' 1'h MUCH
1JCHNSED CON'IRACIYIHS DECLARATION QTY ELECTRIC PERMIT FEE ❑
I Iermy afrmt that 1 am Ha mad under pmvisnaas of Chapter 9(cmmrcme mg JOB DFSCRIPTION
0�Z with Satitm]0001 of Di%pami J of Uc Busirteu amllttte.,imn Culc,uWm Ikenneu
W00 Y PERMIT ISSUANCE. RESIDENTIAL:
FW— In fall fmtm arldc I. 41, ❑SFUWL ❑KITCIIEN REMODEL
aVU Liccn.w:f_.ly.. — IJcM APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBINGRE-PIPE
CuMtKI«
FOH ARCHITIECPS D[CL\ ON PANS ❑MOUTI-UNrT ❑STRUCIVRAI,
ZOtiZ I undenlnnd any plane mall he avd u,sable retorts MODIPICAHON
OZND UPIO200AMPS ❑INTERIOR ❑CHMIN17Y REPAIR
E`�F'W IJcem il'mfcuimal 201-1000Ab1PS IMPROVEMENT 0SWIMMING%K)LS
OWNER-BUILDER DECLARATION
C C < m hereby a0inn tam I ecschnpt toxo the Cumrucmr'x License Law for the OVER IfXd AMTS [I BATII R E "AIR UIJ110.I'r
�1 O6 U ficHouinp..(Section]UJ I.S.B.mrs,,and professions Cole:Any city«county SIGNS ITECII(ICAL CR
Int LLO Ha which"ti re.a perm.,w nfnumm,ulmq mpp ,demnlidt,m rqua any ewmwe
Ir�yg Priplor,iaaommc,also uyuivy Ea.,nicam t«,such permit to liles,,,dvbLLoem SPECIAL CIRCUITAUSC.
f�>. Out ne is licensed Iwsuant to the,provisions of the Contractor c IJceree law(Clm,tcr 9
CrOMMERCIAL
WyCpO Iemmrcnciog with Satia700))of fiAmen hof the Rotor—at l'rofn,iana Cadelm TEMP.METER OR VOID:INST.
d a e C that he i.eemnq II crfnml ami Je ho.i.for Ile alleged extnnpmxl.Any vlolmina of ❑NEW HLDGIADDIION [D DEMOLI'NON
�H Satan 7031.5 by my applicant for. .it.amW,,tcupplamcm loo civil penally of POWER DEVICES [DTFNANI ❑FOOD SERVICE
FZ
m marc Jun r huntteJ Jnllatx(SSflff.>• OTUHR Eh1FNf
< wi ban he or,. llcpe,mucOor my mnpluyecs with wogc So lak(See
mrmpuoaminn, SWIMMING IYIOI.F.LIiCBIC
�(=.0 will tlutbew«t.and,T1,C is nxintencope, olfemO,brat ,A,In
❑OTIIER
Ill_
and PrM.1ar,h Cas:The—threads L.kense law do s m a1TIY to If owvcr of OUfLf:I'S-SWITCHES-%XTUKFS
Ila— pisses whooyces,aimpede,tcmm�,opr wtu Jasmn tina ued or ornhmugn
his own DmpinyeeS pmvlHvl that such ipe nrvorcnw um not in¢ntkJ or ntlirtd flax NEW RESIDENT IAL ELIEC!'R SQ Fl:
safe.If.Nildcsa,ll huiWinguEmprovcrrcmis sdJwitninr bill i.M,,le fla, 1�Q.FT.11.(�R AREA 3/SO.lef.
ertuillYr will haat the hrdcn of proving that be,did rut Will or iminr,cf«pur- P A ' �1
phm of enln.l. In
L as tmner of Ik pnycny.om exdmivdY arwating with IiumcJ cantrunaxx to TA L:
Nn,IrtKn tc pmpt(kc.]DLI.Buritex,W ITores,ixt.Cak:lTle Cautrona(a D- APR 8 AAM
rc low dues trx apply to hln owrw+ofpntpcny war M1uikkwimpmvca then+rn,IIrIJ QTY. PI,UMBINO PERMIT IEE J� �
wm
hocunttn furwch projWts with ralicensed acoralge) purstwuth
nn e Gmpoctors + A
Lnccn.,c Lvw. PERMIT ISSUANCE
01 am spent under See .It&PCtar this mum Ur ("(i
AhTIiR-DRAIN&VENT-W'AIHN(EAt VA.O-acc Do
WORKPIR'SCONIVENSATION DECLARATION HACK PLOW PROTEGE[)EVDEVICElfimil
I Iemby ut mer penaltyul'perjuarvry orm of Ilhu fulbwiug Mdumlione:
❑ Ihavc ardwill rruinuineCmifxamufCam.rntw.¢IGiruurt lM Wuter',Cauhpcm DRAINS-FLOOR.ROORARG.COND. STORIES TYPECONSTRUCUON
Leona,,u pmvidhi ffemi Scotian B]Ip of the labor Cuk,f«ale perrtxtnntxs d the
wink have
which lois mormiis iamcd. f FIM'ILHPS-%iR TRAP
El I 370Nly LI�IC�nmwnate eft C ,40a,,Lm ironce.1—hi 1,rtquiml by Section
e Mth warL.Im wnicn lois permit is issuM. GAS-EA.SYSITAf-I INC.i OlI1lE1'S OCC.GROUP API:
Z ion ,Jy No tqlyyrr��ly�t
Cmden )/'^ I lies Nnrt� �y-/ GAS-HA.SYS'IEW-OVER d(EA)
CERTIFICATE:OI'PXISIPI'[ON FROM WORKERS'
COMP119SATION INSURANCE GREASEaNUUNTRL WASTE.INU RCEITOR
(Ihisr«nire
solo Wnbe,
al n ho pUifthesola is fnrac hmulnd dollars($1(y)) BUILDING DIVISION EELS
or tact GRGsIi TRAP %ANCHECK FPJi - --
IcedifY Cheat in tcfer(tnmantta fife work for which this prmdn isisacd.Ishall SEWHR-SANITARY-STORM FA.M)FE
nx employ any p )n in any manner at m to become subject to lac Worker,'ComWrn- ENERGY IEE
zaZ sad-dada of Californu.Date WATER HEATER WNFYDIiLEC1'R
0 AWgdican t GRADING FEE
p)
NOTICE TO APPLICANT.11,after making thio Cenificatc of Eamnaptam,you hi WATER SYS-D2Wl BEATING
(•^
h,,—,ti w the Worker's Cunpcneatinn Pnovisions ofthe WNn C,sm,Yam mwt SOU-S IHEIE
`. forthwith comply with ufm W rosipanx of Ni,permit shall IN decned tcwAad, WATER SERVICE
4
CONS'IRUCI'ION LHNDINC AGENCY NEW KPSIDINfIAI.PhMN. SUIT. PAIDV Q Ihcrcby a0irm tlwllMreuvt�swctiun krWing ugcrxy t'or the ltedhrmarra of Dve Jivv
LL
the w«t fa which thi,Irnnin is iswN(Sec.J(19],Civ.C.)
Lendcr'e Name IOML:
IU Lcnde'sAddress 'f(HAL'.
1}" y I ttbay then I Mvc poJ this"slicanitm mJ,Lac Jut tc sluve adismeton is BUILDING FEE
to tnrrm,lagan to nxnply with all city and awmy«dioarces mW sure law,relmng to QTY. MECHANICAL PERMIT FEE
U Z huilJln,,-arecllou, it hereby milon¢reprwnwfivcr of this city E,m,,apulne SIiISMIC FEE
Mmn
uve- ui«Icd poppet",Re in,Wcctien parsecs. PERNU T ISSUANCE
(We)emes,mem,indemnify ofd hmG
keep andi the lyat Cupcnirm.gaunt I]SLTRIC FEE
Iicaliuo,judgnums,coagp
and exnteean
s which may in y way aa
cmeegauheI id City ALTER OR ADD TO MSCI I.
I. ansamerc<of are emminp of fids perran. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH PO
ALL NON- I I AIR HANDLING UNR(TO ID.(Mp CPM)
OURCE REGULATIONS. MECHANIC FEI
AIR HANDLING UNIT(OVER I0,00(i CFM) CONSTRUCTION X
Gomm ofgpplicentConttanm Il EXHAUST HOOD(W4)UCE, IOUSINGMITIGAT ,19:1]
HAZARDOUS MA'IH,KI S DISCLOSURE
Will tc alTlkma of(uttuc WllJiog acapwlstnm anaodlc haat""v",a treeriel HEATING UNLTfIO 101000 BTU)
as defined by rte Cupmiru Municipal Code,Clmper 9.12,and me Heehh mrd Safety
Coca.tiu9ian 25514(a)7 1IEAI'INC,UNI I(OVER I IXforp I BTU)
Yea C1No V ApDWATION PAN(SINGLE RESIDE PAID
Dart Racip If
WJI e n,h,am or la om tuikling acurn
lm Ise c,aipnrem err S icca which
t
cant hvankus air aantwrumm,as defiad by the Bay Area Air Qaality hfaoagma'nt HOILHK-COMP(JHP OR ItMIIgq BTU)
DiTOTAL:
❑Yes 0 N HOIIJiH-COMP(OVEH I(u.(10011N)
I hose rcW me haauJws mutmal requirement,anal Chatterer 6.95 M the Cali- AIR CONDITIONER ISSUANCE DATE
funis Ilwhh&Sad'cry Calc.Smitne 255(15.2553)anal 255: .T mxkraand out if the NEW HCSIDF.NOAL MECIL SQ.14.
ami Wing ak- -fund,nava.wmnt.anal it is my m,puninigty mtwtify tlmucco"in
M the"mmat which muss be,mcl Poo,to mamrce oft,Cmilkwe M ocearmcy.
Owner ur wtnoriml ngant Ihhm T1 rAL: ISSUE[)BV
OFFICE