S 0132 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0132
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: G/ )e-+ SANITARY NO. AP`PPPLL'91CATION SUBMITTAL HATE
OWNER' ME V CONTRACTOR S NAME: OH LIC NO: `'
Qv B~v EL/ G- S L( NIC CONTROL
I•ARCHI =E.NGINEER: EJC NO: ADDRESS: ❑
CtJNI'ACC PHONE I BUILDING PERMIT INFO
❑ CDavaltant Fm Paid by Applicant(Initial) nJtc PLUWK MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ¢y
1 aneby affirm man I am Iitxnxal cotter pmv'niom of cNIT 9(commencing JOB DESCRIPTION
with Stttbn]Ilfgl oflNvin'wnlof the Buaircu ell l'ndcc,iat,Cdc,uml my Grenc la R 91F DENT( IAL<
W O p PERMIT ISSUANCE
1-py- in full face amJ elect. G7 (,rOB OSFDWL ❑uMHINREMODEL.
Lucmc Cla lice APPIIANCES-RESIDENTIAL ElADDIIION OPLUMBINGR6PIPE
yZa Pan, F. Cnmrevam
F<y ARCHITECT'S DECLARATION PANELS EIMOLTI-UNIT ❑STRUCfURAI.
1 udm.untl my Plans shall be u:N a•Public rmxJc A10DIEICAI ION
OZ=1�u UP TO 200 AMPS ❑INTERIOR CCHIMNEYRENNR
Q��J I.ic.cd Pmfcicsimal ?BI�Ig1U AMPS 1 ROVEMFM C]SWIMMING PCOUS
OWNER-BUILDER DECLARATION OVER HMMIAMPS RENODEI/REPAIR IDEMOLRION
I bemby effinm tat 1 um eaerp fmm Be,CmItan r.Linnen Law for tx
tol0w'mg reason.(Section]0113,Nusina'a until Profeaions Code:Any city a country SIGNS ELECTRICAL OTHER
which raryimw a permit m eonurov,ultra,Impnve,demolish,nr m,a r any uremm
g1.
prior to iu ixsuvice,el.omquires the applicamfor xuch permit to flea signer xtmement SPECIAL.CIRCUU]MISC.
f�SN.. that he in licemvW parwmt tour poot.ofdv Cnntncmr,ficmr<Law(Capt-9
IW OC (nrmnwmcing witM1 Secfvm]0gp of Divia:m9oftx Nusimma,ail lhafersioms CoJcpr 'TEMP METER OR POLE INST. COMMERCIAL:
d tat x ix aenma tnvefmm and the aai,for to alleged cxcrpioo Any violation of ❑NEW BIDGIADDITION 0 DEMOLITION
�+w Scetion7031S by troy.pplRzntfa.Permit Tuned,tx applicant moa civil Tmm,IIY of PIWP,R DEVICES []TENANT 0F(10D SERVICE:
rare Ian five modmt dollen(FALL).
F.ZY
not con IMPROVEMENT
f=O lLunwner of the ttmpmy cot my emphrya,whM1 wage arlW'v cote cmnpenmtion. SWIMMING IY>nI,E1.ELT C
{�]F- will doer wet,Cale:sheC ixnMimmWcda cote ifs tale,1,1 an Br of ❑OTHER
"g ural Pmfeviav Carte:The COmrctarx Liana law Jae,my apply tO an namcr of OUTLETS-SWRCHF'_S-F
d 3- pmprny whh Wild-or imp-ce,txmm,arra who docs,uch wnA hhn,elf On through
his own emphryem,provided that xuch improvements am rax Immrided or oReml for NEW RISIDENIIAL ELE( 14.
ante, hdw'ev<r.the Wildingaimpeovemrnt in,Nd wiNin ae yam of canpMion.mx SQ.II',ILOORAREA VSQ,IfT.
owner-W inter will have the dude.M proving tat be,dW not Wild to Improve fa pur-
pmcof owner act Pouf g with liemud aa..... to TOT
crnwact the project(Sec.o am,Bri,wree of mW my wincionx tis or Tx Conrerec x cerr,c cPNY to am ownr of pmnopenywW Wud.nrimprovestxmrm..w QTY. PLUMBING PER MR FEE
whh umtnem,fin ash Imiea,with u contrumiMs)IicenseJ punuum hen the CammetN.
Iaceme Law PERMITISSUANCE
01 aur e,cecT Io Sc. .R&P C For ads rmsm
ALTER-DRAIN&VENT-WATER(LSA) VALOADON
Darter Dmc dAr�
WORKERS COMPENSATION DECLARATION BACK II.OW PROMCT DEVICE 7Q O
I xmby Nem antler penalty or perjury ane of the rolMwing dcclu.dau
O lhavemW will mamtam ecoonae ofConum to.¢IFinwm nerwumkere Cotten DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
boon,v,p covidct for by Section 3700 of rhe Latin Craft,for the I effo rmoct,of too
.co/tfv which this permit i.nearer. FIXT'URIS-PER TRAP
VK Loo and will nuintum Workers coryrnavtion Inxuramma,as requimL by Section
37M ofthe lade CNe,fa the perfomuwc of ter work for wNchmhm,penmen n usual. GAS-EA.SYSIEM-I INC.4 OUG LEIS OCC.GROUP APN
F1Y Worla�`S portion In— er PONT' _mmtfn rye o f�f
Cmricr.?v'f� / A'I- No.:(j e5�O�` GAS-EA.SYSTEM VER 4(FA)
C HT PICATIi
OF
E%IJNPfIUN IItfIM WOHKERs'
COMPENSATION INSURANCE GREASFANDUSTRI,WASTE INIiRCEPD)R
BUILDING DIVISION LEES
(This chetah raced nttxmmlRmer lftxpmnit isfaamehuncrerdollaa(S100) GREASETRAP
or Ica.) NANO HECK FEE
I cenlfymat in rhepmfommaacofmcwork for which IN,permit iz ixsad.l shall SEWER-SANITARY-STORM F.A.2W FT
na employ any N.in any manner,a a to lre..'uhjx't m the Waters'C.'.- E4ERCY ETili
o z anent law.of Califon a Dene R'ATI7R I I A CR W'NINVEL EC K
Z O ApGRADING F
mlkont
N NOTICE.TO APPLJCA NT:If,enu making IN,Cenificam of E,e.ynrn,yen slumid WATER SYSTEh l HEATING
F ^' bece.subject to time WMrrh Campensmion -ci,m,M the tenor Citric,you must S(RI S ME
WRrthwith comply will each pmvisiona or this perdm shat]be dmrcd mocked, WATER SERVICE
0. z CONSTRUCTION LINOING AGENCY NEW RF_SIDINI'[Al-PLMB. SQ,ET PAID
u Z Dam Rwcipe
U O I Mr which IN then onit i ks.coaune.Y)U.Cins.ge^cr(ne is lerfmmwmec of
the work for which ten,Tnmit i.kuueJ(see.JOY[],civ.C.)
QUDOTAL:lante ,Arn Name ' TOTAL:
r LT7 12Mcrx Addrux HUILDING FITS
1 mnify that I Nov,read thea application amend core that mfr ed,ve infammdmt i.
Tai) correct.I epee to comply with all city mW county adinanem mill ave law,relvingto QTY, MECHANICAL PERMIT FEF,
U Z nmiding mrwrvniun, it lm,oNymFhri,o mFcvmmnv,<onhi,city mcnwrupon rhe SEISMIC FEE
aWvc-mrmioned pmpmty for in emima panacea. PERMIT ISSUANCE
(We)epee to vac.inlemnmfy mmd keep barrat Ne City ot Cuperiru a
vginV EI.ECIRIC TEE
ImNIitla,)udgmcm,.c,olud c,,nscs whi,hnny inany way occas up men seal City ALTER OR ADD TO MECH.
nxslanm of cox granting of this pmmiL PLUMBING IIiE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR IIANDLING UNIT(TO I0A000CEM)
SOURCE REG UI ONS MECHANICAL N T
.�•�- ' �,�/+ 6r7 ALR HANDLING UNIT(OVER I0,000 CFM) CONSI'RIILTI(IN TAX
Signmum ofA ent/COmrena IJT Umfc�� EXHAUST 1{(pp(µgDUCT) HOUSING M111T1 TION FTIS
I LA%ARDOUS MATERIALS DISCLOSURE
Wi11Jc.pplic.,or fumm Wildingmccupunt wile or handle hm:Wous mamdal HL?ATING UNIT(TO I W.000 BTU)
u defined by mhc Cuperim M.nicipnl Code,(Tattler 9.12,and tx Hmlth and Safct,
CMc,Section 25532(e)] HEATING UNIT(OVER 100.01(0 BN)
0 No
0
Ycs VENIIAIION PAN SINGLERISID) PAID Dmc
W II tx.pp].or or to.Willing oc,v,am ma,tyuip.em or 4vicv which
crit hvaAua,air cmtemumm,uJafiretl by tx Bay Area A'v QQuliry Maropement BOILER-COMP(3HPOR 100.000BN) /'`' TOTAL:
Dish.,? BOILER-CO
IYo CNo MP IOV ER 11X1,001 BTU) U
I ave coed Bb: memerials ryuhemrmw under Chip 6.95 Nthe Cale AIR CYINOII'IONI'k ISSUANCE DAM
Tania Hcmlth&S.fmy Cde,Sarioeu 25505,25511 mrd 255:0,I muYmtw tat if the NEW RESIDENTIAL MECIL SQ ET
Wilding Cummaly lase a trnNt,town is my rc4nmmhilay to nthfy the Occomt
ofdem{ nv which x pia to weans a.Cernmcete a Ocaryemcy. -
(Tvntto nrirW agent Dem TOTAL ISSUED BY:
OFFICE