B 0464 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI 0 4'6 4
BUILDING PROJECT IDENPIFII'ATTON
BUILDING ADDRRSS'. SANITARY NO. APPLICATION SUBMITTAL DATE
//Q
�OWN R'S NAME: PHONE: CONTRACfOMS NAME:p IC,�O^^ NCONTROI,M
IC ARCHITTC(ENGINEER: PJC NO: ADD SSS R 7(X3 Ej O
CONTACT: PHONE: BUILDING PERMFIINFO
❑ Consultant Fats Paid by Applicant(Initial) BL�DG/ ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I rereny aremt Elm 1 w.Ik��ved ands pn'vi.rian,or ema�+91mm<zing JOB DFSCRIPTION
O0Z win SttSise 7"PaDivi,ion3ofdc eudte�„m Dnfmimu Crag at mylicereei, RESIDENTIAL
�00 / PERMIT ISSUANCE 3
��F� in Bill f«cc anJ Lk ❑SFDWL ❑KITCHEN REMODEI,
1GZU liccme�lica - APPLIANCES-RESIDENTIAL. Q �)ITION [I PLUMPING RE-PIPE
Vl a a Dulc Crnlocl
(_Oh ARCHITECTS DEC IA I'ANIHS ❑muim.uNIT ❑SfRUCNRAL
Z O'�Z. lutakNvtd nlY III"m.,11 be urNuPublic msB MODIFICATION
OZ-� UPT0
Q2(XIAMPS ❑IM'BRIOR ❑CHIA1NEY REPAIR
EF"j Lian.aJ Nofunioml rill-1000AMPS IMPROVEMENT
-t POOLS
OW NER-BUILDER DECLARATION
Q 1 beahy minm met 1 am exempt from be Conuvctor'•Licmw Law for de OVER IOU(AMT'S El BATH REMOUEI/REPAIR DI:NOLITION
K SU ballroom,reunI.(Smim70)15,Budrcx„nd Prnfes,inn,GJc:Any cityor mumY ti1GNS ELECTRICAL ❑f1fIlER
3 LLFya., which nx,ma a permit to contract.alter,improve.d<roolisn,or repir any spuclm<
prierm it,issuance,alw¢yuims iM awielm f«such prnit to rile a signed statement SPECIAL CIRCDITIddLSC���
teal hes is Bernd pursuuxm toes pmvkiorvof the CwuracbKs Licen,<La.(Chors,9
-Q Q (� COMMERCIAL:
C me,
witheralmn arllofU vi,formertaIed eenfe Pv,Abyaxv Gvle)ar 'TINT.MITE LE IN J
a a e C But he i,esemPt lnere(rnnl eN the lads I«Ines elk{cd uemryirm.AnY violative of ❑.NLW BI.IXi/ADDITI(lN ❑UI:MOI.fT10N
Section 7031.5 by my aWlicvm for a permit eabjSd the applicma to u civil Penally of POW L'R LEVI.� ❑TEN ANT ❑FOOD SERVICE
ml mac e""Eve M1undnd dollar.mobb.
F Z T IMPROVEMENT
_< ❑ I,muw ,som penny�w inyusomeraas with wagoner 11leiOoe. 0Wt B.,i,, SWIMMING t].OU
3 w O wBl do the work.Cafe nn,cmreme.... reMN«oR osocItr ,.,Ic.7014.wascr o, ❑QTIiER
and ITafcnrimr Cr.k:Thc Gnnracuds hiccnw Lew Ata nut apply m en avrcr ofUt OUTLETS- TCIILS-fixrURES 12,
ptgeny w'b huildx«improves mcnmo,and wino doe wish wurk hirrselfar thmugh
his rrwo cnmlo,-,Provided that,«h impmv<mcnu our nes inlcaRY1«oB'eml Ee NEW NESID NT'IQ�.F1,ECTR SQ le.
,ek.If.Imwuer,the builho,or improve..is-Wwithin ore,ycarofcamPledov,th< SQ,FT.FLOOR AREA 5/SQ.IT
rcr-builder will have ile hurdcn of Pmviog met he did not builder improve f«pm-
tio,eorwe.).
❑ I,u.,of me pmpeny,am e,c[usively sconzabott with I'eeml cu
ecnaecl«s to JA
tY2-
a..11eproject(Sex.70W.Hlt,itex,and 1'rofcsaioo,Cove)Thu-oo-t«'s Li- 2 2-
came
cave lawdoe,tri ,4y men owar of pnpeny who build+«improve,lhClR"m,..d QT'Y, PLUMBING PERMIT FFE
whoeon .s for such toe witha obloselons)licemed p-ccoo el thecool morn
Liana law. PERMIT ISSUANCE
0 I em exempt Order Sec. ,B&PC for INN maws
t ALTER-DRAIN&VEST-WATER(G) J-L„J VALUATION
wn<r Ihln
WORKERS COMPENSATION DE: RAT7DN BACK FLOW PROIF,CI'.DEVICE T /^�/^�
I hereby efimt order lwmaltyof prlury ores of the following dcdamtbms: O VIJ
❑lease erW will vuimeinv Ccnificue of Comrnuosdf-inwue fm Workers Camprm DRAINS-FLOOR.ROOK AREA,COND. STORKS TYPECONSTRUCHON
,inial,as hick art for by S,i. 371X1 of Lha lynor Codc,for the Pcdomlmcc of Be . 1
wartfa which thisor by ecawed. IT)(NRES-PER TRAP ,`vJ
❑ I hevc end will nwinwin Workers CompensmimI Immeme,w myuibol by Swoon
3 Mlufthe labor Code.for the p,rfomuna ofdle work for which mix permit is isles]. GAS-EA.SYSTEM-I INC.SOLfILI;LS OCC GROUP e]/ tN��
My Wong Mn n io los inose cortimoli yNoPol.:�Y" 5'r 414S GAS EA.SYS'FEM-OVERT(EA) s l�
tI Currier: Policy No.:IY WORKERS'
6T3.
CERITFlCA M"SE OF H ON INS IZANCE RKERS' GREASUNDU.STRL WASTE INTERCEPTOR
COMPIiNSATION INSURANCE BUILDING DIVISION ItiES
t
«eu)(Than a'
is weli ,d not b<completed ifoe lemu't I,t forrc Mn
abud"Itr,(SIM) ORI- SET'RAP p O X 1�1 Q
lPIANCIIECK t•DI!
iceniry lou in rile lerf«nurceortha wort f«whichlhixprnrlit k oohed.l shall SF,WER-SANITARY-STORM EA.)VO F1'.
nm employ myPerson in eny mromer mbecome sogesm to the W«km.ComP,m ENERGY FEE
O z
..an Law of Coliftorria,Date WATER HEATER WNEYDE- ECfR GRADIN lUi
z APplicem
H
NOTICE 170 APPLICANT:If.after moving Ni,Cerdliuie of Exemption,you Ybosl WATER SYSITSVIREATTNG
F" nccotc scow to me W«kers CmmpenWion pmvisiau ofnelobar Cale.y«muq SOILSF11
a '� f«mwilh comply with such provision,«this Pemnt shall be darted rtvokdl. WATER SERVICE as
:D Q
z CONSTRUCTION is a TONRtionE LENDING AGENCY NEw'RESIDENTIALPLAIN. SQ.FT PAID c RcreiPIN
C.J 0I baeby oRmu perm t r i,a n l Sax.on lclldegmtoy for tnc Pcdnrmarwe of
La wart r«wni,n this Ixnnil k iswW Sax.3(m7,Co.iv.C.)
{lx I,endn'x Nunes TTJIAL:
�y U koala',Addret T Q
a. mW I certify that 1 have Thi,a,licdlmo Old state mut ow above Infor-am tan i, BUILDING iE
4 _ O
Z cnncci.lagnevlocomply thenhy city mad crxtmy ardinarmaand sura la mrelming In QTY MECHANICAL PERMIT FEE
C.1 z huiding curl,wmion,and herthy Outhonu apmenmtivc,of lou ciry to cher upon the SEISMIC P. it
- 3 0
r above neni«xil prgemy for impvtism purpura, / PHRMITISSUANCEL Z
(We).gree to,ave imlammfy ural keep hmml<.s the City of Cupoiirru egmra ELECfHIC IT\ re
IiaGl' .ludgnenu, I expense which may in troy wvy ocene.flaimt veal City AI.TER OR ADD TO MEC[I.
vena of of Nis plPLUMBING FEE
It. (J
T 'AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'at lbriat CIrM) O
MECHANICAL lTS
AIRHANDI.WG UNI'I(OVER IIL(IIX)CFM) CONSTRUCTION TAX
t
tiigv mMAPplicunUC ,b - Dot, BKHAUST IOOD(Wmuc-D - V HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will meupphnml or furore bolldlogoccopomdoe or hmdk hmurdnu.muaiel HEATING UNIT(TO IW.IXXI BTU)
m defied by do Cupcnino Municipal Cada,Chapter 9.13,most the Health and Safety
Code.Section 255320)7 11FATINO UNIT(OVER I(XI IXXI BTU(
L3Yev VENTILATION FAN(SINGLE R'ESID) PAIDHava Receipt
Will the appticw cboom,building occupanl use eriuiJo em car device,whiN
❑OIL(?R-
cd havardwrOir Omnaribrom,as&Fioed by rine Bay Artm e Air Octily MerugmaCOMP pHP OR IIXLIXMI B'IV)
curdTOTAL.
IRsuict7 mu! HOILFR-COMP OVERISLIXXINTU)
j�n —iv
p...r ,
AIR CONDIT'IONRR
e 'Ws rtqu'ucmcna under Cwptm fi.95 of the Cali- (SSU NCE DATIif1 2505,2153]eM 25531.1 uMmoorml Inn if the NEW RCSIDENTIAL MECIL SQ.Fr. //a.�//hitlemy rt+Ponubilin to tmtify to occe'sum .� f1 ohxcnfv Cutifxyeof(ksvpmry. �Y ((((Oganl Dote TOT ISSUPDBY:
OFFICE