B 0364 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLn1CTWCAL Ptl�RfMI$ O.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL SOOOI fY_J 0364
BUILDING PROJECT IDENTIFICATION
BUILUINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT2,
v -Ie.- S' 7— g
OWNER', MG PIIONB CONTHACfOR'S NAh1 E: .ICN
e t/ r�r NIC CONTROL
sepHCHOECF/F1.GINEIiN: (,b TIC NO: ADDRESS: Nl0 T� ❑
uT ST.
CONTACT: PHONE_ BUILDING PERMIT INFO
❑ ConsWlant Ft Va Paid by Applicant(Initial) BLOC ELECT PLUMB MUCH
�£2ToLg`7• 23 ❑ ❑ ❑ L�
s LICENSED CONTRACTORS DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby affirm Ilw 1 an Ikense l under powisiorts of CMper 9(unrobe Icing JOB DFSCRIPI'ION
.0ZO wiOSccuu.7Md.fD,,o.Jot lde BuaircastM l'rofaskn Code,abed mylicemeu PERMITISSUANCE RESIDENTIAL:
aF�wr in full forv<anJ CRaI - A ISgDA !` ❑$FT)Wh ❑KITCHIiN R1iMODE1.
N<C DwLicrnse CP _ C�;n.. D`W I APPLIANCES-Rt'-SIDEM'IAL []ADDITION ❑PLUMBING BE PIPE
'Dob ARCHI DUCTS DECIARAIION PANELS ❑MULTI-UNET ❑SLRUCNRAL
Z 0t2K lundcra.mi nrypl.nnrhull buse .r
edpueic rm«da MODIFICATION
OZ-Q UPtt)MMAMPS ❑INTERIOR ❑CHLMNEY REPAIR
N�FW LicewT VmfcdorW 1111-I(MAMPS IMPROVEMENT CISWIMMING POOLS
mf-j OWNER BULLOCK DECIAIGGIUN OVENL WAMPS [I BATH REA10D JREI'AIN ❑OGMOLITION
C=Q I hereby alfino that I ore exempt front the Connector's License Low lie IM
L O W U following reawn.(Secln+l]11113,Business and Pmfnd«u Cdc:Any city nr countySIGNS IihELTHICAh ❑OTHEit I
311 which nut.i a t Permit to c..4 cher,ire I,ri dernoiill.or mPair any slrecam 1
k�Lo� prune lu lac i..tnric,ulwe rryulro lhcupplieum fers.eh femlil w Bk.,lineul wourneml SPECIALCIRCUff/MISC.
,E�} Lha he is lkenrsdpunuanuo lheproviuoolof the Cnnlmc1-Ltenw Le, Chapter
W'Y�p (cowrcocing with Seen..]000)of Divisive 3 M the Badness it Pmfeisieos Gxk),, TEMP.MIi IVR OR POLE INST. COMMP.RCIAL:
a I],e y that he is demes Ihcrtfmln avf the bed,f«dee alleged ecern ion.Any violation M ❑NEW BI.DG/ADDITION ❑DEMOLITION
Xm¢. Section]0313 by any applicant foraPecensubjewx lM.pplicmel In.eivilprnWly of POWER DEV ICES
W_y ❑TENANT ❑FawselcvlcF:
ml hrcrc than Five nuMrcJ dollvs(g51M).
: IMPROVEMENT
< QLnowrcroflhe the
imfnl.yees w oftemiesulheusec.eompenamiun, SWIMMING POOI.ELF,CIItIC
WHO will Profession,envthe he urn iwtor,Licroem Use
doesll sak(Sy1.onB of ❑OTFIFR
13 ono erty who builds CeJo:en,Cnn 11moc s land w I.nw does rd apply W an owner of OUTLET'S-SWRCFIES-FI%TUR
his own whooye,,p imded in yet vich i none who JrMs.such work nimselr«IMnugh
his own amp eb.th,lxrrind NY...h imnt is sn nw thin ml inlrnekJ arc Offend t« NEW RESIDP.NTIAI,EI.fCIR SQ IT
se.ILhmveveillbbuddingblenrym'emeeuesat be,didint Wild urnponitare.IM SQ.FT FLOORAREA USV.PI'�
own
er-Meilek will Mve IM buNen of previug IMI k did ml Wild«impmrc Rer Wr-
lose of ale')
Fl Luwtvofc, SeWeny.Bexclusively a'nu.cling wildIc Ccontractorslee TOTAL:
«xNNel Inc es not(,Sec.]Ott.Nusizss tote .hit on,build,
d,e,Code: TLes«then on. est Ali
Ww Jts fws pMymonithaouire,uny sine beddrvhnprovn Ncrer..and QTY. PLUMBING PERMR FEE
wtb Wnllacu f«seen p[eftta with a[tenlmCinlfM licenced pumwm In IhC CrmlfnCln!r
License law. PIRMITISSUANCE MAY 0 7 �g
Ej laneexcmlxu«kf See. ,B&PCfrrldismawn
p n r DoeALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROIISLT DEVICE BY
I hereby a0irm under perwlly nt perjury vele of be,f...m'ing ink-Ivmia.
❑ Ihave aeJwiefixbyeetion3a¢nlCmLwnrao Conic,mrehe Worker's Conspen- DRAINS-hl(]OR BULL AREA.CORD.
vll(YI,as provided f«hY Sal'vn t]1M of The lahnr Cede,f«Inc performance of The STORIES I' UCI'ION
work fer which Ria Pmeit is tested ted. FTAT)RES-PER TRAP
I hove and will maintain W«kcr's Coml'ete«tion lnsurahax,m butuind by Section
37Dloflhe LaMar Cole,on-be I—ect euflhe work f«which this permit,ronvl. GAS-EA.SYSTEM-I INCA OUIIETS ICC.GROUP APN
My Worker,Corr IM.don Insure.-tamer aced Paley number ate:
Cartier: Policy No.: GAS-FA.SYSTEM OVER 4(G)
CERA IIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSFRL WASTE IN'TERCEMOR
NUILDING DIVISION FliliS
(Thisseclive need nut he cueopkld iflhrn
e pnil is for ire.hundred dollas($100) GREASETRAP
v"' PIANCIIECK hliE
eco
Ibal' ur(u nfldeweerkf«whichaJapemeit isisseN.l shell SEWER-SANITARY-STORM EA.2)()FT.
nm cnepi.y.nY v Ye n u�y.tnb me jalm W:WurW:n'Campen- LNERGI'FEF.
O Z Wien law. if Da •1 WATER HEATER WNENDEE"CTR GRADING FI:E
Z2 Applicant
N NOTICE tt APPLICANT.If,uflcr..G.,Nis Cenifwue of Exemption,yr.should WATER SYSTTiA REATIFG
a , be,com wbjet ate Iter Wol ort Ccrn,n,ninu pmv trona of IM Latin Cede,you muse SOILS FET
4xNw'ith emeply wild nedproviskrm«This Pennil shall heJeemd revoked. WAFERSERVICE
.7. z CGNSTRUC""PION I.LNDWG AGENCY NEW RESIDENTIAL PfAIB. SQ.FT PAID D ReceiptY
U O I hereby olliem lMuhem is a cnnamrtion lending agency for the eerfunnecvu of
I- 'he wM fa which edit Pninu u i.ud
. (See.3WT.Civ.C.) TOTAL:
Lrn hr's Name
U Isnhrs Addoc,s TOTAL:
1 tecify Lha 1 have noel thi,"licalino amt nu¢in the above Infonleanu t is BUILDIN -C
� 14q coneainge toro lywithallcilyaldce lyWnaenaMmalelawnmlaingln QTY. MECHANICAL PERM IT FEE
U Z builJiop conwuclinn yvulhvau neynvenlviva of lhls city reamer upon the SEISMIC IT
al.,v--mc pmpcn rimpamn puryosa. PERMIT ISSUANCEPON
'e).8reem AIA,
ETECIRICFE'lMnyinanywaylettrve.gtinlaeiJ Cly ALTER OR ADU tt)MECH.cng of lhi itcPLUMflING
NUS 1 - GQMI'LY WITH AL1,NON-POIhT AIR HANDLINGUNRCTO IN,fpCfTD, MECHAN'ICAIAIR HANDLING UNIT(OVER 100))CFM) CONSTRUCf1ON AX
let« Dec ESIHAUST I IOOD(WMUC I HOUSING MITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicant(mere Wilding oecuPanl ae«c«herdic Mwrdous mncred HEATING UNIT M)100,1W BIUI
v defined by dee Cupertino Moroi Code,Clu{ner 9.12 and the Health and Safety I IFA'TING UNIT(OVER 101000 BTU)
GWc,Section 25532(.)1
Ye xNn
VENTILATION FAN ISINGLF,RESIDE PAID --
WalInc,ir, nl«twat-building Kehp Eisaeea Ai Q lyM which Uate Receipts
emit dvuNmr airoimtumi nm mJc0llcd M1y the llay Arca A'r(JeWlily Mv.gcrtela BOILHR-COMI'pHP OR IW.OaU B'IL)
AL:
�'rQ141yBOILER-COMP(OVER 100.00)BTU)
Yn
I havelclulW maeriild
s Ii under Chatter I jut G95 M'dx Cali AIR CONDI LONER ISSUANCE DATE
freta HealO&S C s 2 5,255 +nit 255N. meeknund IWI if the NEW RESIDENTIAL MECIL SQ.PT. �- 7� 4 9
IbonwingdoeFV venol Ill. b,lMm.siMlity to Miry lM occuic l .. /
erthemquire lbetrc W oftcerifT
Ow«r fir uu xxiaW ogcm Dam )TAI 0 ISSUED BY: �Ir7
OFFICE