00030126 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY b O ,/Aat
CITY OF CUPERTINO BUILDING-F,I.EC7TRICA], PERF
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECIIANICAL S0001
BUILDING PROJECT IDENTIFICATION
NUILDING ADDRESS: SANITARY NO. API O OB0,1171ALDATE
10411 Rom- 054n, /4 e-
OWNERS NAME: YNONE: CONTRA O 'S NAMIL LIC NO
�
Op 48 75 as G/fly NIC CONTROL#
CR
n ECPENGINEER: LIC NO: —I� ❑
CONTACT: '' ` /t�- PHONE
G: 5 w BU ILUING PERMIT INFO
amara JotJQ(� op' T��— ❑ Co ulfan[Fees Paid by Applicant(Initial) BLIP 1EC� PLU.NMECI)
LICENSEDCONfRAC C)R:S DECLARATION QTY ELECTRIC PERMIT F4r,
❑ IrJf YrJf
I It,mby shutout hat I am liceree l ardor provouoru of Clupter 9(commencing JOB DESCRIPTION
O�Z hSectim](XIO)MDisiSionlaftle BusircaavN Rvfusiom Code ad mY IEcemoeu [AL
+100 �� I PERMIT ISSUANCE.
full free and eBem. , ❑KITCIIL'N RE1.10DE1,
aF.UU LlrmrSeC /clic.# pPPL1ANCE5-RUSIDEMIAL DITION ❑PLUMBING RE-PIPE
t Z' D it O Cmuurnr
Foct.y ARCHIII_LTS DECLARATION PANELS
❑muLTwISIT [I STRUCTURAL
z O n Z 1 undetsuM my plain shall be urd uN Public tecmda MODIFICATION
OZ—� UP TO 200 AMP'S El INTERIOR ❑CIIININ17Y REPAIR
F-4E"W LianW l4ufec�iaa+J 201-Iqp AMPS IMPROVEMENT 0SWININI POOPS
OYG < RATION
1 hereby ulfinn that OWNER-BUILDER exempt from
the Conmuclols License law for IM OVER I000 AMPS ❑BATF RLMODE1 EPAI ❑D' O.PTI IN
ippx5,�0 LU tullowine reavm.ISa+ion]11313.11usiress uixl l'mfcsiimr Cuda:Any city ur cuumy SIGNS RECTRICAL ❑OTHER
f[13 t vFai which be,ire,a Permit I.eum..eller,ii se.denwlish,or rHsdr any.0te
poor to its ia5tana.dso scof ea the applicant for such penium to file. stud streamed SPECIALCIRCUIT/MISC.
gg } IME heia Iseenaed putsuam talhcp't'msoun,of the ConuecnMa Liccr,c law lchapier9
W C, (annmencingwihS,.i...?("))orlHrLrdm Sof the Bueircixamd PrulnSimr Ctdc)or TEM P.METER OR POLE INST M
COMERCIAL:
s E e fz that he is exempt thctefmm ad Ik Iasis for the 0cgd exemption.Any violation of ❑NEW BLD0ADDITON ❑DEMOLITION
_ Srction]O1LS by wy applicant for a pemul soNe<u he apJicml m e civil Petri of POWER DEVICES
y
nor than five hundred!hJlvrs 1551X11. ❑TENANT ❑FOODSERVICE:
F Y IMPROVEMENT
4' ❑ Lar owmrofhu pnpcny,ormyen'plvyccnwith wegcrmhair.alcaampcnmiinn, SWIMMING POOL FI DORIC
EFG will dohcwmos Col, IbcCmcuctoO,mnkd,Low
rak(Scc.]ULJ.Busirc.as ❑QTHER
13 and Prt,wins,
Cad.:the Conttactrem License,h Luo don M al,hi In If owner of OUTLETS-SWITCHES-FI%"R1RES
ryopcny wMo build#ur,i&dm,m,f,x f och i n, —odors.such work bimrelf aertul l M1
hlx own employers,pruvid.J hm inch i ter,of'.nu ore nm inmr wfd cr aBetrd tate NEW HILSIDEN'IIAL ELECTN SQ lel'.
owner.hax'ersr Joe Mitimg on ebuntRutofpr int itwWwioll nrcnk!or icplooe Fr the SQ.FT F1(1<3R AREA SISQ.FT.
rcr-0uilkr will Kase the W Nen of Imt�nG that k JiJ nal twirl a impmas fmIxm-
rysc of rathe /
❑ I,auowner of rte property,am ceduailrmtuc
vely contin0 with lwed cmrix
ttors to TOTAL:
mtstrun the I'rojen IS«.]OW.Budxsl and Hofcssiau Calc:)The Contrncttx'I Li- 1�
c oio d,,snm.pplyman owrcrMpr'p.rtYwben.,,l orarttovcs JKtcon.a'd QTY. PLUMBING PERMIT EFF, V
who mnlmde for suuM1 pmjats with a nmtrw�eMx7liccnvrl Imrvmm m'iM Gmtmcur'a
l.ic.'ue Law. PERMIT ISSUANCE
ALTER-DRAINA V
LT-WATER(A) VQALUAION
WORKER COMPNSATION UEOUfATON BACK ROW PROTECT DEVICE oo
o,/Owner
Itetchy Iliumumkrpmd1Y leof Con areofhefol fw Jcclaatims:
IMvc and will for
a-I...3cme of ftI,uaCot!-insty Ifm Wmkeh Cottle n- DRAINS-h1WR,ROOF,AREA.CONE).
wiinn,ss prt'vWd fm by Smtion 1]1X1 of IM latu'r CaW,for the ryrforcnaxe of the SfOR11S TYPECONSTRUCTION
worklfor which this PerFI
mit i.i-1. XTURES-PER TRAP
LFn rove aml will maitunin WmF:er's Cmtpenaotiue humane.,n tequiml by Seclim
1]gIM'Je lAtar Code.Gr he peAorname of the woh for which thio pertnit is iuucJ, I GAS-EA.SYSTIJN-1 INCA OUTTZS PICC GROUP ANN
My Water'#Tompynyli���'#In.otom - JPoluA nun)h.r 'N07 //�� JX-�f/�
Carrier (i nF'Frt1LC .'JRYLS cPolicy No.: 17. - �� GAS-EA.SYSITN-OVL'R d(EM 32� �,f' 1Y
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASP/INDUSTRLwASIP.INTFACI?PIOR I1V
COMPENSATION INSURANCE: BUILDING DIVISION]TIES
(Thixscction moi bemmplmedifthupermit is Tome huedrul dull.($14)) GRPASCTRAP
m Ins.) I'L\NCHECK RE
IttrtifYdaminhe perfomarcc d'tbe work forwhich hulenNt isiw'd,Ir>vll SEWER-SANITARY-STORM EA.2(p FT
ixR employ any Pc',rn in any..so n to hes me subpWr,
i to e Workers Co ,tii ENERGY FEE.
o z whom luws of Cubmiro u.lAtc WATER HEADER WHEN VI3LECIR
o Ap I.l GRADING IcEE
z
y NOTICE TO APPLICAT:IL after making his Cenificuc of E.scroNwo,ym should WATER SYSTEM/1REATNG
a ; become oI to the Wake.Compensation pon,im.of's,MMr Ctde,you moat SOILS FEF:
pl .. fo'rhwith con'ply wilh,uch Femu,in us or this pawl,dull MJnamal rewkd. WATUR S13RV ICI?
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL,PLAIB. SOFT. PAID
UQIMr hi,h(10 otwmil i, amnumniml.Coe.agrnryfahe perfarttana of Dole RariryN
U-worts for which thin Icrmn'.'svmJ(Sm.31Y)].Coe.Cd
0 U Iatdela Name 'TOTAL
W Lcmlcr'IAnty,l TOTAL
}
IL
- BUILDING IIF
f"+ I ccnity oet 1 Mac and his y ORJ cou and are but tlr uMnc iws rmaim is
h cn ldir,cagroo
mmusd omply Roby
uthorD eg re,cnm,u ofmul'.ity entrclming m Q'ry, MECHANICAL PERMIT FEE
L) z Milling cunuru<tire.od hcrehy auJNxlze rept..sentvivesMthir city In enter up'n he SEISMIC FEF.
above-orntiuicl p.,,,y for im,,ecdo o rynpi PERMIT ISSUANCE
(We)agree to one,indemnify and keep hoo less the City of Cupcninu egaina [LFCfRIC PTF
Iiubilairr,juJgnmms,-1,u'duapn¢.rx'hichnwy in any way accrue ogoi net and City ALTiR OR ADD IO MECI I.
in rmscquctmc of the gm'tin,of did,permit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNITUO 111.000 CFM)
MECHANICAL FEF.
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10AX)CFM) CONSTRUCTION TAX
Sigtutum otApplicanVG.mactor Datc EXHAUST FOOD(WMUCT) HOUSING MITIGATION IiE
IIA%ARDOUS MATERIAI S DISCLOSURE
Will Of,upplicaut or future buildings upm(Vacto Mndle M1umrdous uonmrial HEM INC,UNIT('10 101.001 It'fU)
to dArcd by the CuPmgm Mutdc/Pul Coda.ChW er 9.12,mal the HedIM1 and Safety
Code.Senin 25532(.)^ HEATING HEATING UNIT(OVER 1W."BTU1
71 Ye
VENTIIATIONPANISING1.13RFSIDI PAID
Ilvtc Receipt x
will the applicant or future dui Wing ocsupwJ use ayopossum or skvim which
t hvudoua air cantatninads as daft 1by to Bay Are.Air Quality Manugcrrctu BOILER-CONIP(3HP OR 100,000 BTU) TOTAL:
Nrict^
Cyr, 0 N HOILI?ft-GDMPIDYER IIX1.IXq BTU)
Iha.s rsad due haaudaua nmtcridx rcyuitet ,mocl.r Char fi.
ptc95 NJe Cali- AIR CONDITIONER ISSUANCE DATE
Tornio health R Safety Cde.Swims 25505,25533 and 25511.I uaknm'd that if he NEW RESIDENllAL MECH. SQ.IT.
Iwo Wins JauS nm cur'cndy have a mown,Ili it Ir my tevl'onsiNlity to reify the.[.m
d'thc requirements which most be firer prior to iawatxc of a Cenifirate rd Ocrupaocy.
Owrxr or amhodual ogcm Dom TOTAL: ISSUED BY:
OFFICE