S 1050 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF MIT NO
BUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1050
BUILDING PROJECT IDENTIFICATION
IhDING ADDHFSS: SANITARY NO. APPLICATION SUBMITTAL DATE
04I;L Fo �1vc9
(JYJJER'S AME, ^ PHONE" CONTRACTORS NAME: LIC NO:
NIC CONI'Rot.0
ARCI UITC711iNGINEER: LIC NO: AUDRI6$'. ❑
CONTACT PHONE: BUILDING PERMIT INFO
nsvltant Far Paid by Applicant(Initial) BLDG ELECT PLUMB MECI
c: 4v ❑ ❑ ❑
LICINSED CONRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE 74
I I h,of iom that I am Ikc.o,d old. Imrv6i�a..of OuIN„9 corm mcmg JOB DESCRIPTION
yMy]]a'Z with Sation]IpUl of Disixbn 3arthe Businmx and Nofersims Code.aM my liam'e is RFSIDF,NTIAL-
FI- in full fact a+d effeet. PERMIT ISSUANCE, �SFI)WI C3 KITCHEN kES10DEI.
Gana
YI
SZ� ,csc aces Lc.4ContAPPLIANCES-RISIDENJAL ❑ADDITION ❑PLUMBING RE PIPE:
InQLARCUI'GICTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZOr�Z IuMaxbrd my Pleat shall be uxdmlablic mcoNs PANELS MODIFICATION
OZ-0 UPTO200AMPS ❑INTERIOR ❑CHININEYREPAIR
H N.F'u1 IiccnsW Profmsitmal 201-1000AMPS IMPROVI?MLNT ❑SWIMMING FOULS
J OWNER BUILDER DECLARATION OVER 1000AMPS ❑NATHRF DEL/REVAIR ElDEMOLITION
C C 6 1 heathy ufOmn IMI 1 ant ,scmp toxo the Cool ma,'s Licen.m Low for the
X C W Uy. following rta Im.(Si]Oil S,Buvinasa wd p,h,,dars Cub:Am city m e m ny ,SIGNS ELECTRICAL :R
W 3 i,.N which rtquE,a permit to coloaloo.aha,improv,hmoRi or repair any suructurt —�
C) prior to ince Lcsvana,It.,t,pirtallrc.1filam fa such hail a file a nigwd aatmncnl SPLCIAL CIRCUIT(MISC.
Eyy Nekis licensed punuaaln the feovisimts afdseCwrrcta(s Lkms, aper9
ta1'd❑O (nxnn¢twing with S,aim]Impd Uivisinn3al'Ne Bmirca erd l}ofmxilion ms Gde)or TEMP.MITER OR P( INS).
Q. o a that be'is exempt tMefmm W the hats for the alkgcJ mcmpoun.Any vinhai or of Ll NEW BLDCIADDITION ❑DLh10LTH
uXl la' tiatim]UJ 15 by any.Wicant mr.gratin wnkcl,Nil asaficent to a civil malty M POWER DEV IC E:1 TENANT FOOD SERVICE
F_Z_r�N
not tom,tan 11,c ImadW dollars($5410)). IMPROVEMENTe'er �I,mrw.¢r of Be prgcny,ar my cmpnYa�with wegm as their vdc comPcnammn, SWTMMIN I ILUCTRIC DOTHL'R
andwdl do its work,and Ne awctum u Dun intrnhd aaRcrtJ for sok(S¢.]U1i,Husircu
3 aAnfc no,CWm Tc Comm,o,IJeeme Law do,v.apply ..in owner of OITI. S
-
SWIICIII-S-FlX'RIkIS
pagr.ny aro naiwa m improv,N,,man.ata won does au,n w.,rk nima,Hm mmugn
his own,,mploycmmv
.pidW that such impov,r wnla oat not imended or ntT,,,d fa N RLSIUINTIAL L'LECIR 50
sak.lf,however.the buildingaimpmvmsnt is mlJ wilbin ane yeunfcomPletionnhe SQ.IT FLOORAREA 5/SQ.FT.owner-builder will have tk hurdler,M'Droving dor h,did od b o munifmpw-
p,c of alu.l. TOTAI
❑ L m rewrcr of tk progeny,em exdushcly rnnvading with lianad amlmeta2 m
umVnct the ryojnt ISa.]Illi.Husircaa urd Pmfcaiau GWe:)The Camxlura V-
montBnaepplyman swrcnd progeny wlw huikl.�r impo Ncmin,aM QTY. PLUMBING PERMIT FEE
who rnmrecD fa sato pm,,with a cmuxmn(s)IicrnrcA quwaor to Otds t Cmtracur a
License w. PERMIT ISSUANCE
❑ 1 seat,umkr Sal. .B&P C Br thisrt`oo
ALTER-GRAIN&VENT-WATER(EA) V/aLJJ AS1 1 V►
u U
nc I' /q�WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT HFVICE
1 lcrtby dfamn under prn Iy of grimy one of N,following k lonlims
�]l have"will onotinoCmif mofC.,no lif-inwm fir ,Wurkcr'e Comom- DRAINS-FLUOR.R00F,AREA.COND. S'IORI � UCTHID
,admin.Its poAi Ter by Natrium 3700 M Ne labor Cod,fill rbc perfomurc,of Ibc
wn3 for which thio penult is i_aocd. FIXTURLS-ITER)RAI'
n I hast erd will maturation Wmker'a Co ll'enolban Insurance.as m0nal by Sation -
t]00 of Ne latex CWe.(a the lcr(amuw,ofthe work for which Nbpermit is iszucd.
GAS-EA.SYSTEM-I INC.i OUTLETS (DCC, - a'
Can ,
tsCmtpcnsation ln,wmna wn rend Policy numira ore.'.
Carty. cPolicy No.: GAS-EA.SYST[N-OVERi(I'A)
CFRTIFICATL OF HXEMVTION MOM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCENUILUING DIVISION PEES
(This action n¢d rot Rmtn'lnM if Nil Wool..s faomc hunlmd dollmx(SIfXI) GREASE TRAP
a Imo.) PIANCIIECK FEE
IcenOfy dot in Nil perfmarccofNc work fnwTich bis P,,mrit isionsa],I shall SI:WI:R-SANITARY-STORM EA.200 FT.
not employ any pervat in any manner w u to ccoirc subject to the wrkeni Compen- ENERGY FEE
OsZ adian Lawxnf Cafoom,Dat,, WA'H:R i FATLR WA lI A.;LECTR GRADING FEE
O Appic a
NOTICE 1 O APPLICANT:If,Inc,taking this Canfi,al,,of Exampeon,you should WATER SYSTENUTRFATING
f" to SOILS II:F.
' " become comp m the Wath, menmpcn tion Pmvisi ad of me IaMv colt,y must
fonhwiN comply with such pvviswuor Nis Permit shall4 deemed revakW. WATER SERVICE
6. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhMI1. SQ.FI. LAID to ktteiptl
C..) O l hemby arm that Nae is a cmmrvction kn1n,agency for the pMmmmrce or
— B,wodo for which this rymii i is issoN(-Sh.31897.Civ.C.) TOTAL:
O u I,ada'x Name TO'TA L. Zu
{DLI I,a W,r's Addr,rx
I a. cmify d�I bave rend this application and stet,,Nat the above itiRrmetion is BUILDING FlJi
TV) cmea1.1.9rt locompywiNalleitywdewmymdivrreaerdawelew mWingm QTY. MECHANICAL PERMIT FEE
U building mnmmm:n.and hereby aulhnrim relr4umutivm nfthis city meter ulvm the SI?ISMIC IEE
ahovcmrnlianed prRmy for uls tier Pa9 . PERMITISSUANCE,
(Wilt agrtx m save,indemnify Lod kap humtkfs tn,,CIIy of Cup,rfl..1oo,a ELECTRIC FLE
IiaMiwrl
,lWgoomu.cons ad cxp which may in any why xccm,agonal soil City ALTER OR ADD TO MKCH.
PLUMBING FEE
in roods ,N Ne granting or this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTO 10.WOCFMI MECHANICALFE.E
SOU REGULATIONS.
' AIR HANDLING UNRIOVER IO.gIn CFKD CONSTRUCTION TAS
rt n(App__Conuocta Doc EXIIAUST HOOD(WNUCT) IIOUSING MI'CIGACIONI'IiE
HAZARDOUS MATERIALS DISCLOSURE
wIIthe applicant a futurt huildim,occupant storey handle hoDndou,mureod IIFATING UNIT LTO 100.!X10 BTU)
u hOncJ by Nil Cuprirw Municipal Cod,.Chapr 9.12,sand!do,Hcu1N cad Safety
Cdc,Sala 255321.)! HEATING UNI'!(OVER ino,ohn )
Ym ❑Nu
V EN'11 LAI TON FAN XIN -RISID) PAID R,ceiryl
all No upplinm a foam building cccopam um yuipman o,devil,which
emit hvzvdour av nwan0anu m denrrJ by the Bay Amo Air Quality Maugrrrcnt BOILER-COMP f 'OR 1000010 BTU)
TOIAL
Iyieuicl? BOILER-C . P(OVFAlmoli0B1V)
❑Y, ❑Nn
I havcfd lbc hamre nwcniab mquirtnenu ants,Capco 6.95 of tlw Cull- AIR C DfDONF.R
wdnIS I NCE DATE
forma HeRh&Safay Crile.Seetiom 25505.25533 and 2551!,l undauerd that if the N F,W RES I DENT!A I,M HCI 1. SQ,FT.
huikling ilea nit arrrndy love a nmank Nut iI is my re5'm�biliry m unify the ottvpant
of the r.auimrnenrc which must he min Ix or to is..oda Cenifcme of(k<upancy.
lthlrLlt ag,m Da, TOTAL: INSTIL
or vrDIY:
OFFICE