S 3020 I+ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FLECIRICAL PEtrr NO I(� //�
BUILDING DIVISION APPLICA'f10N/PERMIT PLUMBING-MECHANICAL. LJ 3OLO
BUILDING.PROJECT IDENTIF'ICAT'ION
BUILDING ADDRIiSS SANITARY NCy APPLICATION SUBMITTAL DATE
OWNERjS NAME-, PHONE CONTRACIOR'S NAME: LIC NO,C � G I NM, CONTROhM
CGiJECIYFN NEER: LICNO'. D S ❑ l/ Q �/
C(NTpCp P`IIONL': /� -' BUILDING PERMIT INFO
A,r�I O' � 7 ❑ ConsWtant,Fce Paid by Applicant(Initial) BO ELECT PLUMB MHCCH
IMA 4 /(b / El El
LICENSED CONE kACTOR', DECLARATION QTY ELECTRIC PERMIT FEE
E hereby m rria that I am lioanwcl ander prnv'ulons of Chapter 9(commenting _ JOB DESCRIPTION
IpI�]X00 wefin Semon9nlA)ofDivision 3offe,Busmav and Promslons Crdc,md my liaaan is PERMIT ISSUANCE RESIDENTIAL'
( F W In frill more and,na, ❑SFDWL ❑KITCHEN REMOML
Liecaw Clava LIc> APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RF.-PIPE
h 4 W Ihte Cnntncen
g.,pm ARCHfItiCI'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCHIRAL
Z O v274- 1 undenta ld my plan.%hull M used as Public imide MODIFICATION
UP TO 310 AMPS
pZ�p ❑INTERIOR [j CHIMNEY REPAIR
F..+W Licensed PrM1Y
o ximul 201-I4XIAMPS IMPROVEMENT SWIMMING POOLS
��-f OWNERBUILDERDECLARATION OVER IM)AMPS El BATH REMODEUIRSTAIR DEMOLITION
ullimt that I an,cern,,front the Couturier e%License Iaw for the
p y U fallowing reaun.Slocum.9031,5,Basin.unit Profession.Gdm Any city or county SIGNS ELECTRICAL ❑OTHER
whlch«4utms u Penne ro'conif alts,rmpm v,MTnUish,nr repmr any nmmnm
prior to insLmance,also twuims the a,,fvam for such permit to No a slgnvd amerncn, SPECIAL CIRCUMMISG.
j (hut he i%Iicenutl pursuant loth por,suirsofthe Curtraclor's Liense law Uhh m,c) COMMER
�p (mmmcncingwtW Sarim91M0)nfD'hireron3 ofthc Husinn's snit lho(crsionsCUJc)nr I'EMR MEDR OR PQIP,INSC
d a e C that he I,caempt thcrefmm wit the fact,fur the ull,all c empimr Any vicuume of ❑NEW BLDG/ADDITION ❑DEMOLITION
iCmin Seumm 70313 by any uppGcunt for a Permil subjects lh upplicanl to a civil penally of POWER DEVICES [I TENANT ❑FOOD SERVICE
LLl^m freers men Five hundred dll.,(S5W).
SQp IMPROVEMENT
I,a mr of ineRte prnputy.or my employers with wages re.tier mle com,cmatiun, SWIMMING POOL I'l,U!CL'RIC
S. El OTHER
will des me work,and thearactum is not intended oroDemd(rr sale(Sec.70,M,Burr',.
W mkt Profcvaice,Calc:Th Commmm's hkcnx Lyw docs nu apply to an her of OUTIJTS-SWITCHES-FIXTURF_S
4i 6 phu v y who Wilds or iml+nva,thunm,end who due such wrx4 hiut if or through
his own empleycm,prii' cd mat cash improvements etc teat interdUl or of rl fur NEW ES
NEW F.LBCrR S
le.If.hoever,tle building nr impmvenam ls,mld withinnnc ychr.t camplgieq th .Pr.FLOOR ARCA 95Q.IrT.
-mw
mer-buildur will have the burden of proving that be did on.hould or ina,mcc for Pur-
qnc of a1sL
Cl 1,us owncr of ib,pnpcny,am ciclirm"Iy eomm"in,with licenced rommehm to TOTAL
omlmr.the pejm(Sce.91ktL Bu,ioc,unit%oruaons Code)Me Comeacmr%LU- -
wLaw,d nma,lyetwawrerof qm,i wh hadd%or mr,roves mire,..and QTY. PLUMBING PERMIT FEE
who amtrams fat such pmjan with u cuntrncmr(s)Iven.sol punuanuo me Consmrs
License Law. PERMIT ISSUANCE
❑ Iamc ofundcrSa. ,H&PC!
AI:fER-DRAIN&VL'NT-WATER lLA) VALUAS'ION
Le14�
RKE .'COMPENSATION DhfolATLON DACK Fl,OW PROM-Cf'.DEVICE o00,
I huMy%Bret under pvnelly oflcrjury otw of the following dtclurvumr.
❑ Ihovc wdw)ll1r h,naCmifcacofCe LafxaCodrnsurc for Wrilcraccof In- DRAINS-FLOOR,RIX)PAREA.GOND- STORIES TYPECONSTRUCTION
ah provided fnr by is%,a J]lp of rhe IaMr Cudc,for IM1c peHormarce of the
wuknfm wM1ich this Tyner is hewed. PIXTURIS-PI?R'I'RAP
1 bury.and will mental.Walker Compce,flof Insurance,as ea,n'ne.by Seddon
3910ofthe"t,or CWc.but pefronmeo,ofrac woill for h.,h rhes pcmdt,is,rcd- GAS-EA SYSTEM-I IN _171'5 OCC.GROUP AI'N
My Workers Co rNmatim Insumnt,curlier and Policy number mc:
Carrier: PolkyN,r aA.SYST -OVE 4 )
N CERTI%CATIi OFEXFMPPION%20MWORKERS' AP, DUS WA 1 BRCEPTOR
t C19MPENSAT[ON INSURANCE BUILDING DIVISION PEES
(Tile xetiw nerd M hcuxnplued tris pemtifn tirrxmhunrEtnl rlollon f51
a Ism.) GRGAS ) PLANCHF.CK FEE
I verify that in Ill, cam mmntcof tie work for which mi%pennit is irsltal.l _ R-SA ITARY-Fm .3f0IT.
rex empinY enY pence l^vny nwnncr%a m m Msonm,whjn't In the Wrrlen'Coml>c ENERGY FtiG
O z %mean laws of Cullfnmia Dem WATIiR IIb:AT1iR WNENT/GLE GRADING FEE
Q A,ichor
NOTICE TO APPLICANT:If.alcermakln,this Cerodwamof Eavmppion. you Jmu WATER Sy
t•"' � harm:subset to t be Wrrlsrn Com eon Tris ladrzCodc.Yrxt rens SOILS FEE
1 pcnrrI Pmvit hall
GMwith comply with such pmvisiommthis prmir shall he Jangal rcvokW. wxEEk S1!RVICE -
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PTN[B. SQ,F1'. PAID -
= z IMdty alTrm thauhcrc ltoumarvdinn lcrldmg ugcmy fnnhe perfnmttmcc or Lima Receipt#
titre work for which this pu ant is IYsuM(Sec.3097.Civ.C.) .
(~
Least,Num, TOTAL'
V Leri Address TOTAL:
�L.t, Lia 1 mnify that 1 have mad thin appl',samem un1 state that tle these information isE �j
HUIIJJING FEG
it fail counter-I agrvom romply with all dty it ammyreditmrecy and aam law,mutual 1. QTY. MECHANICAL PERMIT FEE D
U 7-t huildin6mmill tion,and hemhy a.moere mprnentutives nr mea city m.nmr upon the SEISMIC FGF
alnva,mentitai poc,c ny far inspection,pmEl,e,. PERMIT ISSUANCE
(We)ugra,o nave,indemnify and kap harrnlas me City of Cupertino against FIJ,CI'RIC FEE
Ki a1ircvjudgnwnt,coal hand eep.ncs which may in any way novel minima said City ALTER OR ADD TO MECH.
nnuyuuntv of the granting of Ihi%pemmo PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AUR UTANDLUNG UNIT(TO l 0.0(X)CFM)
t I CF REG tATIO
l� MIiCHANIG,ALPEE
SO
zI �� AIR HANDLING UNIT 10.00CCFM) CONSTRUCTION TAX
tgnmem uFAWlicont/Conmmchor Dam F.XHAUSP GOOD(W/DUCG HOUSINGMI'I GATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will th,aP,licunt or future huildreg uer,mrmac nt handl,,harnndm,nmmral HEATING UNIT(TO 100,00X1 RUV)
as dcOwd by Ile Cupcnim Munlclpul Code,Chapter 9.12,end the Ikvith arta Safety
Goo,Saurian 25533(a)? HEATING UNIT(OVER 11)(1,100 BTU)
VcsNa
� VGNfILATION FAN SINGLE RESID) PAID Dmc RasyrN
Will my.,Tlem m furore building occupant u.a cquipnwm or duviv.%which
emit hu�oev air cantunhmm a%dcFnnE by the Ulay Arta Air Quality Menugmtsnt BOIhIR-COM1'pHP OR Bi BTU) 2(YT
Dorri.t't
C]Yu U]No BOILER-COMP(OVI?k I[0.f1fM1 BTl))
AIR CON DI'DONER
I have teed he mr roh o%matentds mydnereent,c ander Clmprer 6 95 of the Cr i- ISSUAiJCE D
barren Hrslth&Safety Code,$a'dons 8505,25533 wd 255M,1 uMoamld mer if Go NEW RIS ID13Nf1AL META, SQ.1 � r' L (�
- 99
huddtng docs rot cunerely have a a ,.lint it to my ipnnsiKhty m highly lhm.upunr
of the mry ormem,which must h eel Pnor m tc%vmtcc of a Ccnifcme oI occa,anc,
Owner or uuthoriacalogcm (lets T(TI'AL' ISSUEDBY: N a
OFFICE