S 3236 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCTRICAL Plzµ if NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL V 3236
BUILDING PROIF.CI'IDF\I'IFICATION
BUILIIINGADDKI'SS: SANITARY No. APPLICATION SUBMITTAL DATH
1-ti MOW
(IWNBR'S AMEN PHONIi. CONTRACTOR'S NAMH: )u I.IC NO:
i + q SIC CUYfRO1.M
`ARC ffECT/ENGINFER: LIC NO: ADDRESSAAQ4 ❑
111. 7
CONTACT. PHONE BUILDING PERMIT INFO
❑ Cnnsullaot Fees Paid by Applicant(Initial) NLDG El PLUMBMliCll
APWqLq O- -• O l A I ❑ ❑ bd ❑
LICENSI!U CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I her,hy elan,Inns I an,filer"i no&,prnri.innF m Chapin'n(emnnwrcing _ JOB DESCRIPTION
Z width Section JOIXB
0 1Di—x,n3of be mioev ad Pmfacimv Costs.amy lieem„F PERMIT ISSUANCEISSUANCERFSI)ENTIAI,
CZ,
nd fail f«cc vrd=R ❑SFl)N'L ❑KRCIIFN RGIODFJ.
< hittnFe Clava Lich
Q U AIis 'I'LIANCIiS-RESIDENTIAL ❑AUDITION [I PLUMBING RUI'IPE
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ARCHITECT S DECLARATION 711 C+ ❑MULTI-UNIT [I STRUCTURAL
~hZ Iundervard my Plana shall be uFed m puhlc n,onla PANELS MODIFICATION
O Z=4-a: U11 r03g1Ah1PS ❑IN'ITAIOR ❑CHIMN17Y REPAIR
QNFJ
Licensed!Professional 201-10011AMPS IMPROVEMENT SWIMMING POLLS
a a IX Q I hereby aRinn
OWNER-BUILDER that I EIA tDECI m the Conlr.cf wt's licensee how for the OVER 1000Ab1PS ❑BATH REMODEIAFPAIR ❑DEMOI.ITION
W U tollowmr=1 n.(.9,ctian 70315,Bueircva and N,evions Gale:An,city«.only SIGNS ELECTRICAL ❑ 11'IIER
3 W y
� which arcane,s Pe rm cnnw.,h,h,r,imlan.=.eearrAW« epor any wucmrt
I—
Lie, ,;«min na.v,n«.a1w,n ,lil�atl<nl'rBcem r,.Fnen permilmrlcaFigned ame nem SPECIALCIRCU1T/MISC.
�yytyyIIdlv,isliccnwlnmwunl nr0¢pmvisiuns nfnM Camma,nrn Ucu,w lsw(Gegea9
a'CQ (rommmx�ingwith Scctu,n'I01XIlof Division3 ofthe B.sirteaa are Embeasi«u GJelor TEMP.MLTI:R OR 1'OLE INST. COMMERCIAL
a a e Inst he is,xempt therefrom and Ik Msis for the allegd cxcants or.Any violation of ❑NEW BLDG/ADDITION O DEMOLUHON
r, S.atoo 2131.5 by any ap im Toru efinit subjccls nM1c.pnbcanl m a dvil ry:nafy of IK)WER DEVICES ❑TENANT ❑FOOD SERVICE
N none than five hundred Mims(SNMry.
I-Z Y IMPROVEMENT
W williaammefoflM theerosior myomnbodarl wiNwagu aatheirwk7044.B mess SWIMMING POOL ELECTRIC ❑OTHER
will do the work,Co the ire Comon,is ti—I-Lada!«oifertd Rrt W Ie(Sic.lyto an BEvmuF
413 o4i and Pmrusinns Gee:Th,Cnnlracnxi L¢it s Iww Jcex not apply himself lf rth of (R1'IL?I;S-SW HCIII!S-PI%'IVRES
L
prelpedy men wM Elks.po imnn,rca J«rmn,send wM,Joum m w«A ddnameedfor
his men amp the providd That such improreold w thin mg intended«oBmd for NEW RESIDENfIAI.FI.ECIR SQ ICT.
sale If,bmvever,the huikling nrimpmvenrnl is sold within mmyear of ttm,plminn the QE'
.IRIX)H AREA S/SV.PT.
rcr-builder will buve the burden a1 Easomi IMI he did mo bold or imprnve for pm-
nose.of mleJ.
❑ L as nwrcr of[be Mince,am exclusively nxnractin8 with liccnsd contractors In TOTAL:
Instruct IM Iruject(Sec."10,11.Basmocrs and Prolusions Code,,)'Dw Commenor's Li-sense Law Does hit sti to un nw,rr of pmpeny who ltuJJt,m lmpm.v.therms.arta QTY. PLUMBING PERMIT FEE
wMcoeares f«such prnjmlewithacomiscrod,)licensedPwsmint Into,C,a.r'a
Lkcn.m Iuw. ITRMI'I'ISSUANCE
C] 1 em eaemq mdcr Sec. .B h P C fm thla«uvm
(lw'nm Dale ALTER-DRALYR VIiM-WATER IPS) �J VALUATION
WORKERS COMPHN SA'I'I ON DECLARATION BACK FLOW PRQITCT DEVICE H.
IberebyolBmlundcr paellyof pedtay sa of the folkning Je,lththims: "'I
I lane and will eminuina Cerif I,ofC.,1.self-inture Or Wnfl:er's Comlerr DRAINS-MOOR.ROOF,AREA.GOND, STORIES TYPE CONSTRUCTION
wtim,m F«ridd I...by Smtion 1700 of the Icon,Cone,f«the pcA«mance of nM
ort mr which Nis permit a iamd, Il%'I'URI:S-PER TRAP
111 tune ed sill nes,fin Wnpr Tia Gmy of 0m on A 'c,as requi 1 t i Sssued
"TRIO of tlwfav aSb«C«e.for 11`M,pmreccyrtncte nfnM1cwdM for which his pcm,it is issucA, GAS_FA.SYS'IFJN-116C.40lTl,ld15 (>CC.CROUP APA'
Carte='`�.�71`�`rli" Kt Policy No:zjkk"0IEIR I GAS-G.SYSIEMOVER4(IA)
❑3R HFlCATE OF FAINFIDlN FROM WORKERS' GµGSf%INDUS'TRL WAS TIT IN9TRCHl'IUR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This i.rod rW be complete!ifthe peemit is for hurWddnla,,($100) GRGFSETRAP
«las_) PLANCIIECK Ile
I cenifytMlin the perfxn,nnceo astorerkfmwhich thio Pnnni1 ,r%'d,Ishall,.- SI?WER-SANITARY-51ORM G.MXIIT-
nm employ any Purxn in any n,unnu.a as w hadnrc vubjml w 1M WMm'Gddnpen- FSENCY FLE
OZ .tion laws of CeliGm,ie.Date NATER HEkTER W/VENDELECIR GRADING LLT,
z o Apphcanl
NOTICE TO APPLICANT:IL.flet neaking this C,r ifiute of EFetnption,you sbemd WATER SYSTEMl1REAHN6
? b,s.a brei nethe Worse,Co.,..leaski«u or of the LabCole,you must SOILS ITE
W foAtwas comply withamhpmvis'vmm hispenandehlt he damN rtvnkd. WATER SERVICE
Q
7Z CONSI RUM IONLENDINGi.l6GENCY NEW RESIDENTIAL VLFIB. SQ,F1'. PAID Date k—pc qN
U 0 Ilrrtbrich Imllutthert isoacd(. xrion l,diog sge^c'Y for the perf«rmncx of
Ihe'mier"hN which nM1iF pCn„il is is.dlScc.31MA.Civ.C.)
L10 f~ IanJcr's'Nanc 'I[JfAI_
LLILrntivl Address TO NMUMBINI
OE?
I certify thin I havc read Nis appllovmn and sone Iles the alove aberration is
tH-dN
correct,l.gramumTly vim all citymdrn...y nrJnnmr..me stat,laws mladng to QTY. MECHANICAL PERMIT
U Z huildine,a¢anctien,send!berehyaWxno,erelreamstivea.f Nit citymenmr,uEsen theEE
.. ubor,-memnnrc.l l nali BN imix,tion Efil ”. PERMIT ISSUANCE
(We).gree to rare,indemnify and kee,Iemdev the City er Cupertino.geiml ITL:
liahilltics.lndgmcnne.cna ard" Ban awhich hey In any why occur,uguins.uiJ Cily ALTER OR ADD TO MECH.
fia mmryucnc,nflhcl tinpo 1 sp i1 Q APPLIGNT UNUr .STA AN WIL t LY DLI.NON-POhNT AIR HANDLING ON!'I'QO III,( I ZjSOURCE RF ION. .LTG
AIR HANDLING UNIT(OVER Io, 1) fRUCTION TAX
Signal of "'c" C uuLi I Due IWIAUSI11001)(WMUCf)
HAZARDOUS MA'I'ERIAIS DISCLOSURE HOUSING MITIGATION I'GE
Will the applicant«furore n,iding«,.pain slme«haMk hnaadaus mthenal I ILr STING UNIT(TO 100.006 ll
as ceirsed by the Cuncnino Municipal Cock.Oerycr 9.12.and the Ile,lth ad Safety -
Coi S,clino 25532(a)? F117NI'ING UNIT(LIVER I0Xl(S I BTU)
Yu No
VIlTIIfATION PAN(SIKGLIiRESID) PAID Ih¢ RccciplY
Will the applicant or f.mm M1aikingoeeu!'unl use equipment or devices which BUTLERCtIM1'fJlll'OH100.000 BIT)bmurJ«u air roamed ,tes Jefi,ud In, he it.,Area An Quality Maw -
gement , TOTAL'
�Distinct,.
E3 Yes LD No BUTLER-COMP(OVF.R 100JXp BTU)
I
have read UseMannkwx matendx rtqu'uerrcNs duster Chapter 6.95.!the Fish- AIR CONDITIONER ISSUANCE DATE
ban ia Ilcallh k Safety Cdc.S«Nxru 25505.3553.1 undf iSS.la.I udcrvud dun if ike NI!W'RESIDENTIAL MECH. SQ.IT. / �)
hailding Juadmuvrretily b.rc a ofii hnt it k my respesibility to anify the tccupata
'if its,«yainamenl..whim moa he nen Prior asawa rte or.CeniBcam int Ceactsai.
Own''ur nutboniN rg Date TOTAL: ISSUCO BY: 0
OFFICE '