S 0891 111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
{ CITY OF CUPERTINO BUILDING.KLECI'RICAL PE MITNO.
If BUILDING DIVISION APPLICATIONWERMIT PLUMRING-MECHANICAL 0 8 91
BUILDING PROJECT IDE.NTIF'ICATDIN
SANITARY NO, APPLICATION SUBMITTAL DAns
4 BUILDING ADDRESS:
G l'zr
f 'N 'S NAME P ONE: CONTRA NAM /5 LIC NO:
NIC /� C CONTROL N
�ARCHRIiCf/F1. INIiER: LIC No: ADURISS: ❑ �P�
I CONTACT `4S` C*t% - ho BUILDING ELECT PHR LU INFO
( Y �Y` l ❑ Consultant Feu Paid by Applicant(initial) I ELECT PLUMB AIECII
E 'i
LICENSED CONTRACTOR'S DECLARAnON QTY ELECTRIC PERMIT FEE
l Ilemby,fr tom lmn Reemd oder Pro;,iom MCEaptcv(ewnn)ettcing JOB DESCRIPTION
OZZwilM1Smion]DW)nf Division3ofthc Busimm�,nd lNdcxzims Ctxk.ad my liccmcis I
W O p PHRA11'I'ISSUANCE
O W. in full brat,and elft. DWI. ❑KITCIDIN REMODEL
aUU License ChXi Lc.I APPLIANCES-RF_SIDFNTIAL (ADDITION ❑PLUMBWGRF.PIPE
FZW Dalc Cmtratm
I FSH ARCIEELTSDECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
Z l codenntmd my plum,hull he ucd ax publw' rmxJ.s MODIPICr\'('ION
v�
_ UPT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
En F F-C IicaW Profeuimul 201-I(XMIAAIPS - I.MPROVEh1FNf E]SW'IMMINGPOOIS
Q OWNHROBU1LDUR DECLARATION
x i e' 1 hemby offiml that 1 am exempt from the Convenor's Licenu Ltw tM tW OVER 11X111 AMPS O LITHIF ppR��IiMODiiIIItIJ'AIR []DEMOLITION
a V Ioilbiw ng nom.(Section 70313,Be,,.erd Pmfu�bm Cole:Any Chy of county SIGNS ELECTRICAL P'
3 t,� ,,,hien feynita a lemon to cono.,,Ilex mr,o,ve.demwixh,or fm u,eny..Ime
,!j:0� prioclnaxlrnuance'alw mquitvslhcapplicanl for v,ah pmintit In Blcv xiemvl,aahem., SPECIAL CIRCUI'17M1S,,
�'�Y thnt W is IicrnW pulstunt mine povir'tuau ofthc Cwt,xtm'f Lkcnsc hw[CM1nptu9
W�p0 (rommrncingwith Sallae]OB(Ilof Divi.unlMltte qusinees ml hvfwitma Cak)a TEMP.AILTIJt OR POIE IN. .
'a d Sec io is 31-5 b Iwny applicant
end the hasix it IW dkg0, cacmpnnn.Any d co coaly
of NEW HhD AI '� ❑DEMOLITION
LLx.�LL
Section]Ill 15 by vry mplicant for v Permit xubjmu the applicant m v civil Ir_rmlty of IK)H'UR Il1iVIC,ISS ��jAN( El FOOD SERVICE
nu trove then live heandrtd dulfl .(SN)0). (MPR
FZ6 SWIMMING POOL ELECTRIC _ II/I1�
2p will da,Wwttrk,and the mim
eucture is enfn
dedoxcrcd fw wIn(See.' Resume.,Resume. ❑DTI{I:R
F
ad Prywhonr Code:Tk Conlnclaie Landes Law rhesn applytolf rulerof OUfLEIS-SWI'(CIITS-FIX'I'UR6
Pmpcny who Wilds fein flim michn,,ownt Wase me,ork le,1 fofthough NEW RFSIDbAL El FC1R
his tvwm cemloye¢pm,;dd mm man itnlxmelrcntr x sM imrnded w Mfend fes
xak.If,Hwcnr,mebuildingerimpowenem ie,old with,,oreYw'r of emnplc,c the SQ.17,FLOOR AHI3A $fBQ.ET.
weer-W it c will have the When of prnvul,the,be did trot W iW w impta.'c fa Pury In �/1a
ptrc Msak.). T 1W�
I,u tater M 1M1e Pmpeety,mn e.admivdy conlmCling with licrnsal nmtnnun to 1 �T T
xutnlCl the peajnn[Sec.9111J,Buxincvs and Rafcxim¢Cwle:)'IW Ctmvenor'x 1.-
emel.awd,tee lest apply to on owtter of gegmYwW nwlt�mimptove.th<mm.cal QTY. PLUMBING PERMIT EEE "cio
who cmlrslx for such plajms with a rnntrectm(s)licensed pune,nt to the CmlRentri ��+
License taw. PHRMIT ISSUANCE
[11amexemptu rSm. .H&PCfurthismecca
ALTE]Rt-DRAIN&VE.NT R(LA) VALUATION
(Hoer Due t
ORkERA COMPENSATION DUCLARAIION HACK ITLOW PR(DECf. V ^�1 qi�
IherthYe inn under pnalty of icrJury arc of the fNlmtwing tlmlvm(mnc �/ 1
I] IWve end will foibin a im3`7uv ttfCmernt toCo,lensutelercl umhComprn- DRAINS-FLOOR.ROOF.ANFA,C STORIES TYPE CONSTRUCTION
solo,u hick thi fes in Sectio 3-((10 M the I�Wr Code,for the perfomtnna M the
I work ave mch ill moutiman ienwd. FIXTURES—PER THAM�
❑ 1 ave mc!will,,c,fo, i p,,f. Camp ofthe n I kfor nce.which
vh nquied by Section
J]W of Je L,bw CMe,fm lie Perfof^unc of the wwk for which this permit is iswd, GAS-GA.SYSTEM-I INC.Co ()CG.GROUP APN
My Wndter,Comet Inrut,rce canner moll Policy numm me:
Cartier: Policy Na.: GAS-13A.SYSTEM-OVGHJQ!AI
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF%INDUSTRL WASTE INTERCIJTO
COMPENSATION INSURANCE BUILDING DIVISIONIti15
( ,i.m,ionned not M completed ifthe Permit or toe hundi dollos IS 100) GREASE TRAP
m ur kat,)) I'LANCIIECK PGU vtr�
I cenify ohm in lhepemmmmcac:of the work for which do,pefmitif ivnnl.[,hall SEWER-SANITARY-STORM EA, FT.
rot employ,-Y Pce+on in any swmrcr m ns to hcmte wnleet to Ile Wmnm n Cosnpen. ENERGY FEE
ZO am In eusnf Cax1omly.Date WATER IIHATER WNIMAiLECR
GRADING PEE
h NOTICE TO APPLICANT:IL,m,making It.Cmif tc of Hvem inn,ytm hold WATER SYSEAUTREATING
F ; b cnoe,whJcct to the\Vmker,Cn.,ens,titm Mimi.,of the,LA Code,yes mum SOILS FE
C B,nnwhh emopty wi,b mch on,,iou,mr mixes Jt,hall W deems nvnknl. WATER SERVICE
a
6. CONSfRUCT10N LGtDING AGENCY NEW RFSIDFNf1AL PfAftl. SQ.FT. PAID
7 Z Iherchy,ffirm lhetiWnixncrostrtxvim lenJing vgeltcY for the pcHmrantt of D,te H iry♦
W O IWw.rk our which Thi.pwntit lx load QRm.J(lY].CIv.C.)
Q I- IcMcr,tante TOIAI.:
Icdcl,AJdtcss Q �y�
I emi(y incl I Wve rceJ(his eppliotLm vex[come(hal ole above idtnmadm is BUILDING V I ►�
V)t anfrecl.I,greem comply wish all cit,end,,mmy, dimmi and ame laws'Mmiing to QTY. MECHANICAL PER FIiF.
I V Z building cunarvction,and lemby aum, ire repmsenmtivo of Ni,city to enter upon the SEISMIC ��
eW vemrntimied prof cOy In,inspcnicn pufT— PERMIT ISSUANCE
(We)Agra m wvq indemnify end kcm Wnnkcs the City of Cupenino timm HLECfHIC FEE
linbilidttldgmenu.costs and,,noot_s which on,minty is,accrue aydm sed City'
ALTER OR ADD TO MECH. PLUMBING FEE
in PLIC ucncc Nrte RSTA a SNis permit.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IOOW CFl.f) MIiCHANICALII i
SOURCER 'EON
AIR HANDLING UNIT(OVER IB,OfA))CEAD CONSTNUCDON AX
Sign,�imtre><Appli ✓Commnt a !t(_- ete� VF�HAU,� OD(W/DUCi) HOUSING MITiGATIO,1{A%ARD([ SMAn{RIALS cmcuWIm CLO URE
handltall the epPlic,ntm Tatum building occupant uotmwhndkho,"^mmsrrote+WT(IU IW.DX)HTll)
m defnd by tie CumOo Municipal Cotte,Ctultic 9.12 ed the Health etld Safety
Cdk.Section 29532(a)o (OVER IW.NX))BTU))
❑Y., ❑Nn PAN(SINGLE RESID) PAIDDoe RcacilHeq.i'mcmwdericxswhich
,onI hmudms air cmamittantx ux jefineJ M1ythe tiny As Air Quality ManagementP(311P OR (XI.000BTU)monied TOAL❑Y'e ❑No MPfOVER I(q.(M)O BTU(
I hove rod the by ,Itos n ounalx nyuirementx mdef Chapwr 6,05 M ft Cali. AIN CONDInONI?R ISSUANCE DATE
fmvia Deollh&Safety Cock,Sunimx 15505.25533 and 25511.I unkn., n unto if the NEW RESIIIENTIAL MECH. SQ.IT.
Wilding doe,not ethroolly hater a local.IMI it is my mporeatility to eolify the tut,
of the eetryileme u,which mum W rte[Pfit'r to cs6omce of,Ceniftcue of Uecalotwy.
Owoa m euthonud,gent Due ISSUED BY:,
OFFICE