S 0201 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING R OJECT II)MECHANICAL S 0201
BUILDING PROJECT IDENTIFICATION V
SANITARY NO. APPLICATION SUBMITTAL DAT!!
BUILDING ADDRESS:
el 345 ev�w _ L 1�t
OWNER'S AME: ` / V- PHON�3-43+14 C�4ACT Rl NAM` / I( LIC NO'.b831U . N� CONTROL♦
RCHITECOENGINEI!R: \✓ 1-1C NJ/O: AD 4144 Huihlsvi �. ���,i1�Y ❑
CONTACT': PHONE 7,Y BUILDING PERMIT INFO
S)o ��� ❑ Cwuvltant Fees Paid by Applicant(InidaI) BLDG ELECT PLUMB MMI
1 JJ\ ❑ ❑ ❑
LICENSED C(INTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FTE - JOB DFSCRIPTION
1 hereby of ion Nal 1 oat llRmd under pmvisioes of atiNer 9lcommeucing
=�Z wiN Setion](IlMll of lliv'ivonJof the Husines ad RofessiumC anJmylicenseis RFSIDENTIAI:
Yl C (� I'I:RMIT ISSUANCE
gwr infullforce unJ etrecl 031`t ❑SFDN'L ❑KITCHEN RF1.10DFJ.
FFQ--UZu Ltatlx a Cao APPLIANCES-REMDENIIAL []ADDITION El PLUMBING RE-PIPE
oola ARCHITECT'S DECLARAIt ❑MULTI-UNIT OSTRDCTHRAI.
f- Z 1 udersmmr my plans.hall be usd as mblic mcmds PANELS MODIFICATION
OZ- C UP TO 2U1 AMPS ❑INTERIOR ❑cium NEYREPAIR
(=',3FI Licensed Pmosiomd 201-I"AMYS IMPROVFb1 LCI' OSw'IN1N11NG POOIS
�yf,
OWNER-BUILDER DECLARATION OVER HJEAMPS ❑HATH REMODEI/REPAIR 0DEMOLHHON
e'Iz a 1 hewn,N Ihv 1 am event"form UK Cdurectr s Lketue Low fw Ire
K L U foll wing rcr mr(Sectial 70]15.Busircry vol Profusions Code:Any cily'x colody SIGNS EIJ:CfRICAL (nH
3 a which Ili o Permit to cnnsaun,alter,improre,demoli.h.Irc tele it any stmewc
ImM to lu icvuareC,elsoreQYlres Ne ap,lwvlu f«}ucnµ+mit A flcesi'md! orclnenl SEECIALCIRCUITINHSC.
thol lm is liurnvel putwunl ml he pmskionvnf the CnnvonorS Lice"law(Outpte)
�2'OQ (mmtrcticin,wiln Seetion7")MDmAW Joflhe Bminere it Poll Nims Curie)or TEMP.MITER OR POLE INS'P COMMERCIA.
a a t ,he it cormµthemforrn od IM bus fer tK allege!exemption.Any viol.nkm of ❑NEN'BLfH'i/ADDITION ❑UEA101.fIlON
Seclino 7031.5 hY any opplleam fm a peori,sobjmO Jo opplicem lou rive!pcnolly of POWER DEVICES ❑TENANT ❑FOOD SERVICE
ria mate Jun five M1undtcd delf.($W). IMPROVEMENH
=O Las owner of Ne prtped,oe my empbyas with wages ore Their sok cemperlaluion. SWIMMING POOL ELECTRIC ❑OTHER
h. wJldoNwso,k.ad Netrocmmlp rte tnmdnimoBetdforlole(Sec.7(U ,BuMor.
ad professions Code:The Con Or's Liter,Law Joe tet apply or as owner of OIIDETS-SWITCHIS-Fl%TURCS
a 3^ ,ml,who buiMl or imPorws thnarn and w W duo such week himself ser dbvm t h
bis own employee,pm,idecl Ott such impmvettenl,an:not imendcd or offend fw NEW RESIDENTIAL 1!LECTH TJ
We.If.inow,the Wilding or imptowtre,w sold withinmm ycarofct.rlpR,ion.the SQ.IT 11-OONAREA 5/SQ.1rL
moor-Wilder will flaw the burden a I roving Thad M did ort W id or improve for fol 1f�
'otof wled. TOTAL: P A
,e L m lone of , See.7 ,inesiwly contructin8 with liecnad vmttractmx m
cmwruct the Pmjttt(Sc<.7013,Busirc.Nz and Pmfexvw CoJe:l Tie Cauructsrs IJ-
xclywdto.rseepplYloetithiomrupetywerWilds.a, TcComird,luvl
QTY, PLUMBING PERMIT FEE JUN 24
wro amtma[nr seen 1miata witn.emtr,rtm(a)Rcenacd pnt,nant m Na cmttmcrR a 'D
Liccnv'c law. PERMIT ISSUANCE.
01oatese Norder Sz. .B&VChrNi-etome
ALTER-DRAIN&VENT-WAIEN(EAT T]ON
Owrcr Dam � O
WORKER
doder'SCOMPf Ermur on UECIARATI ON BACK FLOW PROTECT.IIEVICL'
.�M wahereby alron.Orpc*uhcare.furYnneof bee follow
burreingworder'sCs:
Qlhew arlo wilt!fort inection 17P)of the icmto Cod,orefor WorkersC ofthr DNAINS-FLOOR.R(1(1fi ARl:1.CUND. STORIES TYPE CONSTRUCTION
sated,!, r phieh Oil!mi Ss ode 9]1X1 of the laM+r Cdq for the pcNomlwce n the
wort far which illapatenis is.ned. FlXTURES-PF,N TRAP
1 how ad will maintain a ed(s Cmec ofEi,w Irkfor w.which
as myuimr by Section
370X0 o(IM1CWWrCtdu.for Oe n(Ihewnrk for which Nis permit is iuud. GAS-BA.SYSTEM-I INC,HOUTLETS (xC.CROUP APN
My\Yorkers Cmtpertution In.sommS,curie ad Policy number are: PI
Corrie,, Policy No.: GAS-EA.SYSTIJN-0VER J(EAT '(
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTP.INfERCF:PIOR
COMPENSATION INSURANCE: BUILDING DIVISION FEES
O11rsseetion tied not be complad ifth,Terror is foram hooded dmlon(S 100) GRI3 SETRAP
a Icsr.l PLANCHECK FEE
I mnify NY it Os perf.wfthwnrk fmwbich this,.'ili.wted.I,ball SEWER-SANITARY-STORM C\.21X1 FT.
cwt employ anyµnett in any monrcr rsu/Iabcr9rp9 {'the Wodns'Carnµn- FNERG1'FFJ!
Z ,aeon laws of Cwt Dam„ Y"l WATER HEATER WNEN'VELF.CIR
ZO Apps seat NIX- t rlcnnm0 Flee
In NOTICE'TO APPLICANT:If,after making Nis CertiHcwc of Exemption.You eou)d WATER SYSTIP]ll"L'ATING -
abuconte_hjem to the Worker,Cmnpcn.uuiun pnwivimo of the labor Code.you toted5011 9 FEE
-. forthwith comply x'ith such Pruvisions orchis permit shall W deemed!revoker. WATER SERVICE
:Dz CONSTRUCTION LIliDINGAGPNCY NI!W R[SIIIIiNTIALI'LN1H. SO 17, PAID Dam Reset,N
U Q I hereby.hthi gnat a,is road!( ee.30!eaten. .) Rrlee lxNomtenaM
� IM week fm whch Nia permit iv ivud!See IW7.Co.C.7 'TOTAL
p F"' bodere Name
{U11 fir_Ami TOTAL:
0. 1 certify Illy 1 have reed Nu applicviun onJ stye that the abase inf«nuaimt u BUILDING RE
N mtsar.1 epos to comply with all coy ad county orJimnccs onJ stale lows relating to QTY. MECHANICAL PERMIT FEE
U z h,Wil,emoometim,and heathy autWxix repeeenurivca Nthis cilymemeupon the SEISMIC FEE
adw-meationd porpctty for Inspection pm,m;cr. PERMIT ISSUANCE
ELECTRIC RE(We)agree to love,idcn rify end keep hu mere' he City n[Copcninn 1-i-11
liabilitin.jdgrrcnu,costoad capemes which may many wayacnueageiw said City ALTER OR ADD TO MECH. PLUMBING FEE
in mmequerce of IIB gevlHng of thisµmoll. -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT110 o,IMXICFM) MECHANICALFHE
SOURCE ApI.ATTONS, /1
AIR HANDLING UNRI0VER 10,00q CFFD LT)ryS'IHUCTION TAX
Sight oy,fit sstm Doe EXHAUST HOOD IWmum HOUSING MITIGATION FEE
HAIAItW I MATERIAISDISCL 'URC
Will the applicant urfurre Wilding ereupanl store or handle hvsrdod'retteral HEA1INGUNH(TOEXi0aXIBTU)
as dAleM by tic Cu,Psmor Municipal Cafe,Chapter 9.12,and the Health ad Safety
Code,.Sefton 2551).1° HEATING UNIT(OVER I(IO.000 BTU)
0Ye. ONo VENTILATION FAN(SINGLE REST) PAID --
Uam RareµN
r e
Will We applicant or future building aeopsom use eatuip l or device wmeh as Jef BOILER-COMP IIITP OR IIXI,fXE HTO)
Il tit M1ueeNoua air mmentinonu b IN, Hay Arca Air(7uality Mwugenxnl T( AL:
Disorder' BOILER-COMP(OVER Ifalfat)BTU)
oyes ON.
I haw nadtbe haaa materialsode Clsaptcr 6.95 of Nc Cali AIRCONDITIONER ISSUANCE DA9'F,
(moor Held,&Safey Coda Neco,na 25)15.25533 vol 25531.I undnseoal that if the NEW RESIDENTIAL NIECE. SQ.FT
Wilding elms Ilot currently hove a tco,en,that it is my re.s,soellhilily In maify the m'evpont
a One reyuiremcma which rtuu be err pnm In icsuarcc a.Certificate 4 Occvlwry,
Owar«uu oriudogem Use¢ T(XTAI_ ' ISSUED BY:
OFFICE