S 1815 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-P1LEcrRICAL Pli 1'I'NO.
BUILDING DIVISION APPLICA7'ION/PERMIT PLUMBING MECHANICAL 1815
BUILDING PROJF,CP IDE1NTIFICNI ION
BUILDING ADDRESS: SANITARY NO. AI'PLIGI'ION SUHb11Tl'A I.DATE
a O a b N m b e►- , '� v e.
ili'SN Mli: PHONE: 'ON'I'RAC'IUH'$NAMIi: µ''`` s hIC N(1:
_ q o ..,�..� �,.� Air
L NIC CONTRULa
• ARCHITECT'/ENGINEER: LIC NU: ADDRESS: 1 1 1 1 ❑
CONTACT. PHONE: BUILDING PERMIT INFO
I ❑ Consultant FccS Paid by Applicant(Initial) BLIND ELECT PLUMB hitch
LICENSED CON'(RAC'fOR:S DECLARATION QTY. ELECTRIC PERMIT FEE Irf,Q✓
1 hereby tern Na,1 am licensed node.pmvhbns of chapter 9 0sommeadng JOU DESCRIPTION
CMZ xi,h Sworn]1XXHof Divchv3of Ne Bloi....and Professions Codd,anJnry se licenis PERMIT ISSUANCE RESIDENTIAL'
W p
FLL- infall race send e7cry, 11L1 f"-' ��•t ❑SI'DN'I. ❑KITCHEN REMODEL
QUV Lcense❑ass ` APPLE ANCPS-RFS IDENTI AL F1 ADDITION ❑PI.UA/BING RE.PIPE
p-Zw Dare Contractor
ri6d
❑MULTI-UNIT STRUCTURAL
FoASIAN?LS MODFICTIO
N
ZZpZ In,airs ndIny thch—hell be used amithicneandx
O
4-+ UP 10 200 AMPS
❑IN I'I:RIOR ❑CHIMNEY REPAIRE.wNW I.iccnsed Prof u..immi 201-HXX)AMPS IMPROVEMENT [D SWIMMING 110015
I match,affrm,has I' am ex m ,frmnNER BUILDER 'the Contractor' s Licence Law for the OVER BOON)AMPS ❑BATH REM110DEI/Rlil'NH (]DEMOLI']'ION
6 A2-of
W r (:1 DTIERk36U h ng .(Section]0315.Business and 'ndesOde:Any cor county SIGNS ELECTRICAL
is. which responses t t t , at p demolish. p anY , mare
NONJ pool , 'l. 1 h ppl ,f hpf , flsigneda tcmenl SI'I CIA(.CIRCUIT/h11SC. '�.�.tJ .ler 0
>. Ih:IM1 Ip E, li p t rl ( , , 0 1 I' (CI Chapter -
�006+n+uai:,wJ SuE mJOfXO dD'v Xim9ef h,.Nti vsvi 11 R,.doty Cede nr fI:M P M E ITR OR POLL 1N S'T. COMMERCIA.: GE
G q o y YN
Nul he is exempt OcchcIrmn and the basis for the alleged ew pilon.Any—da inn of ❑NEW It1.DG/ADDI'1'IUN ❑FOOD
W_,n
Section 7031.5 hymil applicam for upenna,uhjcO,thaapplicant to a civil lxmlil of TOWER DEVICES I]IENANT ❑FOOD SER
n mom Nan live hundred dour,1851X11. IMPROVEMENT
SO D La.ownend,be propcny.m mY employees x'i,h wugcs as,hfir xde cnmpfnzmi..n, SWIMMING PO E,ELECTRIC
p. will du the work,and the.Hucmm is not intended nroRertN for sale(Sm.JHL4.Business ❑OTHF;R
W3 m and Profession%Code:'Ile Caamaor'e License Law does not apply m an owner of GMLETS-SWITCHES-FIXTURES
prapeny who mold,or imp rnse,,haes and whit docs each work himeflf or through
hlx witemployee,,provided Lha,eocl iimPrnwn em,are no,Tactual ur all"eyed for NEW RESIDENTIAL.ELECllt
ed,H,Iawc c,heballd'Ilsg ser inrpmv entisaild within()Ile Ye,r..t conliteron,the SQ.Er.1:1.019 AliNA� $ISQ IT.
owner-Milder w 1111co, heharden..fpreorng that he did not hander improve for put-
T /I'll
pow nr ole.).
❑1,a+tracer of the p,opny,amcedu.snely, contractingwi,n licensed contractors I') JUL 10 AMID
instruct the project(Sec.7(W.Ba.ineo and Profosiom Code:)The Cnn.Theam.Li-
is—Law does not apply to an owner of pmperly who build,or ln,pmec.s thereon.and QTY. PLUMBING PERMIT F ,
who contacts for such pmjces,with a contractors)licensed pursuant to the Contractors
011 VF wrCn11 Its)
Lissom Law. PIiRMI I"ISSUANCE
❑ lam cxonrpt under sac. H k P C to this
ACI'lilt-DRAIN k VI?N'I'-WA'T'ER IEA) VALUATION
Owner )ale
• W(IRKIiR'S COMPENSATIfIN DIiC1,ARATION ({ACK IB,OW PRDI'IiC'I'.UIiVICIi
I nerehy alRnn node.pe,alty of perjury one of,hc fallowing Jody tions:
Ihavf and will nuimxino Certihca¢af Conwnuo zdf-insurt for K'nrkcr.Campcn- IIRAINS-FLOOR,RWI:,ARfi\.GOND, STORB_q TYPE CONSTRUCTION
sa,inn,as pmvideJ far by Scainn 3]W of,he IvMr Code,for,he perinmiance of,hc
wnrA far whim,his pfnnil is is,ued. 1'1%TURES-PF.R"fRAI'
I hme and will maimnin Worker's Q+mpenemion Imumncc,see requited M1y Scainn
9]1X1 nlihf LaMrCude.forlhc pert rmm�cc..t Newark forwhich Ehis lmnnit is Leu W. CAS-L'A.SYSTHM-I INC.q OUT1,ETS
OCC.GROUP AIN
My War�(�Q rpenssliun In�ur�ny<e. i @II'nlieY nY !y
(hrricc�k111' )1'!'11 a L�YY �^YOaN�aUM Y�RK�b� CAS-EA.$YSTISM(1VIIR 4lHA)
CI?RTILIC OMPE SATIO I I
COMPENSATION INSURANCE GRIiASf%INDUSTRf.WAS'T'E INTERCIiP1Y)N BUILDING DIVISION FEES
GHis.writonneeJnmbecnmpined if,hepem,i,isfonmchundmddollas PHOOD) GREASETRAP - - -
I'LANCHECK PY:E
or less.)
I cenify,hm in the perfn,manec..Rhe work for which this permit i+ism(d.I+hall SEWER-SANITARY-STORhI EA.2(NI FT.
ten employ any proton in any manner so as it)Mena swzi dirit+tAy):('&In- ENERGY FEE
z +:nlnn hawse o ` i +is,.Dire ����— WAI'IiE I IEATER W/VENT/ELJiCI'R
Z 2 Applkanl GRADING FEF.
Nit]IC17 R 'PLICAN'Li IL alter making this CcnlBcatf of Excrupm.n,you should WAGE In SYSTEMn RI?A'I'INC
% SOILS IIiH
a tonhw its
Comply
die Wmh fl.COlnpfoVtic.perm,µtortlof l deemed rs Ar . mail
� IonhwiN romply with such pmv+.+ions or lhi+penni,shall MdnmeJ res Art. WATER SERVICE
0 PAID
UZ CONSTRUCTION LENDING AGENCIagency NEW RESIDENTIAL('LMH. SQ.FII Dam Receipt p
U 0 thereby:dlimi that naconvmninn lending agency for the performance of
LL [r the work for which this punnk,,i...ed(Sea.3097.Civ.C.) TOTAL:
O Lender,Name '10'I'AI,:
LULL Lender's Are... I{DILUINO FEG
I certify that 1 have read this application and state that IM1e above int..nnaunn is
F" (/] a+nfc,.I agrccwmn,ply with all city nnJ umn,y nrJinancc.and state laws relating to QTY. MECHANICAL PERMIT FEE SIiISh1lC lei",
Uz building cm,swc,inn,and hereby amhnrim mpmcn,mivcs oflhisci,y a+cnterupon the
aMet.imlioned property B+rhopeeli..n pmryocs. ' PERMIT ISSUANCE lil.l[CfkIC FEE
(We)agree hs save,indemnity and keep females+Ne City of Capetian against
I labilincv,ludgnmm.,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of thls penoil.
APPLICANT'UNDERSTANDS AND WILT,COMPLY WITH At.1,NON-PTHN'F AIR HANDLING UNIT 00 HtkXICFM) MECHANICAL FEE
SOURCE RECULM ONS,
AIR I IANDLINGUNI'1'(OVER 111(XX)CFM) CONS'IRUCfIONTAX
Signawrc of ApplicxnVCnn,amor Ua,c P.%1{Al15T HOOD(WNUCfI 7 []DOSING MITIGATION IIiE
HA]ARDOUS MA'IRRIAI S DISCLOSURE
Will,he applicant nr future buildi,ocOupnn,.hme or handle h malts material IIHATING UNIT(10 100.{X0 H'IG)
as defined by the Curys,im+Municipal Cose,Chapter 9.12,and the Health and Safe,,
Ode.Scatiun 25532oo! J IIIiA'fING UNIT(OVIiN IINI,IIINI HTO)
]YiY j(J No VEN'IlLATION PAN I$INGLH RE$ID) I'Alll
Uatc Itccci PE#
Will the air coria in a nefJ ng by the Bt use d,riArea
Air Qu nr devices which BOILER-COMP OH1'Olt 100).0 0 RTU)
emit harallous air umtemsndn,x see JefnW by the Bay Area Air Quality Management TOTAL:
Uis,rict�Ya No BOILER-COMPIOVIiR I(p,(Xp BTI17 �/
I have read the hwamou.material..requirements under Chapter l 95(if the Cali- NH CONDITIUNIiR �SUA CI:DATE
lomla Heullh S,S:de,y C,dc.Sections 25505,25533 and 25534.I undcroE 6 Lha if the NEW RESIDENI'I AL ML!CH. SO I'll
bufilm,dosle oat cunen11,havesa, 1,LhaaIronyhs,croibility II....Elly Nfe+e:apaa
of ,, n'uew y LLehne niclyriyLhr i..0 Ccnil t
Oraahnrirsagcm Date '1UI'A h: ISSl11iDI
' d ---
OFFICE