S 3958 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERAHT PLUMBING-MECHANICAL S 3958
BUILDING.PROJECT IDENTIFICATION
BUILDINGADDRFSS: SANITARY NO, APPLICATION SUBMITTAL DATE
DUrr-c- D2\vc-
O ERS NAME: _1 PI GNE: CONTRACTOR'S NAME: LIC NO:
Iv.V N a , N/C CONTROL«
ARC CTrENGINEER: 1. NO. ADDRESS: ❑
CONTACT: PHONI_ BUILDING PERMIT INFO
❑ COnwltant Fm Paid by Applicant(Initial) BLDG FI ECT PLUMB MECH
5?-, ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 nearby�dm,n that I art hanged under rprvi.idea or Chalrer 9(sopecocing JOB DESCRIPTION
wOZ withSectirn]DIO)of Dvuian lofthe HurnewamllTnfcaituu Ctde,.rW my licemeis R CID NTIA -
O PERMIT ISSUANCE _F F I'
F - full furtt.nd effect.
y'1+1 ❑SFDWL ❑KITCHEN REMODEL
HP.ZW Llano:Cleo Lich
N<i E,U DNe Contranor APPF,IANCPS-RFiSIDENTI,\L ❑ADDITION ❑PLUMBING REPIPE
1-=. ARCHOECTS DECLARATION PANELS ❑MULTI-UNTP ❑$TRUCNRAL
Z O v2 Z 1 uMmtxrd my plot,shall he usnF no public records MODIFICATION
OZ—M UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
F-y F-W Liccmcd i'mfevienal 201-I0MAMPS IMPROVEMENT
a _ OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
=— 1 hcrehY vRm Ihel 1 nm cxernp from Inc Ctntina[Iols License Law fur the OVER 1000 AMPS ❑BATH REMODELfREPAIR ❑DEMOLITION
3 a U reproving reason.(Section 1031.5.Has.,vtxl professions Cud¢Any city or munty SIGNS ELECTRICAL ❑OTHER
0 which restarts•permit to csruuum,alna,impme
r ,denNi.sh,re repair any slmnlne
imcisiaparce,al...requlresthc apPllenm fp,otch prnniuo 0lnusigeedstmemem SPECIALCIRCUMMISC.
��" Ind nenheemed Err....,,,to lh<pmvinau nrtha crtttr.ett�.Lken�e lew(enager9
C�G� Uummeeeing wile Section]0(M)rf DivisianJufthc Nusineu oval Rn(asims Ctdc)nx TEMP.METER OR POLE INS , COMMERCIAL 1
a d 00C that he,i.exempt Ih—hor,and Jte hesia Ir lint,allcgcJ exemfnioa Any violue.of ❑NEW BLDG/ADDITION ❑DEMOLITION
X Q+oo Section 10313 by any applicant for.pe.,wbjms tnc.ppn•,n,to•civil pctW1Y of POWER DEVICES
I✓:-'n ❑TENMT El FOOD SERVICE
HGten rose than live M1 P"Pe Uol-t ycer,l.
❑ Lu owm ar rbc poperly,umyamphoraswith wages..theirsere c ,Bunion. SWIMMING PO01.ELECTRICtaft A, Duff EMFM
will do the wort.Cd the heoreacture isnot,Lineal or Law
co fu sale(Sec.Nin,owner
of OTHER
C 3 m and Professions Cade:The CtaJreeltV s itnJ w do dao tW apply In.n mveer of OUTLETS-SWITCHES-FlhTURES
hi,
who oys,lil w tmlroves Ovcon,oral wtro dues such work himself u flocodeed for
hiv own owe er.fli Watch,
r r such inert i, tM ere not i cardfJ«pDera,for NEW RFSIDP.NTIAI.EhEClR `!oFr
sok.ILhwer%HT ebuiWingurimpnvemrntis wM witldnx burld afrneave Tri tie c. SQ.FT FLOOR AREA gISQ fI'.
Tier-milder will Mac ik M1UNcn of proving Beat k did rxt bwlJ or improve fritter17
-
�cn.
m'( r of the Soc,7(Y..tn caclu golf mnusling widt:ic pho CcrverxYm m TOTAL:
cranoemo (Sec.lllal.Business eml y no Inui Codc:)'lirs,ith r'a nal!
amcLaw
racts not applywan nwncr of propmy war buJJs rr impmmthcran.and QTY. PLUMBING PERMIT FEE
wlM cmtrenssuch Erojecu eilnnnwr.ctu(s)IiansN pursuantw lheCmtrrcta's
U'.low. PERMIT ISSUANC17
❑lam excm h R. ,B&PCfrrehis.
�OFo - Dare ALI'I7R-ORA1N&VENT-WATER IEA) VALUATION
'SATION DECLARATION BACK FLOW PROTECT.DEVICE O O O
Ther punallY of perjury one of the fol lowing doeua .e uun
C] Ihavc ill mainuin eCmif Icof ConsrnnosdGinwn,fu WMer's Cecnpcn-
DRAINS-FLOOR.ROOP.ARFA.COND. STORI TYPE CONSTffDLTIGN
mo
tion,us provided fur by section 37M of Ire Labor Cade,for the peffonnance of an,w /
work far which this pc rod e,isweJ, FIXTURES-PER TRAP (/ v
1 Nowt anal will maintain Worker'.Corrytens,aim Insurance,as rtyuiral by Section
37IMaftheI,Na Crlc,fonMlcrfomtveeeafthc work forhen this Erma,is iaoued GAS-EA.SYSTEM-I INC.a OUTLETS OCC.GROUP r AP��
My Worker's Canftenwim Inuverxc earner iter]Policy oumbm man,
Camkc Polar,No.: GAS-EA.SYSTEM-OVER n IEA)
CERI'IFICA111 OF EXEMPTION FROM WORKERS' ® Z
COMPENSATION INSURANCE GRE- SMNDUSTRL WASTE INTERCEPTOR
tlhis rection eecd not hecontplmed dlhcpcnnil is Etratc hunt edl dollars(V00) BUILDING DIVISION FEES
cr ksc I GRFASE l'RAP PLANCIIECK FRE
I sully slut in the padmrwa ofte,work for which this permtl is issunl,ldull SEWER-SANITARY-STORM FA.200 FT.
z
nnl emm ploy any persin nary career so to to Irum.t ma a th
bjee Worten'Conifer- PE
ENERGY E
moi.Laws of Cdifomia.Dre
Q WATER HEATER E
W/VENTT1CIR
z O ant GRADING FEE
NOTICE TO APPLICANT: SOU
r,aface C.ampmaking This Cedif Ie of Excmptkoc year should WATER SYSfEMIIREATING
E ; bccorrc nuhjecr Ir the M'orkch Cuemntxn nov
pisinm tO Jte Istnr Code you u.m S IHE
fmhvah comply wish such Prnvatum ur this Permit shall de decntcdreveked. WATER SERVICE
Q
Uz CONSTRUCTION].ENDINGkd,hrAGENCY NEW RESIDENTIAL PCMB. SQ,FT PAID
V. Thereby aR thmlMeif.cwmmc.30D,tCivc agency rOr the performarcc of Dec RaciptN
V. .. the wink f«which this pertnil a issued(gu.309].Civ.C,)
p U lender's Na. TOTAL.
Wlerdcls Addrear TOTAL:
AiI certify rhnr 1 have real this upplicrac.anal sae then the aluve infom mirn is G FEE
h conceded I89cce 10 comply with all city and umnty Ordinances and state laws relating a QTY. MECHANICAL PERMIT FEE
C..) ,Z buidingmnstmcdon,aM lrerenyauthonve representvivc.of lhiaciry lomta rpm the sEis FEE
uhovcannrmcd puprny Gr inrpatinn purports
(We)agree to sat,indemnify.rel Id e i h.rmku the City of Cuperdnr against THSOL ISSUANCE EJ.E IC FE i
IiaMIiJ«,jW ms,cosrs and expntscs which may In acy way accrue against said City ALTER OR ADD TO MECH.in ronscyu f ,onto,of this Pemti,, PLO BINGME
APPLICANT IN 'RST YDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO 10.000 CFM1H FIE LAICAL FEE
SOURCE 1 O11 XN, I
AIR HANDLING UNIT(OVER IONO CFM) CON STR ON TAX
tgrumrtM to Dale EXHAUS'THOOD(WMUCT) HOUSING IGATION HE
US MATERIALS DISCLOSURE
-antrr lcture hodtingnrcupanl store,,handle hamNuunnatnrl HEATING UNIT ITO IIM,W0 BTU)
a%do y the Cuperlim Munkipt]Code.Chapter 9.I2..rtd the He.IN and Safely
Code.Section 15532(u)] HEATING UNIT(OVER 100.000 BTU)
p Yes L]No PAID
VENTILATION FAN(SINGLERFSID) Date Receipt WillroEllam o ,xpu
c., r Iran,hulldiagcunt ore oce,rcm Jevlem of which BOILER-COMP dHP OR 1W.000 FOU)
end,herardou.s no cOnumnunts-defrred by the R.y A.Air Quality Management TO
D saki f
❑Yu 0N BOILER-COME(OVER 100,IX0 BTU)
Lha to lta.,New T:nenWv resuiraarCrtln utxlcr Cnr fi.95 of the Cdb AIRCONDMONIJt
per ISSUANCE DATE
fan Ix Hersh y Cd Secdue]6516,25533 aM 255?n.1 wvkdeM Jut if the
huiding docu Jy an4 thrit is my rnrymdbility In oci the alltwnl NFW RFSIUGTL\LMECH. SQ.FT.
a Jac reteire t vendee of v Cenlbeale of Occo'ne'. h/rte �O
tier nry t
Date TOTAL: ISSUED BY,
OFFICE