S 3107 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.DINf:-ELECTRICAL PI IIT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMB INI:-MECHANICAL J 3107
BUILDING PROJECT'IDENTIFICATION 3•
BUILDING ADDRI'" SANITARY NU. APPLICATION SUBMI'TIALDAI'F
bel -IFA- Ileenl Le4f
(lWN AMI:: PIIONB CO, Q R"N 1E LIC V(l:
�4 .1r� �T /�� Ile NIC COMTROh4
ARCHHECUENGINHER'. _-+_• LIC NO: l� ADD S: W //dee1 ❑
CONI'nCl; PHONE (/ BUILDING PERMIT INFO
❑ Con ad and Feel Paid by AppliraM(Initial) BLDG ELECT PLUMIV MSCI!
❑ ❑ ❑
LICENSE[)CONTRACTOR S DECIARA'I'ION QTY ELECTRIC PERMIT FEE
I hereby Alm dn'l am hw
aed pr sinter evio v of Chapter 9(cam
nenclns JOB DESCRIPTION
BOZO with Section 900)uf Divisim 3orde Rueinosond Profen, ax Cede.endnry license is PERMIT Fes_ in full Grlve and�c^Rm•.�N 9 SR)WL [I KITCHEN REMODEL
Va6U 1Ode O'i't" �'N APPLIANCES-RFSIDINI'IAL Ll ADDITION [I PLUMBING RF.-PINE
a Dam Contmorz
ARCIIITEC'1'S DECI. RA PANELS OAtUhTI-UNIT OSTRUCNRAI.
to Z 1 undcrswnd my Mann,lhad A uscl¢s pthine renis MODIFICATION
OZ--'0 UPT0200AMPS OINTERIOR ❑CHIMNEYREPAIR
�4t:lil Liaoal Pade'socal 201-IUM AMPS IMPROVINENT OSWIMMINGI'OOIS
�Y=-] OWNER,BUILDER DECLU.AT10N C OVER Iff0AMPS ❑ATHREMODHAHRAIR ❑DEMOLMON
0.' C I haruM1y.dfirm thus I etll.n..nq Ir..lr IhL Cmlmvl.!'J License I.uw hr the �
3 3c U IMlowing o,a tl.(.9eema]8313,Businesx cud professionals,Cale:Any cily aerw"ty SIGNS ELECTRICAL. HI;R e
which r,ni s a hared,m coronacl..Iter,impnwc,den dish,a rtpu.r any xtm,, r
plum.iU boaarce.olur naNuire,be applicwl far sixth permit'.Iik l'igml sUlettem SPECIALCIRCULD1,11SC. �(�
LI GE then he is lineasedpmutunlluits,provi.sion,Olive Cmdre,lar,l.'tcen.v lmw(Cler,cr4
DO (cmmmwncing wink Salim 1001 uflliv6.nnluftbe Businea lead Pndentaa Code)or TEXIP.METER OR POLE INST. COMMERCIAL
a L that he is eaerf,Ecrefmm and he basis fa to,alleged c remrim,Any videtova of ❑NEW BLDG/ADDITION O DEMOLITION
Salitm]OJI5 by any apPliam for a sarin suNccu the upplicanno a civil penally of POWER DEVICES OTFVANT ❑FWD SERVICE
m-den five hundred"I.(S500).
�_� ❑ 1,asevion ufOm pmlcny,or my employers with wages as the!r.wde contpcnsuion. SWIMMING Db L1!LECI RIC IMPHOVIiMP,N'1'
win the rk.find thviolentnotvcwrt is t intended or offered fn 044
ble(Sec.1 ,Busioc.s El OTHER
ll dwl
L :..d 1'mfessions Code The Contractor's Linen¢Law docs n.l apply m un caner of OU'1'I.IHS-SWITCHES-IIXIURES
Property who"dinner therein,and w'In ca ew« m
cotch k hitelf or throuh
g
hie.wn cradoyces,pnrviJOJ teal aitch mull.r11t,are lex Inrcnrkd.r o?cmJ frr NI?W RESIDENTIAL 11ECTR 14 ri
We.Ir.howlthe bolding fir lmprosont is sold within one ye,,ofcompleraon.the .FT.FLOOR AREA LSV.F1'.
eertvidcr will hmc tM harden ofpmving her he did m hand nT improve for pur-
1ncaf ale.).
O 1,as.Wtcr of the properly,am caclosively ecsomeling wish Inclosed]ucommur,,to TOTAIJ
elKauel(be pr.jnl(See.701 Nasions aid Pont-,.Cede:)The ConmerNx LL-
sense,Law dkven no,apply to an lesion
i-ernaLawduennuapplyloanmsnr of poiety who builds or improves donut real QTY. PLUMBING PERMIT FEE
wb. xtllal:L4f.r YAlehpr.j eCIx WIIh YerMltrnCt W(rl iIXnxcd pursuant in dKC'untrael[a_a
license Isw. PERMIT ISSUANCE
I rm caa.11p node,Sec. .If&P C for dais reaxx.
Owner Item ALTVR-DRAIN&VENT-WATER(EA) VALl1A1'EON
• WORKER:SCOMIg1,1SAT1ON DECLARATION BACK FLOW PROTECT.DEVICE
I herebyaffirm umukr,coollyMperjurycite MtM fold ingdedumtims:
IhavumW llmuinwmaCatCtu aCaaenrlowlf-insmefm Wuhet's Curren- DRAINS-FIDX)R.ROOF.AREA,COND.
wtim,¢s provided Ter M1y SCtlinn 391111 of the laMr Calc.fm the perten.wnanf J¢ STORIES TYPECONSTRUCIION
fur which This pttntil is i.aLN. FIXTURF-S-PER TRAP
ha.e anJ will ntnintvin WSrker'n Compec smitm lmu t,ax neceed by Section
IO of Be Labor Gale.er the Pcrfanwtace of the work tor which thin remit is foaled. GAS-EA.SYSTEM-I INC.4 OU-ILEl:S C.GROUP APN
CynW is o pcwrion lona '(IkTR14 Plead nacyole'L p�i{j, !&tti_ry
�m /V TU,Yd�I GAS-IA.SYS'MM-UVIik 4 PA)
CG FICATE OF EXEMPIMON MOM WORKERS'
COMPENSATION INSURANCE GRPASIVINDUSTRI.WASTT E INTERCEPTOR
BUIL G DN FEPS
(This veil..ncN mlM1e compinW if the permit uftx arcunlrt
hd JWlarx CS 100) GRIiASI!'UtAP —
rx less.) IPIt1N�1110rK,FEE-I
Ioyany onOnllle pcyoraft ceuflhew icone which dl it, th,Workers'
dnall SEWER-SANITARY-STURMPA.200FT.
nm employ any faun. any. ear u.uxmhvwn:wM1jat e.Ih[WnAari Cmntpcn- I?NI?RGV FEE?
O z wino Lown,of California.Don, WATER HIAIER W NENI'/E1.ECTIk I/ GHAONG FLli
O Applicdm _
0%] NOI'ICH'IU APPLICANT.If,after nwkmg this Cmificate M IfomiNim.You ah vold WATER SVSfENVIRFATING
FxM1cavtw mijevm the Wank,vCone'.1om pmvislasof the,Lahr Code,you mor SO
ELI L+ Rxthwilh amply will....hpmvisiom on lhis pemmilahill bcdeemed revoked. WAER SERVICE
Q O
CONSTRUCTION LENDING AGENCY NEW RFSIUEN'TIAL PLM H. SQ.FT PAID
V O Ihcrtby aR thmtMe ue ced(Se,mD.Ci"g .) fn tic rerfumarcc of Date RcaIpIN
dm w...❑x which thin re'rmll in iasucA(,See F191,civ.cel
O Is T's Name . I TOTAL:
S,,W Lenders Address TDIAL: U
[ y 1 certify that l hese read this application and uadc that the above inforeare m Ls BUILDING FEE:
I-' tn c..Iii,tee w e.."ply scion.11 ehyiedc.amy.rniwTees and note Nov reining to Qry, MECHANICAL PERM IT FEE
L) Z building caoaumi.n.red hereby anbunee repms<natives a this arty to ever upon ilr SEISMIC EYE
ids ve-mcnatmM pnrycny fa inspxOm p.rPoses.
(We)agree 1.save,ddemmfy and keep M1umlea the City of Cupcnino ugwnv PERMIT ISSUANCE ELECTRIC FEE
lirbililies,jndgnemn.em,and earenoi which may in any way ocertro agrhM sob City ALTER OR ADD TO MECI I. ^
ill n yecnc of the granting of this permil. PLUMBING FEE! V
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONI'IGO 10.01X1 CFM)
SOURCE REGULATIONS. MECHANICAL IIID
AIR HANDLING UNIT(OVER 0.000CLM) CONSTRUCTION TAX
Sigramre fA,1.aruC...mr Date EXHAUST FOOD(WIDUCD
IIA%ARIXHJS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will lheapplicant of future Wilding acvpanr noteMolle hvudeua mverid HEATING UNITTO 100.000 BTU)
a deft teed by the Cupe rim Municipal Code.Clarice 9.12,vast the Ilealth and S:Rety
Code.timtim 25532(o)Y HEAPING UNIT(OVER 101.100 H'N)
ryes 7 No AN PAID
VENIILADON IISINGLE RES Date RmtipI
00911 the applicant m fulurt heeding t ore equipment m devim Which
enol hmurdwe air aw
mntinanf rcby the Bay Area Au Quality Monugmlenl HOLLER-COME'IMIII'OR IfX1.00X1 BTU) O
Diwicl9 TOT
[3 Y" ON. BOILER-COMP(OVF.R IOI,(I(N)IITUI
Ilmvc readlhc Mrardmsnwlcfilum.rnL.ivorwdcr Choplcre.95M'1hc Coli- AIR CONDTIIONER ISSUANCE DATE
ftmu Healdl&Safety Cock.Sabena 25503,'351)533 find 25500.1 uuktstaed dw if tK NEW RF_SIDF13'IIAh MECH. SQ,IT Z )/
nfthe re�r avculcnunt.thrribi"ausexelficilirymnnifytheerevtnm 9
.Tole rtyai �'- t�m�i..aa�e,.aC1zi,��"`� �
OwtrtroraudvvricJagcm D c TOTAL ISCUF.D HV:
OFFICE