S 3841 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMIl-MECHANICAL S 3841
BUILDING PROJECT IDENTIEICATIOry
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
O F,R'S NA ML: / Q //I10NI!:F�, CO ACTOR'S JJAME: / LIC NO
[' OLA, t, NIC CONTROL x
RCHTRCf GINECR: LIC NO: ADDR Su: n /k2l. ED1 ) / 64 I
CONTACn PHONE BUILDING PERMIT INFO
�G /
El Consultant Fees Paid by Applicant(Initial) BI.DG ELECT' PLUMB MECH
❑ ❑ E2-- ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 b aby.fent that I am Eceese!nn,kr pn,.;aon,of CTtaper 9 Dommamiag JOB DESCRIPTION
Won with Samlar9BB(pof uivWan 3MIc,fmor1n,;it Ptofesnioos Code.ettdmy l@cods RESIDENTIAL'
F O in full force and affect. PERMIT ISSUANCE
c, ❑SFDWL ❑KITCHI-NREMODEL
FaF.UU Iicen¢Clam Lie.Y �^
ln6a Dote Gmlmct« APPLIANCES-RESIDENTIAL [I ADDITION Ll rLurv1o11,v R6PIPE
ARCHITECTS DECLARATION PANELS ❑MULE-UNIT ❑STRUCTURAL
Z p n Z d
1 urersmul no pbms m,11 he used us puhlia ratxJ, MODMCATION
OZ-o UPT0200AMPS C3 INTERIOR [I CHIMNEY REPAIR
F�FW IJcamed PtMcssiorul 201-10)(1AMPS IMPROVEMPM'
OWNER-BUILDER DECLARATION E]SWIMMING POOLS
Ko w< I thereby afftm tent I am exempt from the C«unremi License Law far the OVER 1000 AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
pe L U b1hosm,,cacao.(Section 7031.5.Haeince.0 eel Profession,Cute:Any cily or a unty SIGNS ELECTRICAL ❑OTHER
Ir] which require,amli
pct to comi alter,improve,demof,lt sec relawrt
ir any uctuprice to is iuuame,elm reyuims me applicant for inch peanut m file ammaulmsomosnt SPECIALCIRCUITMISC.
M tort lou is Geemd po r,omuo the provisrone of the Conlrazuv's License Law(Ctl9
CLQ (amtnrncing with Scut 7")of Division J of the Rumes.cad Prof.Cee)o- TEMP,METER OR PULE INST. COMMERCIAL
a a e telt he is,xcrnpl thersfrom and the Isis fa the alleged esemption.Any violviun of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Sa,00n70315 by any applicant Rx a1enoit subjects tel eppllcum to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZY ^at mm than live huMrcd dki(S5o0).
IMPROVEMENT
=Q F_
❑1,es nwmrof tie propny,nr my employee with wage o,mcir,alcampcn,lion. .SWTMMINCIPOOLLILECTRIC
will ant iM wxk,and tic,wtturt o nw rnlended nr Mlere f«,Ie(Sec.]11,1,1,Buaiticss [I OTHER
a3� a°d Pmfeutwts Code:The Contractus lialru Iww does notapply to en ownerof OU'II.EIS-SWITCIIES-PIXTUR
pmlcny who Milds or tmpnwaa themm,ad who does such work himwll or thr,mgh
his own empinyecs povidul Ile such imptosemaMs art not mucinsfei or alarm f« NEW RESIDENTIAL ELECIRFIF IK
uk.If,however.ttr building w improvement issold within ort,Yaar ofcmnplction,che SQ.FL FLOOR AREA SISQ.h-L
wrcmldcr will have chi MNcn of proving mal he did nM tvid w impmrc f«wr-
poscofmide.j.
❑Las mune,iv let prapcny,,Business
sivdy conlc,simg with Iicansed ennuaclors - TOTAL.
cans, achice,not (Sac.plan, .,0 aid Ptofe.aiam Code)TheCme,rei V- 0
nmDrm O,fi,«ch tojely to an with
ofprnpertywho buildsrsiml'be he thcrnn.wd QTY. PLUMBING PERMIT FEE
who niMtactst«such pnJemn won ocontnulatl,)licert¢,l pursuunnu he Conlnemr's - O D
Li en e,Law. PER-MLT ISSUANCE )
I am axempt ardor Sec. ,B&P C formix truon
Ow re, Daa ALTER-DRAIN&VENT-WATER BOO AL
WORKER'S COMPENSATION DECLARATON BACK FLAW PROTECT.DEVICE
1 thereby affirm udar Ievalty of pecjury may of the bellowing dechoommoa:
F1 I thstse"will boatman aCerif abcdComcnuoself-imute f«Wurkcis Cber ar- DRAINS-FLOOR ROOF,AREA,CONIC, ) UCHON
,tion,vs provide for by Semon J11ID of chre Lehr Cudc,for tel peAxmana of the
work f«which this permit is ksurd. FIXTURES-PER TRAP
e-I-Fn'icmJ.will maintain W'orker's Compnsetku hom unce.as remitted by Section
3II0 of me LvMrGda,for thepr6xtmnce of Use wwk for which Nis permit is lsme. GAS-L'A.SYSTEM-I D NC.4 OUTLETS OCG GROUP APN
MyW tC a PKI n mrxr tad PNI, Q� GAS-EA.SYSTEM-OVER 4(PA)
Cemc i'olicy No.:
CERT ICATI:OFEX IPI'ION IM1tO WORKERS GREASF/INDUSTRL WASTE INTERCEPTOR
COMPEN, TION INSURANCE BUILDING DIVISION FEES
Th is sectionncad nxbeeomple,M i Oho permit i,forum hwdtul thallus fglf0) GRPASL'TAAP
or less.) PL NCHECK FEE
I camfymat intha pefwtromeofthe wool,for which this parmit is issued.i shell SEWER-SANITARY-STORM EA.2W F1'.
nm employ troy pe,in in troy mourner,,or to Mc«na.mbj,,t m the Woherr'Cmo,em- ENERGY FEE
O z
to.Izews of Colifmnia.Dec MATER HEATER WNI:NI]FJ.ECTR
Z 0 Applicant E GRADING LL
N NOTICE TO APPLICANT:IL+fter making this Cmifiu¢of Eaeit ian,you should WATER SYSTEA REATING
become subject to the Worker's Cwnparcu tem pm tevisions of the abCalc,you mum SOILS FEE
Wfndhwith comply with ouch provision,«this permit sbull M domed revoked, WATER SERVICE
aQ
=
CONSTRUCTION LENDING AGENCY NEW RESIDFMDAI.PI,MB. SQ.FT PAID'z Ihcrcby offinn shut lh,rt is u,onYN,linn kding agcny Gc lh,lerf«matcc of V RetttMg
U.OI'-' dr, erkme which this Tamil is immed(Sec.."D.Civ.C.)
Udcr's Namc TOTAL:
Lcnkr'.Addr,ar L
j- y I anify that I hove teed this eppliration and mine chair de aMve inf«nmuim i, BUILDING FRE
III cwrect.I agree to comply w11h all city cad aunty o"monam rod mai,laws relwing to QTY. MECHANICAL PERMIT FEE
C„) Z hudding ansometion.and M by vumminee repeseetatro.M this city to ctuar upon tk SEISMIC FEE
above-mrntiued pro my fw inspection purryacs.
(We) go-tri xava,Imbmmfy and trap harndars the City of Cupeoim agaiw PERMIT ISSUANCE ELECTRIC FEE
liebilitie4 jutimno,costsaM,spanrerwhichtmym.ywy.c agai.mdCity ALTERORADDTOMF.CH. PLUMBING FEE 2O
m anie9a,tla of de gom}IIIm'.no lyJY it.
APPLICANTU jyTANI SAN ZLLC MPLY WITH ALL NON-POINT AIRHANDLINGUNIT(TO IO.0010CI'.SI) MECHANICAL FEF,
SOURCE _ IN
6c-��yp AIR HANDLING UN (OVER IO,00CM) CONSTRUCTION TAX
16,plicestrutcrel Ih, EXAAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
DA]ARDOUS MATERIALS DISCLOSURE
WdltMopplicamor future building oecvpant store mhaedle haeerdwss muumbd HEATING UNIT(TO 210.000 BTU)
as define by the Cu im iru Municipal Code,Chapter 9.12,and tel Health and Safely
Cul,.S,,ti.ZPG20IC BEATING UNIT(OVER IWiM BTU)
❑Yee ❑No
I VENTILATION IAN(SINGLE RESID) PATO -Data, Rcaiptg
Woe tel applicant m fmum raiding b,the Bl use aq Air Out«devices which
tthvadoua or ttxllamirainb as define by the Bey Arta Air QunlitY Mewgcmrnt BOILER-COMP(JHP OR 100,000 BTU)
O
O
Uiaria] BOILER-COh1P(OVER 100.0110 BTU)
❑Yes FIN.
Ilwv,udme,Werdws nmanah rtyuientems oder Chapter 6.95 M me,Cali- AIR CONDITIONER ISSUANCE DATE
y [�
furlia Health&Safny Code.Sec 255 25533 aid 2553,1.1 understa,d that ifthe NLM1V RESIDENTIAL MF.LTI SQ.FT. /�/ ^ y�
h' ingdasnotcu smy rtNunsih lllyw nxi[y Oto oempanl I
tle requtm ly Is m n yy /of O�cettparcy O
(Tvtrer owm RIS 1/ n�/ �,Dwe TOTAL: ISSUEDBY:
OFFICE