31184 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CFFY OF CUPERTINO BUILDING-ELECTRICAL ""'NO, 311 8 n
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J 1 f�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDR155. SANITARY NO. APPLICATION SUBMITTAL DATE
�JI, y�f 0e�1.pJ ,�t� ry(Jq�f
OWNER'S N M i 1'HONt.. Cq/�" '4 k ("1 ry !. .IJIC`O: 1
U (y.� .I� NIC CONTROL
�:NCHTI'ECf/FNGINItA: LIC NO QDIV �trl+.A(I ❑ .
,V
CONTACT: PHONE: BUILDING PERId1T INFO
❑ ConsWmnl Fees Paid by Applican[(Inifiep HLDG FJ.ECT PLUMB MECH
❑ ❑ 0 ❑
LICENSED CONTRAeitherSUECLue of ChN QTY ELECTRIC PERM IT FEE
1 lefehy atrmt Nat I am licemcd either pnvi'iaa nr CTaptu 9(emm�encin¢ JOB DESCRIPTION
OZO who Settee aeal)of Divider ln'th Busi«v ud Pofeuim'Code rd ylittnscu PERMIT ISSUANCE
aUm full formi/� t\`I
�j Lircnse CIU'a' .`,-�^"—o IJc.Y `4N � DKRCHFN REMODFJ,
a Rl Delay-scut cut., ' APPLIANCES-RISDADDITION UPLUMBINGRE-PIPE
fOm ARCHfTECPS DECLARATION DMULTI-UNIT DSTRU=RAL
Z - 1 uMasuud m hors dtdl he used ns blie record' PANELS
Z O'_� Y P pee MODIFICATION
O Z�_O UP TO 21Mt AMPS
I.icenxd Profcvicxal - El INTERIOR DGHIMNEY REPAIR
OWNER-BUILDER DECLARATION. � 2UI-❑kMIAMPS IMPROVEMENT
ereby
y 6 1 haffirm un that 1 crer
a ,form the Cmum
ucr' nse s LiceLaw f«Ne OVER EXKAMN 0 BATH REMODEUREPAIR D DEMOLITION
x O a V folloxing Twort.(Section]OI IS.Busims and Prefasiom Coda:Any city ac couay SIGNS EI.BCfRIGL OTHER
:LL O which rtquvn.pcmul to c«uwn..Ber,improve,demolish.m repro any swnlue q e r b e ATt�
t— primtoiu iasov,a,alwraquires lheapPlicw fmsuch pi mfle.si'adl strata.,
N SPECIAL CIRCUI DOLE.
Qf
don hni. .11,n fornicator to NecfDisimsnfihe Comracmrt License,ocpOCMa)or LL.. lla'f�•l.T
apo (cummencinR wish Sectiun]INIO)of DivisionJof the ilusircu erd Nufaniona Cndq or TEMP.MEITR OR POLE,INST. COMMERCIAL:
d y a Ihel he in exam,IMefrwa aid the 1p,,for the Ideal eacmp,inn,Any vlolulion of D NEW BIAG/ADDffiON D DEMOLITION
fa%1 4• Sttl:m]OJ LS by any applienm for.pemlii mhjcets IM upplieentio.afoot pewlly of M)WE UHVICES
FZ} nm none flan five hundred Soll.n(SSK). LTENANT L]FOOD SERVICE
� � Dl.nowlm of lee prvpenY.ur mY employees wiN wo¢e'as Ne'v sole e«npensmion, SWIMMING POOL ELECTRIC IMPROVEMENT
II dotKwork,aidthesvunure is nm inrendcd«oRe do,,rule(.Sec.]NILE .of ❑OTHER
63 I t and Prof%ho b Code,The ova,aracn Liceme Law Jaen not p),op lf ownu of OUTLETS-SW'ITCFJFS-FlXTURBS
— hk..n who builds«Improves such i and who don wen wnrk ided or m Nmu{n
his own employe.,provided Nat such ntern cf dd a one on ion ol'c of,lefi.d f« NEW RESIDENTIAL ELECTR S
Wc.lLhoweverlllothe ve IN, or iaa f,rmcnl ismWdidr thuld,fn,rov,ion,the SQ.IT.FLOOR AREA - TLSO.FT.
rod mic.ar will have the huNcn o(pmving NnI Ne did nm build«improve for[1
r-
[1 1 of soled.
1,u owner or the pac.7(o ant sisiivny contracting wool OansN c»mractm or TOTAL:
croswct de pmJut(See.)DW,Bluir,eu and Porfusioru C«k:)The Cmu.cmr's Li-
cause Law does Ton appy to m owner of przpcny wM1O lsudH«impova Nermn.and QTy, PLUMBING PERMIT FEE
wbcawau fa such pmject'xiN•cvnu.eta(s)Iteensal purvmm to de Caeuauota
Up.Low.
I am esemp under Sec. ,B&P C for this ISSUANCEls reason / J
O rcr Do,, ALTER-DRAIN A VENT-WATER(EA) VALUATION
WOHKIiH:S COMPBNSATIIIN DECLARATION BACK ROW PRO=.
1 hereby uIDrm under penally of perjury orc of the f0lovong Jeclamions'.
❑Ihavc oro will meinainoCrnifica¢ofCm¢non acl6iowuc fm Wodc(s Cnmpan- DRAINS-FLOOR.ROOK AREA,COND.
ssti«g as pmvkkd for by Section 37W of de UsNr Code,for the,perf.of be, D TYPE CONSTRUCf1ON
work fa which Chia permit a i w d. FIXTURES-PER TRAP
I lave and will mainuin Worket'S Compmsvim Imsomea,n ragdral by Section
.,of11,,II././{{,''__T(.... ole.for��'yf�,fafrafae ofdew«kff}{n'w�hicchh,,,Nniimpro`kisinuued. GAS-EA.SYSTENIAINC.iOVIT . , U (f'/� APN
Myra yin thin IpT�ynn oroy No.:•1�- Tlg.aJ J/ / - 4(J
Gooier VVVYY Ina C"r Policy Na: GAS-EA.SYSTEM-OVER C(f?A)
CBRTIFICAITio 7 EMPTIONFROMWORKERS'
COMPENSATION INSURANCE GRBASUINDUSTRL WASTE INTERCEPTOR B 1 $IpIVIS10N FEES
This ation neat nm he mf th
mpli ie pe,mit u furntrc hundml coll.«leu.) cGREASP.TRAP
Imofy filar in Ne perfasnml¢ofNcx«t fa wnichNie pores,is i..•„.l Jell PLANCIIECK FEE
)
not ansi any Fuson in any meflarn a'to hecmrc subject to the Waken C«npm- SEWER-SANITARY-STORM G.200 FT. ENFRGY FEF.
C) Z swim Laws of C.lifor ia.Data WATER HEATER W'IVFNT/ELEC R
Z O Applicant GRADING HE
.N.I NOTICETOAPPLICANT.ILaflum ing Nix Ccnifeelect acmpti,m,y(m. mld WATI?H SYSIEAVIREATING
(~ ' beevonc Imbjett to the Worker's Cnmwm
penuon pvixims of the Labor Code,yoe insist SOILS ilil3
0
a Llnhwid comply with-,h roviiicio,« mhill Ihis pv ,i,sbe deemm
ed vukal. WATER SERVICE
7 z CONSTRUCTION LANDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
I horw cRrm Nntdere ia.mmSee.30 lcldlo¢e¢ettYf«thc pufamnrla o/ Doc RealPl{
� � Ne wok f«which Nia penNt is i<sucd(See.JD9],Civ.C.)
O U Lcodafs None TTYTAL:
LcNNs Adtlrta TOTAL: /
a 1 cmify del I have need this application and stem Not the thrive iaRe ion is BUILDING FEE
to nMF[l.1 agree m tnn,ply with till city and nvmy,vllmao end nom low.relining m QTY MECHANICAL PERMIT FEE
U building consoto,ual herebye.b ompracmallve.ofdbk city to mmf urynthe SEISM IC ITE
abuvnmentiored pmpeny for inspection purptnca'.
(We)agree m save,hdcmnif,and keep hLmoew the City of Cupcnim.'ain't PERMIT ISSUANCE ELECTRIC FEE
Iiebiliues,jld¢trcncS east'and expenses which my N my*ay.ccsse U”said City ALTER OR ADD TO MECH. ` rs
io camequv,cedNe{mdn{of Nispmdt. PLUMBING FEE J (f
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO HLOMCFM)
SOURCE REGULATIONS, MECHANICAL 12E
AIR HANDLING UNIT(OVER 10."CFM) CONSTRUCIA)N TA%
Si{nmme nfA,fcaoUCopiru:tor Date EXHAUST HOODWDUCO HOUSING MITIGATION FEE
HAF.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding nccvpantnure or handle hareAws naerial HEATING UNIT(TO 100.000 BTU)
as defncd by the Cupeni.Muninlvl Code,Chapu 9.11 vW Ne Health and Safety
Code.Scrim 35532(.)? HGTING UNIT(OVER 100.000 BTU)
DYn Era PAID
Will
uta VENTILATION FAN(SINGLE RISID)
1 ll the epplw-um It fumfuturebuilding arulwnt ux cquipmmt m JedevicesdevicesDate Rettila¢which
BOILER-COMP(LHP OR IM,(XM)BTIn
Una,,,..uua air mnlnmitanu m defied by Ne Ilay Arte Alr Quelily Mmagrnam
Dixlritt? TOTAL:
L
�(No BOILER-COMY(OVGR IIp,fXk)HIV)
e waaJo a natuW' AIR CONDITIONER ISSUANCE DATE
fcquitnnma un to 6.95 of Jlc Celi�
rCoda,S oats 25505.25577 1 uNvswW dol if Ne, NEW RESIDENTIAL MECH. SQ.FT. /
aly hes lvmlt Jut it is r uruiM'liry`mifyrcmyvnt U .
ho tyagrnt Uum TOTAL: ISSUED BY —�
OFFICE