S 0942 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE GALL POINT PEN ONLY
CITY ON'CUPERTINO BUILDING-ELECTRICAL P IT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUM 0942
O �' 4 2
BUILDING PROJRCI'IDb]NTIFICATION
,BUILUING ADDRESS SANITARY NU. APPLICATION SUBMITTAL OATS
79 (o7 5-ro JF_ CV-11"I A19 CA y-S-o i
'Mii NAME;; PHONE () ACTOR'S NAME: I.IC No
&C) P ' � 7Z-S 0930 RcKIeoY,aHrFse..lR�' IC No
N(C CONTROL.
• ARCHI'IE(T]Pl•'GINEHR: LIC NO: RESS: ❑
CONTACT. PHONE BUILDING PERMIT INFO
/ ❑ Conslicant ultant Fm Paid by AppUnidal) BLDG ELLCT PLUMB MITCH
❑ ❑ ❑
LICENSED)thatCONIIId!anniS DECInu TFON
Char QTY ELECTRIC PERMIT FEE
1 thereby alhmt IMI I am Band ander prnviaimx�r LTeplm 9(rm,nenr;ng JOB DESCRIPTION
1,.Z IhS Iio.100(Oor DNT,aa 3orme Bwme,caal Poceoinm CodwarW my liecrcr i. RESIDENTIAL
F�-�B na full fi.e.nd affect. 2� PFJtS11T ISSUANCE
uccn¢CWv 2 Lka H-X'F 6e GSFDWL GKITCI{lard NFh10DEL
I641 Dee Q ARCHITECTS DEAPPLIANCES-RESIDE"AL [IALLMON 01'I.UMHING RIiPIPl!
NTSDE,,. ��
❑
F-5 CLARATION FANF]S ❑MULTI-UNIT STRUCTURAL
Z O rn,3 I understand my plan•Jell he u.ed a•public recud, MODIFICATION
UP TO 31X1 AMPS
OZ�OuI GINTIiRION "LINNET REPAIR
Q� ..1 Liccn.cd Pror"verel 201-1100AMPS IMPROVFI.1EYr SWIMMING POOLS
d,� , OWNPR-RUILDFR DECLARATION OVI3H IgX1AMP5 E1HkIIIRIMODEIIREPAIR [IFI-MOUTION
C w Q I herehy effmo 11hol I aMT Gmv
Too exempt front IMT hlcM nve I.aw for I
K
W.V reproving ream.(S irnt 10315,Badness awl ProfeWom,Code:Any city or cmnly SIGNS ELECTRICAL ❑OTI{FR
3 W which myaim,a pmol In construct,eller,improve,demoliJ or cereal any•Tructure
pF
prort.it,i.uamec.,laorryuine,the np hoon forwch pcmnit to frn
laasignedsm¢mt SPECIAL CIRCUITIMISC.le Nat haix licooed,manm lolM pmvi•im•oflhcCmtmcmr',Lignac"ve Chaper9
4100 (" Ti,inpwiRi Sacked 7000)ofOivi,ion3oflha Huaircoand Pnfewsione Cdk)im FLAIR MBFER OR LOUT INS, COMMERCIAL;
a a e¢ Nat he i.exempt Ito,odem and Ile,bans fix we alleged cumprion.My violation a 0 NEW BLDG/ADDITION 0 DEMOI.UION
�
4- SeOkm]11315 by any applicant Lx apermit suhjc,u IM aMlicai m a civil I Try of P0WIiR DI!VICES y ❑TFNANI' [I FOOD SERVICE
I.
not mmcthan Brc hudMddl.rr(55IM1).
E G ❑Les�r+marnf the pnrpwy,cn my maployca<wish wage oslhair sole manpnaalion, SWIMMINGPOOLaTCTRIC IMPROVI!MIiNT
will ao the warn.eM de wucmeis not idaMdaroRtteJ fm axle(Sec.]OL1.Bmircv GOTHER
i ud Podcsxinn.Co,l,Tic Cmnncner's IJecnm law Ili—nil apply IU an owter of OITH.CtS-SW ITCHES-FIXTURES
properly wdn build,w impn•cs Ihcrtaa,and whom don xuch wur,himxalf m Ihndgh
hi,own employ¢,,pnrvnM dial mch impmvcmenv wa not memorof@ed for NEW RESIDII rl AI.UFCTR S
We.If.howc.er.the buildingmimprovemed i.sold withinoreyeinifmmpleim.the SQ.I'C FLUOR APA 5 Q.IT
w
oner-buildm will hese Lha harden of moving dant M Jit m build!ca maroon fa mor-
pra,cMvk.).
El 1.a•mvner of TIC ImPeoy nn excludvely manning with Iicrn 1 rnrurxlm m TOTAL Q
edam,Ihc project(Sa.10.14.Businca awl Pmficon nx Cnkf The ConwctmM Li-
me law doe•u,l apply to nnwee of propy who build,or imlaovn thereon,and QTy. PLUMBING PERMIT ITHE
hnemmacu, nrwenpnajecLwimau � mm
mlmelol,Iren,. puaatnlnm
aCtaxcl,.. �y GUS NTI�
1'eOn.Laree' PERMIT ISSUANCH C111 Vf
7 Iemeaanplunkr Sec. ,B&PCfonhi,mmmn
Owner Dae AI.T17R-1)RAIN&VENT-WATFR(If) VALUATION
WORKER:SCOMPENSATIONDRCIARATTON HACK FlPW I'NOH!C`L DEVICE
hnchy effum uMm pnahy of penury one of Ihc fMllwing decln wi,m:
❑ Iluve and will maintain.CutiOcem of Cnnsmlmaelf-inaune for Wlxker'sCmtpn- DRAINS-FLOOR.ROOI'.ARI?A.CONU' STORIM TYPE CONSTRUCTION
cation.ax pmvidcl fee by Section 3100 or the�Code,fur,de,pRomenec of Ihc
work for which Ihi,permit it iw•acd. IIXTH RES-PITR TRAP
El I hone and will maim m Worker'•Cmctpcmarmn I.e.u ralanod by Section
37"I.FIM Wbw Code.for the perGmmncecton, cA forwhich on,ryrmil'o iaa uu . GAS-FA.SYSTEM.I INC.4 OUTLET'S OCC.GROUP APN
y Acide,(,C time Imnruae cerriv anPolicy nyrypp
Carrier: tYmi�"r 6. 1a-- 7 GAS-FA.SYSTEM-OVER 4(HA)
CI]iTFICATI!OP EXF.\IPIION FROM WORKERS'
COMPHNSATTON INSURANCE GRRASL dNDUSTRL WA.STF INI'ERCFPH)R
BUILDING DIVISION IF,LS
Obi„mlm m
will M te<ormpMMifthefem is foramundm
hl ddme
i (SIM) GREASCTRAP
w lay.) PLANCHECK FEE
Icaoify thatiabi,perfamumc eflha wc,k Gm which di, .i,i,iunvc,l,hall xca de w
SHWHR-SAN]TARY-STORM FA.3(10 FT
aw employ any perm in any manner as to horbject m the Wadaw,'Compo- ENERGY ME!
ZZ .onion law,of Ce1.1ocao.Done WATIiR HFATT:R WNTINULLF.CTR
O Applicant GRADING FLT!
(� NOTICE:TO APPLICANT.If.a e,nwkiii,mis Canitican,of Hxcmpim.you,hmld WATHR SYSTGVTRIiATING
become wb*t to the Wwdea� C pmoviddu n Sons FTH
fonhwi
Impcmvmn of meal Calc.You amid� lh comply with wah v
mrni.dmsmthio prmil,hall be lkcmcd rcvnkcl. WATER SERVICE
CONS'1'RUCI'ION LENDING AGENCY NFW NESIDE.YTIAI.PISIB. SQ,FTPAID
V 0 Iheeeby vfOrm lMnhere i,n cmurvctim kM'mg.Ben Yfau the pAmwren( Uma RcaiplF
I.E. 'a. be doh m
far which Ni,pnit is ixwal Uxe.3DJ1,Ci,C.)
Ianikr',Name TOTAL:
IJ 1< ke',Addreas TOTAL:
0. m1« roily that 1 have mod,lik upplicutlm end xmre IMI he ohne inGrncetion i• HUILUWG FEE
rn mrem.l agnac to comply dim all eilY eM cmnlY ldiamex,M Nva laws ndaungm QTY. MECHANICAL PERMIT FEF.
UZ huilJingawn,tmaiun.vnJtAhy umhonze ni,n"cmmive—Ohi•cilyto cm,O.,xnthe SEISMIC FEE
abavcmcmiorcd Pmpcny for inspection pr osai. 1117RMIT ISSUANCE
(We).gree to-ex,iMmmlfy ani keep twnkv dm City of Cuprdnc egeiml ELECTRIC FBI!
Iiabililiex,judgmenw,antxand expcnux which may in any way acme againxl said City ALMR OR AUDIO MICE I.
in cone9uewe of m
Rhe graving of dmil
na Nimm.
PLUMBING!TS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ILM0 CFM)
SOURCE REGULATIONS. MECHANICAL FEF,
R' 9� AIR HANDLING UNIT(OVER IfM0 CFM) CONSTRUCTION TAX
Signalme of ApplicnnUCmlmm
cr um EXHAUST HOOD(WMUCT)
HAL\RP6 MA' ^ IAIS DISCLOSURE HOUSING MITIGATION IEE
Will do applicant or rulmc hu'ddingon'uprit alms mhanik hvudou•material HIATING UNIT ITO I0l1.fllp BTU)
Tal dcBniff by the Cupertino Munkilel CMc.Chapter 9.13.and Ihc Health and Safely
Coln.Scelim 15534(e)1 IIPA'TING UNIT(OVER 100.(X10 BTU)
❑Yc. F7 No viwrHA'TION FAN(SINGLE RMID) PAID
Duro Rcucipl N
P\ Will dm applicant nr Tatem haJding by me,Bay
Alex
Aa,Qnl 1a Milma which BOILER-COMP(3HP OR 100.000 BN)
.mil hvadw•air cnnmmimru•a•Ikfi�by the BeY Aon Atr Quality Mvegertem T1YfAl.
1B.uricO BOILER-COMP(OVHR IM."BTU)
❑Ye, [:1 No
I have tend lh hveNou,exBeial,napircnenls uMer Cleprcr 695 of ILC Cali- AIR CONDITIONER ISSUANCE DATE
fnmw Heald,&Safely Coma,Sectim•25.505.35533 awa 25534.1 Ia,lerwral Ih.t if the NEW RISIDG-MAL MECH. SQ.IIT.
limiNli,dox,nix ammlY have a iewnt,man it To my ncpanriMlily to ramify the occa,cnl
offt rry'uemcnv which ratio ba met prkr to om ance of a Canifaae d Ocvx,aaY.
Oanar a wlhui.ad aged Done TOTAL.: ISSUHD BY:
OFFICE