S 0642 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF 11 NO.
BUILDING DIVLRION APPLICATIONIPERMIT PLUMBING-MECHANICAL 0642
BUILUINI:PRIIJECT H P\Tlk'IGTION
PUMPING ADORES TRSANRARI'NO. API'LICATON SUBMITTAL DATE.
� v56 /V }-oaTNl�� pLJ�
O NPRB NAME: PHONE:
CONTRACTOR'S NAME LIC NO:
AS Jv WC CONTOL#
CT/
It?
• ARCIl1nENGINEER'. LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
(,Lin)
/I q�j� Qom(_�u ❑ Cor-ed ant Fee_.Paid by Applicant(Initial) BLDG El.f(1' PLUMB MECH
'--I�V/�O tJ I . I e{Z ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE `�
I hereby aRirm don I am Beamed ander i ovisior,M Chap«9(commencing JOB DESCRIPTION
O�Z wilh Sbellm]UN)MDiv'Lwalof,he Buii«aearal Peodlims Core.ud my liatue is RESIDENTIAL_
PERn1IT ISSUANCE
Z'- in full face vrd cffee,. �SIUWL ❑KITCHEN REMODEL
QUO Liccre Chiu Idc.. APPLIANCES-RESIDENTIAL []ADDITION ❑PI.UMBING RE PIPE
FF--Znl DWc ConlNCl«
Fy-7 vai ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO�Z 1umlcrumN mypams dull he used..Public rteords MODIFICATION
OZ- - UPTO 2U0 AMT'S IMI'ROVEMERIOR ❑CIIIMNEV REPAIR
r� )Jac vW Professional .III-1000AMPS ENI0SWIMMING PWIS
zj OWNER-BUILDER D17CI.ARATION OVER INXI AMPS ❑BATH RE.MOUEIBIiP ❑DIi,MO1.IT10N
6 I hereby affirm that 1 am caarN from the Contractors License Iyw far the DOTTER V�
X 0,U folkwintirearmdan.(Se703LU Baseness aM Profession,,Code:Any city or coumy SIGNS ELECTRICAL l-{\
413 LLgya. which rwuiru a Permit to coa4net,aha.ittymrrc,olconoloh.or alter any structure
mor toiuLa,vow requires Ne appicwufor such Ionto 10 file a signed aratement SPECIALCIRCUMMI.SC.
f.�} Nm1ci,licemeit pas,uam to the pmvi,iona M ah a Canan.anaCmae lGe Core)
)or COMMERCIAL
iL a: bit has swam N Smian and of Divisione ofda ew asevd Por,on.my siCock)« MMEMETER OR POLE INST.
a a CC ansa he is camp Ncrtfwm azul the hams f«in,alleged e,cmpion.Any viMv,ian of ❑NEW BLDG/ADDITION ❑DFh10LUlON
x N Section]0315 by my Vplicw fee a panel whyccu Ne ayplocanl In I civil Penalty of POWER DEVICES ❑TENANT FOOD SERVICE
W Date then foe hu odecdddle,(SAXI). IMPROVEMBNT
FSD - I.ox owner of tle popmy,ormyemp mnwiffi ammdeirsolecampmmion. SWIMMING POOL IU.F;CI'RIC
I o de work,anejtre, rte,are is nor inemlalor effeml far tali,(See.]DLt,Business [I OTHER
Pm(euiom Cod,Tea Commed'rs Ij d.Imw does not ripply lit an o.wrer of OUTLETS-SWRCHI-S-FIXTURES
Pro,o,who little,m improve,thcmmm,and wow coast such work hmmself lir Naargh
his two employee,,provided shat x.h Imparvemens.n nor inmmdcd o c offered fur NEW RESIDENTIAL.ELECTR SQ FL
ane If.hawo'an rhe Wiling or improvement is sold within are ycmr ofamtplctim,rhe Ilr%fl�/rHIiA SISQ.PI'.
owTerbuilJcr will have the Chit of proving that be did nor hold ne impose for Par-
Piaui
ar- 1 L/
Peau of sale.). Qpd a.�
0 1.m V mcf of the prpcny.am aitab socly cmurial mg wian hoamad cantors h, TOTALN-
amonsi
EP BIZ Py��an
pojea(San.]OLa.Buainn s anal Pmf ssarst Code:)Thc C.Res I.i- sal iso I,
me Law doom apply town owner of psyeny wits,build,«impose,ahenan..ml QTY. PLUMBING PERMIT FEE a�
110
sinmrrens.fmsuch pnojcas wishacm ernaoe(s)licensed poneanlwde Conuuue',
17Y lir ,urEkilNO
License Imw. PF.RMrt'ISSUANCE
❑Ism ex theater Sm. .BKPG for Nis mews
ALTER-DRAIN k VENT-WATER(EAI VALUATION
e n WORKER'S COMFlNSAI'1 I .CG RATION BACK FLOW PR(T F.mI UEvicE
1 b r by riff rot e Wer pnvlty of Icrjary me of rbc following du:laruder,
i]Ihvvcand will mvimmin aCrnittcwe nf(:mcnl6m self-inwrefnr Worker',Cnmpcn- DRAINS-FLOOR,ROOF,ARHA.COND. STORIES '1'YPHCONSTRUCIUOT
,anus,n, hide t d(m by Ss oohm 39fX1 of IM ImMrr Cmde,f«the perfxnanec of Nc
w«k fm which Dili,reame in isvu W. Fl%Il)RIS-I'EH TRAP
Fl 1 have and will mmifar Wo%k f Comaafths w 1n.wmnce,ss repirtd by C<lkn
J]ql of Nelson Codc,fm the perfoxlnvnecof she work!«which this pemmil is iuucd. GAS-EA.SYS'IPJd-I INC.i OUTLETS (XC.GROUP APN
My Worker,C«nperuuim In.uaans cwericir mal Policy number art:
Phi cy No: GAS-EA.SY.SDMLOVER J(EA)
CERTIFICATE GF L'%IJNPTION FROM WORKERS' GREASERNDUSTRL WASTE INERCEPIOR
COMPFIISATION INSURANCE BUILDING DIVISION FEES
Mia nec,ioa paint m «
he cnpMed efthe Amnia is format handrN dollun(SINB GRF.ASETRAP
m less.)Mia
PEH
I esitify tom in Be pHomwee oftM soA for which Nis Ammer is iuucd.I 4all SEWER-SANITARY-STORM FA.2W FT.
mot emso
ploy any person in any manner w a to become auhju
eeo ilhe Wonkcr.'Conifer- ENERGY FEE
,7.m salon lows of Califtnni..Dare WATER HEATER WNEdsUUFliCI'H
zAlri llrnnl I GRADING ITE.
NOTICE TO APPLICANT:If,after making this Ccnilcvm or Exempnn,per should WATER SYSTIWI BEATING
? he.e.sebjeet to Um Worker,,Conopmwhon AmaM L
son,of t ,or Codu on
Coale.yous SOILS tti
W fairb ith easterly with such prvi,ioms or this pamal fall he Jrcned revoked. WATER SERVICE
0
z CONSTRUCTION LENDING AGENCY NEW RPSIDENIAL PIJv1N. SQ,FT. PAID Dare Ratti a
affirm U O . I hereby athx Vert i,a connotation leading Marc,
mc,fee c prfomunc of r
OE^ rhe work fine dad,IN,permit is used(Sec.JIN].Civ,C.) TOTAL
U leders NameW I<Wer,,Addre„ TOTAL
y I certify dart 1 have red Ni,upplialkn and state Net debo
ave ihfo rmanon i, PUMPING FEE
rn ntnca.l agrtcmrnmdYs'iN nil tltyard cmmy«Nmancmvad,arc law.serol^tl t" QTY. MECHANICAL PERMIT FEF,
fJ Z building cmeda.,end hereby authen,re,esematives nfNu coy tomer urmthc SEISMIC FEE
mtl
uMve-menimod Property for Impnolm Perpmcs. PERMIT ISSUANCE
(Wc)agree to save,amenmfy and keep harmless the City of CupeNm against ELECTRIC FEE
iebil,hes.judgmems.ms,ahJ e,pensowhichnay in any wayaeerucugain4 said City ALTER OR ADDTU MITCH.
mnaryucntt of Ne gaming of Ni,Permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO IT(MCPM)
MECHANICAL FEE
SOU EREGt1IAT10N5.
AIR IfANDLING UNIT(OVER I0."CFWD CONSTRUCTION TAX
afgpplmcmVCmwnar Ilya EXHAUST HOOD OVADUCD) HOUSING MITIGATION FEE
HAZARDOUS MA LAI DISCLOSURE
Will the applseanl«future noidiM oeNpanl„mc m harvBc nvzardass material HEATING UNIT GO I NO."BTU)
as defamed by the,Cupntra Municipal Code Cherer,9.12.vN Ne HcalN and Safety
Code.Shim 25532(.)? HEATING UNIT(OVER IN IN)PTU)
C]Yes [:1 No VENTILATION PAN(SINGLE RFSID) PAN
h¢ Heeeip M
Will Ibev'lieareorLoad lwiliingmxeupunt um c9aipmemor duvlma whielo BOII.ER-COMP(3HPOK INI.NCID-J)
emit hal Nous air cmmmimnts as def«d by Ne Buy AIN Air Qoaliry Mmwgcnent TOTAL.:
IEurimV HOILFR-COMP(OV Ek 10101 XID BTU)
C]Yin, ❑Nn
I Kava mudlhc haoodoe,materalnder oChvper h.95 M be Cdi- AIR CONDITIONER ISSUANCE DATE
dirt
feria Haab ne Safny Coale.Sccrima 25V15.153]3 enpret.1 unbuvd Non if th NEW RESIUFMIAL F11:C11. SQ.FT.
Willing hes rd arnundo
rtdY Kase•no , t it is my rmpmnsivdbiliry to ossify de oeavryna
of the m{a'ucneova which mat he mea rim to is uarcc of a Ccnifiate d Occupamay.
(Teter«volhmnzd each, Date TOTAL: ISSUED BY:
OFFICE