S 3130 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BullDISG-ELECTRICAL PET ITNO 3130
BUILDING DIVISION APPLICATIONWERMIT PLUMBING-MECHANICAL
} BUILDING PROJECT IDENTIF'IUA11ON
BUILDING ADDRESS �w �� SANITARY NO. (AI/'I'LI�TI(IN SUIIb11lTAL DATE
OWNERS NAME PHONE ( "fll R'S NA. CND: _4'y
WC / CONTROL 0
ARCIIT:CT/NGINFLR' .IC NOAyq � ❑
S 6') co be (:� ./
CONTACT 'DDRG
BUILDING PERMEr INFO
,-• I �,` y.fNLx,X�I'-� /,/ ❑ Congadi dOt Fm Paid by Applicant(Initial) BLDG ELECT PLUMB M17CH
}CJVI]ftLJ [[[FFiii\\.\F N} 0111///c,{/{WWVVV/III'11\~7NV11 l7 ❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PEE
nerchy anion runt I.ort i,,n,d amts pmvidnm of Chapo v('ann.n,ing J013 DFJSCRI PTION
infullmore and.DecoDivisim 3Ol rhe llmiii—am Pod ssinnn Cul , mylicenm i. NP.SIIJP.NTIAL'
❑C
INRMIT ISSUANCE
1�-�� a � ❑M'DW'L ❑KITCHEN REMODEL.
FQ-UU Lice 1 Lic.N AI'PLInNCFS-0.L'SIDENTIAL OADDTION ❑PLUMBING RF.-PIPET
to QC Date Cdohraci ❑MULTI-UNIT OSTTIUCI'uI l_
nRCHITECTS DECLARATION
1-Doo PANELS MODIFlCATION
Iurdmtad my pL»s nett h:usalupuMic noted,
OZ-O UI'TO 3W AMPS OINIRIGR OGHIMNIiY REPAIR
(a-4�ad Litamwel Pnderxionul 201-1010AMPS, IMPROVEMENT OSWIMMINGI'COLS
CY C
OWNER IIUILDER DEChARAI'ION OVER 100JAMPS ❑RATE REMODEI/RIiPAIR ODEMOLI'I'ION
C 6 I hi affirm mI em eaemp torn me Conlrmtor s License Law for ttr
3
O a U following rca.h.(Semon 7031 S,Bashers not Profnaims CW,:Any city or county SIGNS ELECTRICAL ❑OTHER
1+1 0 co¢ which Iequires.pondl In eOM1N1Vel,aka improve.demolish.or repair any—owe
�LL'yJ soda to iter ixsuar.e also rryuimxlM1e nppliranl for such permilmfile.nigned ornamentSITCIALCIRCULD1,11SC.
that he la lion..!purwmnt m the servo Arms of 0e ConlructrMx Line—law(Chaste,9
a ate' and Sotor
(emream,ingw',In Sadm Taxi)of Divi.itm nno Intl lCOMMERCIAL
xm GVM:)or I'EMI'.MLTRH ON I'OhE INS'C.
a a that M in uanpt nerefrom anJ the h sis for the rllegd cxempim.Any vidvion of [:]NEW BhDGIADDrT1pN ❑DEh101.H'ION
Seedon 70316 by any affEcnnl for.panni,nuhjms the applicant to a civil penalty Of P'OW'ER DEVICES El TENANT ❑FOOD SERVICE
FZy rod mac Nan five hwdmldollars 01500). IMPROVEXIFNT
f=G Ol.mownc�r oftk popcnY.amy empkryeas wia wn}cs ns their�k mmprnwen SWIMMING POOL.ELECTRIC OQTIII;R
will do the work,snit hk sometem is mx mamal vi o.ffmnd for We free.70,W.Bruin.
413
and Pmfevs tin Code:The Cmiracnrin Licence law d ev not apply or N dwaI
r of OUTLETS-SWTCHES-FIXTIREi'
A' snapcoy who hi ilds err impmvo thcrmm rod who dx,.each work nrrnwlf,r IDOO,h
m4 own cmployms,provided drat such impnvern ix ort not metrical m Acted]for NEW RESIDENTIAL IE.IiCI'H SQ ET
sale.If,however,the Wilding orimPomement is sNd within or.year of comploim.doe SQ.FT FLOOR AREA LSQ.IT.
owner-builderwill have the W rnou Of peoving Thu the did not build a improve for Ism- 'e
pove
m-
pove of sale.).
O I,as owner of floc popdnty,am exclusively comoun ing with Iic owd nmtractaa to L' O O
cmxuo i ne pOjcct(Se,.9(Ml4,Trusion and Itofwoom C.:)Tho Gmlme—a m-
vrccLwdresno artily lomi—on dtf fri what hoildx m-mpovas thaterm,mal QTY, PLUMBING PERMIT
wMunnirmtn for rrah po)mhs with a cmlmemos)licca vl paro-etto rNc Gmomelar's
License law. AGAS
UAN '
O lamnempunler Sec. ,B&PCfiwddsnawoa
Ownc�r Taw AL VP -WA Ili\) a���/� VALUATION
WORKERS COMPENSATION DECLARATION 1 i VI A/ yr O o
IhcnihY alliin undWr pcnolry nrp,rjurynm of roc fnlhwing dmlorulirnhr: ttYY <_J
❑ I have and will maintain aCceiicam of Conwnuosclt-in,vum lir Wnrkcr'xC'oml.n- L(OR.R(R1P,AR ). STORIES TYYI?CUNSfHULTI(IN
motion,es p wi,d for by Section 37W of the Lbdr Cute,fa the le fomance Of the
work far which NU permit Lsinud. PEKTRAP
0 1 hoc ad will maintain Wakens Comperuuirm Ittwrnxx.as required by Sarioo
3"!1X1 oftbm labor Coda.fm ihcler(nmurce M the work for which chis Paoli u isu„d. _- f"fS OCC.GROUP AI'N
h1Y WoYdiCaoMrh ppm mememsccmficrarul Polio .elNm�/ YSTEM OVER 4(FA)
PI Icy N 4XCBH'CIFl�-- . CAO O 111 IPPfION PHO.WOHKF,RS' DUS'I'RL WASTE 1NfERCI71'fOR
COMPNSATON INSURANCE. BUILDING DIVISION FFLS
(Thu.sectim ad nd WnXnsk.difdre pcnnir is faro.hmdmloktllan(SI00) GREASETRAP
a less.) %ANCHECK FF1i
I romythw in date frerfonwreanhe work for which Nis permit is issmal,l darn SEWER-SANITARY-STORM FA.31X1 FT.
not employ any perwr i n any manor ud in to become wbinot to the Wnkcx'Compen- INERGY FEE 2 l
Oz wdonl.awenfcadhoorne IAm WATER HP.AI'17R WNINDEUCIR GRADING THE
2 O Affliction
NOTICE TO APPLICANT:IL ofer faking thio Ce,hiticaic of CVmor'xxt,you madd WATER SYSTIM/1'REiATING
1"' ^ beconrm-b,.to the W'aiver's Companat mer prnviixtes W ne labor Chea e,Yri SOILS TLE
forthwith comply with such Pmv'hs ami or N,Permit stud he demand revalued. WATER SERVICE
W G
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ,FT.
7 z PAID Doc aipt s
U O I M1crtby anion door(hem iw cowrucrinn coiling agency forth pmlinnamcof
W. Lc work for which IM1is pcnnil is I,uud(.Sec.31N9,Civ.C.) T AL
QIF.7 Ierdcr'a Nan.
lerrdcr'xAdress TOTAL
W I ami thin 1 have read this eWicuim.oris!one rhat the tMve itim—ion is ING FEE
tail moori l argument comply with all city and commydodinarrm and.,a laws rmlum,to QTY. M ECHA N I CAL PERM IT
V building crosmocdxt,and hcaby wilmOH.e repuenmti ver M thin dly ut mine upon the SI :MIC EEE U
shove mannarod E--Many for innl'ection par mix. PERMIT ISSUANCH
(We)agrw to arvo,Indemnify aha keep omnilcnv rhe City of Culenim cRuma LECTRlC ITE
Iiahililim,)dgments,rnVn and expenses which mayor any way.ecmax,against add City NATER OR ADD TO MECH.
LUMBING HEin munFrcr.e of tit gmndn6 of this pemt.d
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GG 10.00)CIM)
MECHANICALKE
\JJ MY/ AIH HANDLING UNIT LOVER 111,0X1 CFM) CONSTRUCTION TAX
Sigrmmmof AEE1a,wa`Contmnnr Tum li%I IAUS'II ODD(W/DUCT) 1 UMNO MITIOAI'IIIN ILI3
HAZARDOUS MATERIALS DISCLOSURE
WIl d.applinmormtm,Wilmeg comismintre or hvdle hrrv'mwerial HEATING UNIT(R)110,000 BTU)
w dcfnd by Bm Cupertiro MwiciPal Cork,C'hrper 4.12,ad d.IIWth and Safety
Code.SeetMn 25533(.)' HEATING UNIT(OVER 100,000 BTU)
e No
VENTILATION INN(SINGLE RIiSIU) PAID D'v¢ H,miptX
Wil rW nsplicum or town,Tualding oceupun n,rTm,mam err devices whim
ort M1mWrwr uir<nnOmrnamp mdcfaJ hythe flay Ansa Air Qadity ManagementIfOILFR-C(1MI'1311P ON 100,000 11'IL)
e
Disuict? f
OYn ON.
NOILER-COMP(OVER IW.aO NIU)
I hove«ad the IwaNdVhs nurnids AIR CONDITIONER
rcquhrncmts trhvla Chaucer 6.45 Mho.Cali- / ISSUANCE DATE:
Iomla Henlih&M=y Gdc.Sodium 25505,25593 am125.5.W.1 ordwatmxl row if be NEW RESIDPNIIAL MECO SQ.E'. �(�' / 2
building der ma cuavndy heron renunl.IMt it iv my rrepxrsibility to ocidy in,rccufam
often mv,wim er.wh'chmughv nnl pdamic�rui.c ora cutin muf(kcupuny.
Mur a anwarated agent Du< TOTAL ISSUED B1' � U
OFFICE