S 0250 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1tl' t CITY OF CUPERTINO HUH,DING-E:LECpRICkL P15ITNO. O L^�O
r APPLICATION/IaERMIT PLUMBING.MECHANICAL. J
'( BUILDING DIVISION
BUILDING PROJECT IDENTIFICATION
'!I BUILDING DURESS'. s- SANITARY NO. APPLICATION SUBMITTAL DATA
.t
ILII ' OW R'S AM : ONE - LCONA(-UbNA
O
O IL O SuO rhi C :
COMNOL
LIC OA )HIS. 059 WC
IITECTIGI ER: ❑ x
C)NTACI': PHONE: eII ILDING PERMIT INFO
❑ Consultant Fern Paid by Applicant(Initial) BLU ELECT PLUMB MECCH
TI L
uCSNSED Co
MRS DECLARATION QTY ELECTRIC PERMIT FEE
I n :ny a1Brm Inv 1 mn rr d beer pn,vidtvi.nr cla,pa v I:nmmencmg JOB DESCRIPTION
o=z with Sadon 7008 of Di.ri«,3cO usi= ofexai na m�.an yRremsek - RFSI_IIFNTIAI,
Woe, infull forte sod cRs J PERMIT ISSUANCE,
yl)— - /�� ❑SPDWL ❑PLUMBING
iE DEL
PIPE
E,+u� I b,e Claa lies APPLIANCES-RISIDIiNfIAI. ❑AUDITION ❑PLUMBING Ri PIPE
y Q on Umc Con DECL
ARCHTfF.'CTS D[CLAHfSK 151 ❑MULTI-UNIT ❑STRUCNRAL
zonz 1 y plans shall he wN-public natnb PANELS MODIFICATION
OZ—� UP TO 200 AMPS [-1 INTERIOR ❑CHIMNEYREPAIR
OL
F4t:,IL Lianscd Prnfueioml 201-1000AMPS IMPROVIMENT �$WIMMING FOOLS
OWNER-BUILDER DECLARATION
KY OVER 0000 AMPS ❑BATH RE\IODEL(REPAIR EJ DEMOLITION
C U 1 heresy,(Srm the I vex uemq boom the fesq «or'x License Law ei the
x1x O a U following season.(Satins 7031S.Business and Dofcssioxi.Gale:Any city nr enemy SIGNS IiI,ECIRICAI, ❑ODIER
W'3�Oya which mynlms a permit to umamc6 alcor,impnne,Jem,Aiv ,or repair anY etmemm
FWJ prim exits ixwantt.dao reyuinu lbo applicaN fmrueh petoit to file vxigrcd wucrosnt SPECIAL CIRCUPUMISC.
E y�y Nv Its,is licensed pumunnt to the pnwisient of the Cuntxor's Licence Law(Ch.ptcr 9
WCao (eumttlercinpwiB,Seetien7")of Division 3n41bo Boniness and(smite on—Cde)nr TEMP.MITER OR TOLE(NST COMMERCIAL'
d IY thm he is cxentp tncrefmm and the It Orr the uh,,edl exemption.Any vlobtion of ❑NIiW BLDG/ADDITION ❑DEMOLff10N
K'� Secti.7031.5 byvnyappliennt fora permitsobi the applicma m sewn)pcomlly of POWER DEVICES [3 TENANT ❑FOODSERVICE
moe that fire hurdtnl dollax($30(1). IMPROVEMENT
t—yQ ❑1.aso,wner 4the pweBy.oc myemploym with wvgo as tM1eiraule enntpenwfitm. SN'IMMINGPOOLULELTHIC
�La� will do the work.anithe stwommie nig lmaukdunRcred for mlc lSa:]lN4.HusIIICu DOI'BER
Wand Pnafusinnn Code:lbe Cnsmmc n i,Lice.law docs nm upply fa on owner of OUTLETS-SWITCHM-FIXTURES
a3— prnlerfy wno wile.«improver thaa,n.stet wn.,ane.wen w«k nimaelr«Innwen
hi.awn employe¢,pmvided toed weM1 impmvcrtents art nx imcdpl or nRcn i for NEW RFSIDIlsTAL ELECIR SQ FT
ae.
lILMwe Vr,InewildingorimPmvewnnl„wldwanintneyeaTcfc supletior,the $(j FT.II,OORARIA LSV�IT
ncr-hoj t will nave the wbrn of loosing lhm M did Mf wild m imTnuve fm pnT- r/ A r �1
P,se of sd.l. L/
r7 I,as owner of the,poe eby,on exclusively contracting with heen i<mltrstnn m TOTA JUL
I
nOwmel t he n rojeet(See.]Ba4,Bneilsexr and Pn,fcesinns Corex Corte;)TCommmor's L i- {JUL 1
cen,e law duce not apply to m owner of pw,erty with huiiJ%or unpuves Hereon.and QTY. PLUMBING PERMIT E4 U
who,cormaits for oueh pmjeen,with a«muctmfx)licensed!p,onmat to the Contnvetelx
lieenve law. - IERNIUISSUANCE Vh `UN
I am eaemp uodef Sa. .B&P C fm this maua
N,TFR-DRAIN&VENT-WATER(EA) V UATION
T m Use
WORKER nder COMPENSATION DECLARATION HACK Fl.OM`PR(TIELT.DEVICE
I haehy el under prna cane ofCmbe.l ofthnfolks,fts`do4laI nv:
� Ihovc unlwillmai by Seeboni 37W of Cne,LabrCodsnaurtfar sern C-11--the URAINS-FLOOR,HOOP.AREA.CONU. STORIES TYYB CONSTRUCIIOV
w1xr4 as gvvidai for q'$conics)100 of tbo Labor Calc,for tbo pafnmurcc U the
01 forwhich thispermitu orlo,. FlXTURIS-PER TRAP
❑ have and will mai,fin Worker's Gore or,hetm cls r- hi h rtquind by Section
J]IMl oftw UMr Code,GN be per4m,nrce nflhc work Lx whim tone pcm,it is louod. GAS-IiA.SYSTEM.I INC.4OUTLETS OCC.GROUP AI`N
My Wo ces Compensation Imumnec:Vnier and Polity number are:
Canner. Pmicy No.: GAS-FA.SYSTEM-OVER 4(U)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE (IREASEINDUSTRI,WASTE INfERCEPDIH
BUILDING DIVISION FLR!S
('Diu cation ncdnmwctmtpktcd ifthc permit isf«one wrong ddlas($IfMll GREASE TRAP
or Icw.d PfANCHHCK FEIi
I-dify anis Be enrm-milbietioliftwtekfimw'ineh this Perrin is issued,Ishdl SEWER-SANITARY-STORM IA.21 M)I'T
to,employ an It,on in ifRany mbjeet to the Warlmna'Cnmpen. EMiRGY FBB
O Z .eons Lew t nia.D
N"U
ft ¢ slWlnc dcened mokM.
WATER HIA_TER WIVENTML
ECER GRADING
FEE
qOTICE PLI WATER SYSTEXRHEATING
WATER SERVICEauwwhjum InrkeiCon viSOIS 117.F.orthwth .ml,with uch this .it
0. 0
7z CONSTRUCTION LENDING AGENCY NEW RFSIDPJtDAL PLMB. SQ.IT. PAID It,
R«cIp1N
u l lwnmydsrm that Beige is aconwme.nending egeny k.the perfun ,of
U. F' the work fu w'hicb this pemdt iu Kneed(Sec.NXG.Ci,C.) TOTAL
enders N.
V Lan ,Adatis TOTAL:
�+ DJ H1111,UIN, E
- _
,Ly I ruYli(Y that I have read this applicamin and stat:lbat InC nM,ve inlittmentn i♦ P
:«recta aMta m:omply wnh all city.rd cunmy nrdinslf«s and slam low rtwmgm QTY. MECHANICAL PERMIT FEE
U Z wildingcutwructiaa and heneby tufh«irerelossntb one,a On,city to enter upon the SEISMIC
.. above-nnrnti«rd pmpeny for lespectiin pmpo,e, PERMIT ISSUANCE
(We)ogre:lex love,indemnify atd kap hm)llcv lac City of Cupan'mo aguino ELECIRI 1Tm
Iied ilibes.jidsnwnlc ecru and evpensea which may in any way aceme a$aina send Ci ty AI.TERORADDTOMECL
i in sequence of the fingMthis pomiL PLUM GFEI;
AP CANT UND SANDS 4NDWL OMPA ITHALL N-POINT AIR BANDUNG UNIT TO I0.B0 CET) MSCI WICALFFE
S fce REG -Al '*
AIR HANDLING UNIT(OVER IU.INp CFM( CONS UCDON TAX
R.
of Applimn Um Cao U c EXHAUST HOOD OVIDUCT) HOUSING TIGATION FliIi
HAJARDOUS MAT,RIAI S DISCLOSCJ
Will BneaMlienot nefmum wilding rc:vNnt wore,u handle haeanhur meanal HEATING UNIT(TO 100,05)HTUI
ar defined by lase Cupeniew Moviciryl Code.CTapfer 9.12,ad Inc Huhh and Saray
Cock.Section 23532od? HEATING UNIT(OVER 100.000 BTU)
ClYcs ❑Nn PAID
VI'NTIIAI'ION FAN(SINGLE NP_SIIJ) Dam Raeipl
Wall the eppliexns m futurt wilding«cnlwm uw equipcmem m tleviR which
emit hvaNsus air conmminanuu defined by the Bay Area Air Qualify Mangcnent BOILER-COMP(31111 OR 100.000 BTU)
1Yc ❑Nn IIOII,GR-COM P(OVIiH 100,00I(ITU)
IIVoeraid!tK hinunbus meunds negnnenneny coder Cbsai695 of the Cali. AIR CONDITIONER ISSUANCE DATE
Groin Ilcdth A Safety Code.Satiom 23305,23533 mud L5.U.1 uM«nud that if Iw NEW RFSIDENTIAL MI-CH. SQ.IT
huilding div nn cumently have a u,bam,Inm it Is my maPmsihllily to middy the nreupum
of the n ,inemrnu which most be met prim m inuanae a.Cendr.of(ktttTatcy.
Own,"itolneldagcnt Dan, TOTALISSUED BY:
OFFICE