S 0251 (2) r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON'CUPERTINO
BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONWERMIT PLUA1a1NC.-MECIIANICAI.
J RUR.DIN'G PROJECT IDFN'IPIIATION 0251
,}
BUILD] G DO SANITARY NO. APPLICATION SUBMITTAL DATE
O N R i li' CO A O 1
NIC CONT OI,M
�AH HRECDEftGI PER! LIC NO: AD RISS: ❑
AA
pHONf!: BUILDING PCR INFO
'`�-w// � ❑ Consultant Fm Paid by Appllwnt(Initial) BLDG ELECT PLUMB MecH
❑ X ❑ ❑
LICEIISIOTONTRACTORSIDECLARA11ON QTY ELECTRIC PERMIT HE
11pp�11 1 I,eany ern t t 1 em ranad amkr r nil nr CToaN mmeMina _ J DESCRIPTION
inn(ullfbae70(1 ond 1 xivn SarliK Hmlvxvs uy liccnrc is PERMIT ISSUANCE
RESIDENTIAL
C SFDWL D KITCHEN REMODEL
<a.UU Lk g APPLIANCES-RESIDENTIAL ❑ADDITION C PLUMBING RE-PIPE
umc
yQL Date Cmto
A HIIV:I SDECV.RATI ❑MULTI-UNU' CSTRUCrul Al.
Z O m nv PANIB S MODIFICATION
�Z I nx eM1ellne urd e'CLAemmt v
CZ-� n UPTO100AMPS 0INTERIOR ❑CHIMNEY REPAIR
W Liteconel itofcssioml ZHI-I(XX)AMP' IMPROVEMENT E]SWIMMING")IN
OWNER-BUILDER DECIARA)IUN OVER I"AMPS D BATII REMODELREPAW ElDEMOLITION
C W Q I hereby affirm Thal 1 em uempt from the Contractors License law for Ne
3a.U f.11 wing rca
asam.1Stion 10315ro
,Bnofd co, P�dcxsivmn Circ:Any city or aunty SIGNS ELECTRICAL ❑OTHIiR
LL LL which od,eiret a permit to emotive,alter,improve.JcrtloliilL ur apair any%lostrme
� prim to iu iasuvK<.al.ro requires the applicant f«such Permit to tiles c,ml uvemer, SPECIALCIRCURIMISC.
ythat he is liccmad pinternal lu the frov,imr of the Cuntralole Licenew Law(Chugcr9
tYpO (camtnmcing with titttion 10001 of DivWdn3 oftF1 Basitevs erW lTd'evimu CUJc)a TEMP.METER OR NILE INST. COMMERCIAL
d a e K the-k is ucmp thclefmm aM Hut hada 0x the allege)etuen i«r Any violation of D NEW BI.DGIADDITION D DEMOLITION
�MN Sediun 11131.5 by any appllcanl for apenuil subjects dam aWlicmn to a civil penalty of POWER DEVICIS CTENANT ❑TOLD SERVICE
F Z Y m mare door Eve hundreJ dri 155(10)' IMPROVEMENT
�_� O SWIMMINGNIOLEI.ECIRI' COTTER
F. will dvthe%(A.and lheelIDelmt,is tmum cdornlfaN l«mk(Sec.9(M4,But.
L3 and aPmfeeddas Cone:The Conaanu's[it.law docs nal apply to ea owrcr or OUTI.I:TS-SW'RCHFS-FI.XTURF_S 5'
po bi win wilds nr improves dwoose,and who des such work M1imwlf or thrnugh -
hk awn empinya.,provided Nm.rich impovettenta art not inmmd or oHcrtal fair NEW RESIDENTIAL ELECTH SU FT
oil,.If. vn.tFc nuiWingm impnrvcment is•uWwithin d.ycarMnre ietimitnc Sp.IT.FLOOR AREA VSQ.v-r.
sur-builhr will have de baNco of pawing Rim he did rat)wild m im,mve for l`or .P p If)
Ll I.as rear of the preferY,am exclusively mnitmting with licend mumaco eto TOTAL.
c mgmct the project(See.9(M4,Husiresr and Proresion.Coley The Corl......v L.-
-
crnre law Jon rut apply toenoaxrofl mPeny wino builtbi or improd
ves erece.aon QTY. PLUMBING PERMIT FEE JUL
whe Law,
f«ouch Nojccts with n cmtrvaortsl Iiccmul pumuent to the CmlrvClt/. ()
Lkcnrc law. PERMIT ISSUANCE
C I.,a.N cons,Sec. .B&PC r«this realm Eur'
Owner
ALTER-DIAIN&VI!NT-WATER(EA) ATION WORKER'S COMPENSATION DECLARATION BACK FLOW 1•NOIriCT.DEVICE,
I lervny anit;tn 9ntkr IKially or periaD alte of use ronowine declamrnnx:
❑mu,.aryliticlforb ination 37te of Latmode.for e!«W-Rumor Conyeo- DRAINS-FLOOR.RUDE AREA.GOND. STORIES Tt'I'F.CONSTRUCTION
wion,m h t OrJ for by Section]. of Incttc W i Codr,for the perGxmunec of the
L]I fir wli fithispermit ivi�wl. II)"NNIS-PI:R TRAP
❑1 Wase mdLewill Code irwin
, erfuries ComRnsme it Iruwarchi h r, u...1 Sectio
391X1 nTthe labor Ctdc,f«line perfntnomec of the west It,when thh ppmdlnrooted. GAS-IIA,SVti TEM-I INC,40UI'hlfl'S UCC GROUP APN
My W«kera ComiNnmtinn Inaumnce carrier anti PWiry number are:
Cartier. Policy No.: GAS-EA.SYS ENTOVER 4(IIA)
CINPFICATE OPIINEMI•I'ION FROM WORKERS
COMPENSATION INSURANCE GREASFIINDU.STRl WASDi INTERCEPTOR BUILDING DIVISION FEES
(ltit.iontccd oc*bccompleodifthcpcniil i.far err hutabcd dAlea ISI001 GREASETRAP -
or les") PLANCHECK THE
I,,mfythm in die perrvmmantt of De w«t frwnichtl spemnitis iswed.1001 SEWER-SANITARY-STORM EA.3()0 FT.
not employ any pmcn in any mennm.w ux to bec nl mnjccno lM Wattle,Compcn- ENERGY IEE
O Z svtkn laws of Celifnmie.Date WATER HEATER WNENT/ELCCIR
GRADING FEE
z Aificand
O NOTICE TO APPLICANT.If,after making thio Cedificute of B crTucv,you sham d WATER SYgTEM?RIfUlso
P "' hesco a sunjm to ft Workers Com easmion pmviiim. a M tine lanCed,yVu must SUITS PER
L�SdQ Ionhwith cannily with such provisions«Nis permit shall be deemed revoked. WATER SERVICE
Dz CON.WRUC`H0N LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ,FT PAID Dmc Ravipl A
UC) l leaky affirm that Nc,ixncrrnsvuction ktWinaogony f«tle pcff-manoaf
1.4 F' IM1c wok fee which Nis pemth Is issued(Sec.3091,Civ.C.) TOTAL
Irndv's Name
O U nd:rx AJdre, 9(1'TAL:
I<
} LL7
1 cmify ilio I M1evc reed tris epplkvti9n and nate Art the above infvxrretion is BUILDING FEE
Z c ti.laaacmnxnpiy herebycitymdmwmyvedinvrce end Mmelendr u"the
QTY. MECHANICAL PERMIT IEE
UZ M1ui Wing nu.wginn,and hereby vuthurvc preKnwtivcr nl thin city roamer upon the SEISMIC PEE
above-t ntimril Mn yfsrimpenioopurp, . PERMIT ISSUANCE
(Wegtee m veva imkmmend fy keep bandit,the Ciy of Cu,mod apoina ELECTRIC IEE
il)
'enilities,jWgmenu vuavon$perees which may in anyway ace apitw said City' ALTER OR ADD TO MECH.
an Rut,ncof tinadeit" pmnil. PLUMBING FEE
A 1 CANT E STANDS D W ,L PLY .L yYO -POINT AIRHANDLINOUNI'I'1TOI0.IXdCFM)
Sl 11 !GUI INS. 3 MECHANICAL IEE
AIR HANDLING UNIT(OVER IQUXICFM) CONS'IRUCFION9'AX
Sig i o Al is nV naectm are EXHAUST HOOD rWMUCI} HOUSING MTUGATION FEE
AZSRDOUS MA IALS DISCLOSURE
WIII the eppl'cunt«fulutc huilding tccupwtstart mtuadlc us mwcrial HEATING UNIT(TO IIXt,pXt HTUF)
asJ,r1 d by the Cupeniw Muakilel Cone,Chi 9.13,ad tic Ninth and Salcey
Calc,Section 25531(.19 HIFAIINO UNIT(OVER I011XN)BTU1
(1]Y,, ❑Nn VENTILATION PAN(SINGLE NFSIDI PAID
Will thea Beano or future buildin KCu I use I or Jevieca whit Ihtc Rcaipt N
pp av ryin Area
Air
UOILF.N-COMP(JHY OR Io0.000 RTU)
•emit haaarvkaa air contaminants u Jtfitd by the Bay Aru Air Quality Marmgrttem TOTAL:
DtRnn1 BOILER-COMP(OVER IA A10))BTU)
❑Ya -1 No
I bast,.1 the bvin4us marianulx adteimnnts unkr Cleaver 6 95o me,C91i- AIRCONDITIONER ISSUANCE DATE
fort Health&Sefety Coda,Sections 255115,25533 and!255.4.1 utvknrvarxl that if the NF,W RESIDENIAL MECH. SQ.FT
buJJing does evil cursedly neva a letlltl,that n is my n,p«rudahly to roily the uee+9vad
M da:mquiren name which most nen.pros to ieswnce of a Corti Ream of Oa.vpwry.
ATvar«authodred egcm True TOTAL: ISSUED BY:
OFFICE __. ..