S 2777 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONFPERMIT PLUMBING-MECHANICAL 77 L
C n
BUILDING PROJECT IDENI1hTCA1TON O
ItUI jf�D yl SANITARY NOON SUBMITTAL DATE
OWN :S NAME;/17/1,1{• PHONE COVI'R CfOR'g NA is LIC NO: 1 /
NIC w COMfROLp
ANC 1'1 EC'1'IFNGINIiIik: LICNQ A INISS: IDQ rI
CoK3187 Cv. / �/i T: ./<
CONTAC . ��g'IurJ(sl y'_^f fillILO1N0 PERMIT INFO
'l�fb uT ❑ Consultant Fees Paid by Applicant(Initial) BIh—IIIG/ ELECT PLUMB MIE—CIH/
K 2- ❑ Lr
I.ICIiNSP.D CONTRACIOR'S IIIICLA A" )N QTY
EI.ECTRIC PERMIT FEE
Z 1 hereby affirm That I am licensed under provision a he ommeneing JOB DESCRIPTION
with Section 7")ION:I"ianlofla Businessandl'ris nuc de, myliccnsels R SI E
FI full forvunnd mien PERMIT ISSUANCE O NTIA
U I" License I.ir.# ❑SFDWL
❑PLUMBIN RRMODHL
aFQa Date Caa DEC, APPLIANCES-kISIDENI'IAI. B'/I}SnITION ❑PLUMBING RE-PIPE
ARCHITECTSDECLARATION PANELS ❑MULTI-UNIT GSTRUCTURAL
C z -I nndas'wul my pWns shall he nwA nv puhliu arnNs MODIFICATION
Q UP'1'021NIAMPS
F-L�t:u1 Licensed Hnfesstonal ❑IMPROVR ❑SWCHIMNEY
MINGPOOI-
E z OWNER-BUILDIiR DECLARATION OVERPIAMPS IMPROVEMENT [I SWIMMING P0015
I heresy Ifino'he,I tun c.emm Iron he C'omraaar'x Llcensc Law for the
OVER IOIN)AMI'S ❑HAD(REMODEUREPAIR UIiMOLITION
X 3 L F following.,on.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL 0OTHER
whim requires a panniI to construct,altar,improve,demolish,or repair any structure
prior la as iseunnee,'dxor thea lic:m'fmsach
pLy rn, rgno res pp permit m NilleL (Ch.,I°ill SPECIAL CIRCUI'I'IMISC.
C�>.
that he is licensed pursuant lathe pravislans of the Cammcnar'xl ieense Luw(Chapae9
QO (commencing with Section 700(did Division 3oflhe Businessand Professions Code)or TIMOR METER OR POLE[NST. COMMERCIAL
a Zc C that he is exempt therefrom and the basin for the alleged exemption.Any violation of C2 NEW BLDG/ADDITION El DEMOLITION
W�0 Section 7031,5 by 1111 uppliwhn
nt 0 nindt ilhjn'l,do applic o
wm Ioail penallyof POW131t UIiVICER
F?6not more than Five hundred dollars(5500). 01'17NAW ❑FOODSERVICE
0 Lavoanerofthe progeny,or EQ myenpinyees with oagee sIhcirmle tour ,emainn, SWIMMING PO( ELECTRIC IMPROVEMENT
❑OTHER
at F will do'hcwnrk nnd'hcalmnurc is notimcndedmnlivmJ[ar sole(ger.91J4,Businec�
wand Prnlvesintu CnJe:The Co.....son"I.iceme law does n'at apply to an Uwnerof OUTL17I S-SWI'I'CHIPS-FIX TURES
property who builds or improves(hereon,and who Jars such work himself or through
his awn employees,provided that such impmvemems are not intended nr offered far NEW Rp_SIDENTIAL ELECTR SQ FI'.
sale.If.how ever,the huiliing or improvemmat is sold within one your of connplaion,the SQ.FT.MOOR ARRA $SQ.IT.
owner-holder will have the burden of proving that be did not build or improve for pur-
pose of sale J.
0 1,as owner of the property,all,exclusively commuting with I ceded contractors
omnwt the paaject(Sec.7044.Business and Prnfesvians CnJe:f toe Contmmorv....
renseL'wdoesnotapplytoanowner(1lpropertywhobuildsor1mproveslhcreon.and QTY. PLUMBING PERMIT FEE
whoeomme's frusuch pmjeeuuilh a commcto'(s)licensed pursuant lathe Conwnnrs (�- 1
Liceme Low.
1 am exempt wader Sec. ,It&PC Fifa this reason PERMIT ISSUANCE
OwnerALTER-DRAIN K VENT-WATER H:A)
Doc VALUATION
WORKER:S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of Perjury one of the followingdeclarations
O l have and will maintain a Certificate of Consenna self-hour,Our Worker's Cooper- DRAINS-FLOOR,ROOT,AREA,COND. t✓
union,as provided for by Section 37M of the IaMn Code,for the pa,domunce of the YSTORI TYPECON,IRUCfION
work fill whirla this panni i is tamed. FIXTURHS-PER'1'RAP � �0 I have and will maintain Workers Cnmpvandion Insurance,ass required by Section 37004the laborGude,fone performance of the work far whichabis Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS APN
CaIner:My ax's Cam-nsytipldnsumnce conic Patsy iOaVll¢y numbr J� Q� LZ
�w!!I/FF+� //ll GAS-EA.SYS9'CM-OVER 4(EAI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRWHaNDUSI'RI.WASH?fl GG;RCEI
(Thi-lactim aced not M1e completed if the Penni'iu far one hundred dollars($Iq0 BUILDING DIVISION FENS
nr less.) GREASE"TRAP JIPL�ii 'l1ECK FBI? "�
1redidy Nminthe-1 nrmance ofthewadfor which This Ilia
Waisers'C I,n- 7
author Lewaoy alifia in any moaner so as la beranm subject oohs WorAcrs'Compcn- SF,N'F.N-SANITARY-Mldj-,dwo'
- GY FEE
n;nion Laws of California.Doc
Z � Applicun, WATER H EATER WIVEOf GRADING FEL'
NOTICE'I0 APPLICANT:If.cher making this Cedificsae of Exemption,you should WATER SYSTF.MOREA
abecome subject to the Workers Compensation provisions of the labor Codd,you must YPAID
W liml'wilh,ioncyw it vchfowi,inmor l in,pennit,lall hedccmadne,oked. WNTER SERVICE
Q Q
CONS]RUCTION LIiNUING AGENCY
oU. Z I hereby affirm that is a consammiankradinga for the I NEW RESIUEKf1Al.PP the work lin which thispcmrt,is issued(Sec 3097.Co.Cgeney per nrmnncc oC ceipa#Lenders NameULanders Address TOTAL: TOTALI I ccnify ohm 1 hove muA this upplicnllan unA.vuve abet the above inhormadon is ZI cori Iagree sea comply with all city and county ordinances and.state laws relatingla QTY. MECHANICAL PERMIT FEE
U Z mildmg cimstmaion,and hereby au'hnrive represemmives ofahis city a,cuter upimahe property for inspection purposes. I'F.RMI'I'ISSUANCEI Wel agree :mendcnvufyand kap bur Mess Bae City nr Cupcnino aguirva ludditia"Polo 's,ants anJexpenses which inanywayacrneegainsasail Clay ALTER ORADU'TDMECH.in conseue f the gr of his per
APPLICA- UNDER US qN I COMPLY WITH AL1.NON POINT AIR IIA NDLING UNIT 10,"CFM)
SOURCT EGULAT . MECIIAN AI.FI?Ii
AIR HANDLING UNIT JOVE Ia,WII CFM) CONSTRUCTION TAX
Sign ureal AppliranUGmlmnar Dm, EXHAUST I IO(kl(W/DUCI')
I IAZARDOUS MATERIALS III SCLOSURE HOIISI NO MHHOATION FBI:
Will the applicant or frme building o,impand Iary or handle[nationals material HEATING UNIT M 100,000 BTU)
as defined by the Cnpcnin t Municipal Code,Chapter 9.12,and the Health and Safety
Cuda Section 25532(a1! IMATINC,UNIT(OVER 1100,00 BTU)
El Yet J�Nn
r\ VENTILATION PAW(SINGLE HESIDO PAID
Wndoti, t eicnm or future building by the]]I me ea Air Qu or shouse which Doe Heeeip'#
d Iteunloux airamaunimmism dednrJ by the Ifuy Area Air Quality Monugemcnt BOILEk-COMP(.111P OR 1011.001113'fU)
snlricJ TO'ML:
M GYes �fqo BOILER-COMP(OVEk 100,00OBTU)
has the baa Jour ona'e' wmcats under Chapter 6.99 of the Coli- AIR CONDITIONRIt I DANCE DATE
fnmia Bra Safr C N s 2 s ,25511 and'_SSYt.1 undcrsunJ ahaa if the NEN•RT_SIDENTIAL MECH. My IT.
M1nilding nate ryhuxu us oldie nay mvl'ansinility'nnar yaaei'rupnnI
nf'hu i h riot la issuance ill a CcrdFicatc Oce lacy.
rem, N l
,Owneraramhorlaednge^a )au T T
" t ISSUED I{Y:
OFFICE