S 3035 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD -ELECTRICAL PEKE❑'NO.
B
BUILDING DIVISION APPLICATION/PERMIT PLUMING-MECHANICAL J 3035
BUILDING PROJECT'IDFNII'IFICATION
BUILDINGADDR6SS: SANI'T'ARY NO. APPLICATION SUBMITTAL DAI"ti
t o 2 3 - £ cu �l nl GT c�M Gtrfi�/J d �s� / a 2 3
OWNIik.I'S/N�AM 'a�a1 1 /Ph'ONE, CONTRACI'OR'SNWjI, �1� 7 LICNO: O
�'[/L /,l C—� ' JJE. - /At r C �r �f��\.-CA/ S'L k' N RIC CON'1'KOI.N
RC1lrrfc ry S CIJII.J ((k 071 nnnal :oS 6c. S 'WAN2rt/131VD ❑ O �y
CONTACT PlIONH: BUILDING PHRMIT INFO
CnsullFees Paid by Applicant(Initial) BLDG
CLIJLCt/FPLfLU-TMIB� A'CiC/IH
'l_MqfMWnI -f-05-366110-n"
.OU-3 01QO rTI-
LICENSED
CONTRACTORS DECLARATIONQTY ELECTRIC PERNII T FEE
I hereby affirm dial 1 am licensed under provision.of Chapter 9(commencing JOB DESCRIPTION
�IxZ with Section 70001of Uivi.ion3 tithe Husine..and Profe..htn,Cole.and mylicenx is RESIDENTIAL:
WOO
I'IiRMI'I'ISSUANCE
FxWin full hmuand effect O e ❑SITWI, ❑KIT CHEN REMODEL
aUV Liccn.e Claw hic.M APPLIANCES-REMDEN'I'I Al. ❑AUDI'T'ION [I PLUMBING RE-PIPIT
FZW Umo Comrucnn
la 6 a EIMULTI-UNIT' STRUC'I URAL
=y CIII'1'IR;'I"SUI?CLARA'ION PAN21S
FyZ Iand...food my plan.,.hill be used as public record. MODIFICATION
OZ=C UP T0200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
17NFW Licensed Plnfeuiand 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-HI11LD1iR DECLARATION OVER 11XX)nMPS El BATH REMODELREPAIR ❑DEMOLITION
C Q I hereby affirm that 1 am eamnpt Worth,Cotmn
nor's License Law for the
I'uy'3 a F following reason.(Section 7031.5,Business and Pmfw,iora Cade:Any city or county SIGNS ELECTRICAL ❑QTHER
ye which requires a permit n)construct,alter,improve,demolish,or repair any structure
F.W.OJ pro t t .. '1: I 'thapplicantf suchpermitt flsignedsttement SI'LC'IAL Cl KCUITM TSC.
thaM1 Ii Ip . nt m p '.' t lith C I t 1 I '(ChapterY
Inst d'� Ict tv' gwth Sul n 7000):l Inv'nim 3 of the lomat—and lrtli.....' rvC,,dl)or I'LMP.MhI'I:R OR I'OLE INST. COMMFRCIAI'
c.X o a Ih:a he is even,mere[n I and the hunlp
...for the alleged uxulion.Any violation of ❑NEW BLDG/ADDffEl UFMOLUION
5cninn 7031.5 by any applicant ll,ru pmml nubjmu the still-loonto a civil penally of POWER DEVICPS El TENANT ❑FOODSERVICE
W_c,lnnnnre'ban live hundred dollars(ESq)1.
F=G I.ac owner of the property nt loee%with woes as their ask atm tion, WIMMING POOL If CTRIC IMI'ROVLMENT
7=Q trope Y Yamp Y 6 pcn,a ❑OTHER
F will Jo thesions Cedi The ams isnot rs tended License La doesred sale(See an Baser„ D
13 and Ihofe..ions Cade:The CnmruaK.License law does nm opply at an(caner of UTL1;1, SWITCHF_S-FIXTURIil V
property who aidds a imprnves thereo,and who Jaen such walk himself or through
his own employees,provided that.such improvements am not infrared or offered for -W RRSID, rIAL ELECTR SQ IT.
sale.IL however,the building or improvement i.,sold within one yc,ofeum,li Tan,the SQ.FT.FLOOR ARCA EISQ.FT.
oss,w,dmildur will have the barrel, I pno,ir,that be did a.,huddler p far p -
0 he p p ty I ly c ant,on,Is alll'" l"alloolon,tat
l,lrucl the turner,p o na If I I f '. C J i fl L :and
,v Law dce.nm apply m ut ith ar t mmulany who build t p vhe thereat.and QTY. PLUMBING PERMIT FEE
,ct r
who contracts for such projects with a ennmenmLc)licensed pursuant m the Convamoh
Liam"1, PERMI'I'ISSIIA E 3
O I am exempt under Sec. ,B A P C for this reason
Owner DateAI:1IiR- VERT OA) VALUATION
-fD O d �J
WOR order
crOMPEN rjur,on DECLARATION HACK f. W PR DEVICE
r IM1cr6 walfirmundcrpen"Itytte(i(uryoneofthefalhwing Jcdaretion.:
Ihwc and will muinlmnuCenilic:nc al Consent to.elf-insure li)r Wnrkch Cantpcn- DRAINS-Iq.ODR.R COX STORIES 'TYPE CONSTRUCTION
amino,us presided for by Section 3700 of(hit labor Code,for Thu performance oT the
I for which this pcnn[it ixnunl. IlX'1'11R1?S-19iR TRAP
C] I have and will locitiolin Worker':Conopeoverso I ran 4 d by Section
3700ol he Labor CCealtu.noryhe pet urn* .fy'he
walk fnwh hthis re is .-:cd. GAS-PA SYS fLM I INC.4 DO 11.121'S OCC.GROAT' �f{�A/�PPNN�/./
Ca Wrrk5-A-f R ✓NIfiST yN y en� IWD Ik/ S
lyag ly GAS-HA SYSTEM-OVER 4 MAI
CERTIFICCOM19i EXEMPTION
EMPTINSUROOMW SLJQ; GREASI%INDUSTRL WASTE:INTERCEPTOR
BUILDING DIVISION FEES
(TTissectfon need not be completed ifthe permit is for one hunJmJ dolliss SIN) GRI!ASE*EAAP
or less.) PI.ANCHECK FEE
I certify that in the penannenceoOhe work for which thi,tartar itsuaucd[,half SEWER-SANITARY-STORM ITA.200 IT.
oat employ any person in ary manner...no. ,became wbjmnI, he Workers Cooper HNI?kGY FEE Q
,7, .,anion la w.of Calikeniu,Dae WATEk I IIiATIIR W/VENT/ELEC71R GRADING F'F
Z Applicant11
NOTICE 10 APPLICAN'1:If.after lnnklng this Canilielle of Exnnpnion,you should WA I'HR SYS'I EMRRL'A'I'INO
N SUIhSB'('P
F
become t could,
Til Wader',Conan,usmian Aman inns b the Labor Gde you mon V
forthwith comply wilh.wch pmvi.iom or Ibis permil,M1:rll be JvaneJ revoker. WATER SERVICE
CONSTRUCTION LENDING AG12NCY NEW RESIDENT IAL PLMB. SQ.11IA11) Date Receipt
U0 affirm that hereby affirthat them is a construction lending agency fur the Performance of
Il. — the work fur which lhi,pcnnn is issued(Sec.3097,Co,C.)
C U Lender',Name TOTAL:I.cnJeF,Address
'>" 0. 1 ccdify thin I have read this pain and,tam that the di information is BUILDING '
Fah n..... "gree nrcanply withal[city and nmmyorJinnntts and nalcl�wsrclmin6u, QTY. MECHANICAL PERMIT FEE SEISMIC Q
U ,Z building coaainaction.and hereby;vitI I,tapm,em"rlvc,mfllascity to cmlerupnn the
a ,se-nmmionad property for inspection purposes PERMITISSUANCE, E1.I1 RII El a S�
I Wal agree to save,inJenmily and keep banal...the Cay of Cupertino again,"
Iiahililicsjudgmenu.cost,and expenses which may in anywaylecrucagainsuaid City AI Tf:R Ok AUD TO MEGH. PLUMB F-.
in nagoence of the 6reming of"bi,permit.
APPLICANT UNDERSTANDS AN[)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO H]L000 CFM) ADW I NICAJ FEEO
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,000 CFA) CONS'I'RU DICTA%
Ignufare of Applicant/ nhacmr Dam EXHAUST HOOD(W/DUCU IIOf151NG ITIGAT[ON flit?
HAZARDOUS MAIARIALS DISCLOSURE
Will the appliamt ort'uhae building occu rant%tore or ha nJk h"rvrinuc material I IIIAI'INC,UNIT f10 I(X),(XX)[I I'U)
n,dulined by the C.,mou Municipal air,Chapter,9.12,unit the Ileahh and Set,,,
Cal ,Semion 25532(m? HIiA'I'ING UNIT(OVER Iof),mm Ifl'U)
E]Yes VHNfI LA'DON PAN(SINGLE R ES]U) PAID
Will Dam Rece' p
� ,"he applicant or future building occupant use equipment(it device,which BOILER OR 100.000[1 TU)
,ttit Invidious air conmminam,a
default by the Bay Arca Air Quality Management TO
Dinrim7 BOILER-COMP(OVER 100.000141U)
❑Ye.
I have read the ,Nom cria be rements under Chapter 6,95 of the Cali- AIR CONDI ISSUANCE DATE
Lithia fleahh&g y �,la S chum 25 0 553?unr 25534. unJcrnnnd hill lithe NEW RIiSIDENTIAL Ml-Cil. SQ.ER
build'mg Jt tcu myhnv ulauum no,lay rupn isjulity In nobly she nccupm" ( T
Ill the runt' bicb nnnfre ro,i—inm ol-C"Inic.e w�
fJwncr nr vmhon�ugc Dine I I :�f ISSUED BY: �—
OFFICE