31010 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^
CITY OF CUPERTINO BUILDING-ELF,CFRICAL - PERMrr NO. Njq1 O 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PH E. CONTRA RS NAME: LIC NO:
s
S'-.v- M N L 1 NIC CO LN
iGHITECI'/FNGINEER: LIC NO, wDURF_SS:
Rr ❑
CONTACT:' PHONE: D BUILDING PERMIT INFO
G �( � n q/ / L ❑ Consultant Fees Nid by Applicant(Initial) BLV ELF PLUMB MPGA
LICENSED CONTRACTORS DECLARATION (b W QTY ELECTRIC PERMIT F. rL—A11'/
1 heredity am that I aun licen.d urdn po.viama M Chaper 9(rnmncrwing JOB DESCRIPTION
"Z m Smtom 7").fDivid Jnfthe Busincsn end PrOf.inm Cde,vd my licem,e is
r00 .nP - PERMIT ISSUANCE
tall To, a: ddTca j �,�v ✓ FOWL El KITCHEN REMODEL
UZ�j License Clue Lk.M r'1 S
¢� Date _ TS DELL APPLIANCES-RESIDP.NTIAL DADDfIION CPLUAIBLNG RE-PIPE
F.r�Din R If I1ECT5 DECLARATION
[].MULTI-UNIT [I STRUCTURAL
O Z-a Z 1 andcPvand my plans Jwll 4 cool on public recants PANELS _ '
:.1 UP'R�iW AMPS MODIFICATION
r 1n F W Licemdl Rofes.ionnl D INTERIOR D CHIMNEY REPAIR
_ 2U1-IOOBAMPS IMPROVEMENT
OWNER-6 I hertby affirm IMI 1 am Be cmgEfrulmFlhc Contractor's I.iccnse law for the OVER Ul(I(IAMPS D HATH REMOD IF■p EMOLITION
3 a U following m="m.(Secliun 7031 5.Bulinus ami Pmks.imm Code:Any city or roomy SIGNS FLECI'li OOTHER �� "
LLO< which rmuires•permit to mown,cher,improve.demolish.«mpeir any a clure
(:�y3 prior m its issuuce,.Iso rtyuim thr applicem f«such permit to fika sigma uvrrnent SPECIALC UT
f Y 1hN he is li enact puwwmthe povitiw of the CumrxnMaldccose Lew lLlsepter9
u�10 ��0 (rontmcnciog with Sruan]mpofpvieinn3nftM Bminasand Pnrfe,winm Rde).e TEMP METH RPULE INST. . "u
d o far
hen esempt Ilemfmm arul the Foix forms,alkged eumpion.Any Acda m of
^„ diw]70313 by MY applicmnP ine Paulo - ❑NE IADDURCC N• '100601)SERVICE
El DEMOLITION
Se
y pexmi jerk the applicant to a civil pvey of POWER DEVICES OTENANT
HZ} not more Than five h rchm!dullva(SSOO). - IMPROVEMENTO ❑ Lee ox'«rof the popeny,mmy employen with x'.Bu ea dear snk ampeneetiw. SWIMMING POOL ELECTRIC
will do the w.A.and tM evmmm s m.mendd or offod for rale(Sea.70M,Businevv ❑OTHER
o. and Profusions Codc:The Cwtmerors License lawidoce not apply to an owter of OUTLETS-SWITCHES-FIXTURES
property who builds Or improves throve.end who doe such work himrelf m flart
his own employva,pmvidcd that such improvement,are nat inetdd«oRvW f« NEN'RPSIDENIIAL ELECTR SQ FT.
sale.If,however,tbe holding,r improvement is cold wilhinarreywrnfnmtplUion.the _ SQ.1'1'.FLOOR AREA VSQ.LT.
owter-builder will have the mmkO of proving that le did nnl bmld,rz imlmve fm pur- O /
pmc M mlcJ. �
❑ u I.
owner of de popmy,em eulmivelY mntractine with licrnsed mnnct«ePo L'
conutmt the pmjdP IST.]DW,Bosinecs W F'mfcssinm COdc)The Cnnuacml.LI-
cenrtMwtMsa.nm apply men owns of pnspcny who M1uildxnnmpnrvuxtMrntnend QTY. P UM.LNG PERMIT FEE y
Lieca f«each prnjrls wiPh n caumcmr(s)IiansN qu.uenuo the Conwclar's
0 rouc law. PERMUIS
1 n memp under Sec. .B&P C f«Nie ream
Owner Uane ALTER-ON &• WATER(EA) ^ UATON�''Y�
WORKER'S COMPENSATION DECLARATION BACK FLOW PR .D / �` ``aa�'
Ihereby affirm_ .. pemlty UPerjury me ofthe following drlumiom: 4 .J
I have nd will mumeine Cenificmcof Conscnno sd6imuue for Wmke/a C.,O. DRAINS-FL F D,
di,e.provided Gtr Ay Soction 37D)of the Inbar Ctdc,f«tW per .oamn c at fl,, STORIES' TYPE GD.V.STRGLTIDN
v, k for which this Permit is issued. FIXTURES-P
D 1 have wd will mdmvn Warkd's Compenwdmt Insurmrc.u mquiPd by Sextiost -
J]Dddde lab�rCdc.fm tie prrformamx of the wart fm which this Admit isiwtd.
GAS-EA.SYSTGAIN OCC.GROUPAPN
My Workpe
r's COmnmtion lmtr.n d cxad Paltry numhet ere: 1.
Caroler. Pahcy No: GAS-EA.SYSTEM-OVER4 )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASF/INDUSIRL WASTE INTERCEI R
BUBD D ISION FEES
(This srtion reed nn be compWM.fine pemdt is fm arc husdrrl Plnllus Pi 100)
or bsJI I GREwSETRAI' PLANCHBCK FEB `
I oy My dcP mrM prf«mumce of Ota became
for subject
which drmWn i.asud,l shall
mernplOy any niia any Prumerw as to bccosPe whjm code W«kets'Contpen- SEWER-SANITARY-STORM E.A.](IO FT ENERGY F'EE
O Z urian Isws of California,difDate WATER HEATER WNENf/ C R O
It
Applicant GRADING FLF
.N-. become b' APPLICANT:If.alar making this Ccmliuur of Exempdnn,yw should WATER SYSTEM TREATING
bcch.ith mord m the WOrlds'hiama manhu. ammisium of tM laWr Code.You neer SOUS FEE
W Q fmhwith canPlY with such provisiwu«Nice permit stall be tleeooed rtmisd. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW REB.RESIDENTIAL PLMSQ.FF' PAID
0.
U O I Mrthy effms Her them is a an.huction Imcm,agcmy f«me pertamunce of Rrcipx
U. P the woh for which this permit isisumd(Sm.3097.Civ.C.)
C) U I<r allome TOTAL:
U I2rderswmree '
0. 1 cedify that 1 havr oro Prix ep,I"Ooo and ata¢For the ahovc'mforsmsioo Is BUILDING FEE
V) r« t.l agrte to comply wadh all city and rnunp«dimees wxl core lows mlvibgm QTY, MECHANICAL PERMIT FEE
V Z WildiPs"camvunian,and lertbyeudwrizc rtpresmtnuves of Ibis cosy loeneTupon de SEISMIC FEE
above-mrntinned prprny for inspedian porprsa. PERMIT ISSUANCE
(We)agar m save,indcmmry end kcp homiest the City Of CuNnim eguimt F.LI!CTRIC LLE 2
Banal hies,judgmerm.,casts ami e,s,m es which may in any way accme agaimt said Coy
in c«uryucrce a(the granting of Nis pdmis. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.0)0 CITU
MECHANICAL ITV
SOURCE REGIIIATIONS.
/e'-I � /.1 AIR HANDLING UNIT IO.fMp CPM) CON.SIAUMONT
Sig�u uFA'hcar.uCCYJmrttoe EXHAUSTHOOD(W/DUCi .
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION
Wild¢ej.plicent«fumrehilding rcupvm unm err M1VMlohvarGur mNcrial HEATING UNIT(TO I IMI,OW BTU)
u defined by Phc Cupenim Municipal Cak.C accT 9.13,and de Hehh and SafdY
Code,Section 253200 - HEATINGUNIT(OVER IOO.BBB BTU)
❑Yee ❑No _
VENTILATION FAN(SINGLE RESIDE PAID
wll the a t m famrc bWldin t use P err tlevirca 4emir. Dart,Dart,sammda100."
Rruipl r t us Wnupd�
umed hYomA
Je Bay QalhyM sage eN BOI ER-COMP POR IW.ggB U)
Diuricn TOTAL
C]Yes Onto BOILER-COMP(OVER I00,000 BTU)
'/I I hnvc¢od me hlomaotxcru is order fi95 of the Call- AIRCONDITIONER
( m.15333n hailer ISSUANCE DATE
f«nie gdoe,&Safety Code..tenu 25305,253JJ road 25334.1 andvunnd that,sNe NEW RESIDENTIAL ASECH. SQ.FT.
a alts, des oOPcwhich ou alone,. iorthatm n myrespfa CerlPymndifythe«ccy.
M de Pyuimrtcnu which mau he Prey prim Pn issuemr Of v Crnifi®tc of Ornupemy.
(lwrcrmvuthurvN.gear Dose 77 ISSUED BY:
OFFICE