30473 (2) .APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CTTV OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT F1,UMBING-MECHANICAL .,
BUILDING PROJECT IDENTIFICATION
473
ILI]INGAUDNESS: SANITARY NO. APPLICATION SUBM17TA1.DATE
5 NAME: ,!. �II Pi N��(�_- _ A .Na ev �!�,/ WC NO.
/!//VI rnV NIC CONTROL
ARCHITF.CTIENGINEER: T3-3 C�
{aJ ftl ) N-S� C .�� ❑
CONTACP � S J BUILDING PERMIT INFO
Ar ' 6&� GOIi qa ❑ Consultant Fetl Paid by APplkant(Initial) BLOC ELECT 'PLUMB MECH
� � icence Clax LICNSEUCONTRACTORS DECLARATION
I ImehyaRm thin 1 em licensed underprovisions of Chapter 9- dnB QTY ELECI
RIC PERMIT FEE
DESCRIPTIONI-ICZUiiaUivNa7ufda HudnwWPmreaicmCade.ad my,It.., RESIDENTIAL
FnIlIIwsmeffect. PERMIT ISSUANCE
yFLmLic.N ❑ ❑
KITCHEN REMODEL
zym APPLIANCES-RESIDENTIAL ❑ADDrrON ❑PLUMBING
RE-PIPE
ARC1 :Cf NAI'10 PANELS ❑MULTI-UNR ❑SIRUCHIRAL
Zp!OZ h pld MODIFICATION
0 UPM200AMP3 ❑INTERIOR ❑CHIMNEY REPAIR
Ag F 101-10BOAMPS IMPROVEMENT
pMo Oat I red NIccept Ifrmthat RADON OVER 1000AMPS ❑BATH REMODEIAEPAIR ❑DEMDI.ITIGN
CC,,'EE«,`yy 1 hereby affirm that 1 w accept from that Cammetah Lianas Lew ra the
of a fMlawing rcaaa.lScefi!m]R11.5,Buxinaw and PMasiom Code:Any city nr cnm:tY SIGNS ELECTRICAL �H
41 S�j which requiring a lenmt w comma.elar.improve,de son irh,or repair my aaunute
0 prior in its iameae,else require the oppicarrt fin such permit to file u signed smmmmnt SPECIALCIRCUITIMM. .
IM} Ilse be b licensed pueumdm We provisions ofth Coeuamre Licen«law(Clear9 -
^y'DO raavnvming with Smbm 7111111)of Diviaking 3 cards,Husiaes and Profastime Code)or TEMP,MF,TERORPOLEINST. COMMERCIAL•
IMP
m C Ilse he is exampt aartrmm end th ba+is her the elkged exemption.Any violating of ❑NEW BLDGIADDMON ❑DEMOLITION
R7 LL Section 70715 by ony epplices,f«u panda subjects the eppkant We civil penalty M POWER DEVICES
^rn ❑TENANT ❑FOOD SERVICE
pZ} set some,Oren Tice hudrtdng.manm55110) IMPROVEMENT
CCD ❑I.MooftepenY•amy eMoyexa with wages utheir sole compensation. SWIMMING POUT,fiLECIRIC ❑OTHER
wnah p
will dothework.Co e:71.Cum is non tntcnded«oRaed s got apply o sin Bgnm or
aa$ inti erof«dob Code:The import.demfs Lima law dm t appy ge m owrourd 011'OJTr3-SWRCHES-Fl%TUNFS
^ his own wh time.« idesh thmem, p who den suds s ire htmdfo through
his own maritime.er.aha paidad the.ah tmpos"it w av ant immNed a olmmi f« NEW RESIDENTIAL ELECIIt SQ
avorge,howevee da buildinghanded off
iraWdwMmoaat ofm impose for
SQ.FT FLOORAREA EISA.PT.
owner-hOCer will how the buNenMpaing this hdem hilJ«bryrove f«par
❑1.a owner of the poverty.em weelataly aaacting with 0calred caluamn se TUTAI4 ,
amamn the project(Sec.7UW.Best«a and Profession.Cnk:)The Conaamfa Lt- AUG^ g
ams law ma it= apply m m awar or pspe.a ny who polimpv
oethoea
a g.and QTY. PLUMBING PERMIT Uv 0 �n
whocmlunae Taauch projects with o emmmeods)licensed powers mthc CantrmTof. /e
L❑Ism icense I... PERMRISSUANCE L/ 1 v
I
comp underSec. .BolPCf«this oeaxun sit-VUr-Lr, .
Owner Got. ALTER-DRAWRVENT-WATER(EA) VALUADON •"`�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 baeby affirm under pemhy of perjuryone of the Beginning declwionx:
•❑Ihaad w0l mabninaCenifieomofCasentmsulf-imurt faWarkefs C«npen- DRAINS-FLOOR.ROOK AREA.COND.
mtiun,an provided for by Soria 7700 of the labur Cade,fa the performance of the STORIES TYPE CONSTRUCIION
'wort far which thin pgmit in besued. FIXTURES-PER TRAP
1 hove and will maintain Wnthnh Compensation becomes.m required by Section
771E of the laborCode.for as prfamax ofthe work an which thin permit is issued. GAS-EA.SYSTEM-1 INC.J OUTLETS OCC,GROUP APN •
M Wake/w Ic re len lmu ceerier adl'dic ny��yy �•
/ Cmi�MLR/N 1� IWi.,No _L(1g GAS-IIA.SYSTEM-0VER4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASIMNDUSTRL WASTE INTERCEPTOR
TlMeseerionam gat be complallithe permit u forachaddrtddollan(51001 BUILDING DIVISION FEES
a lase.) GREA511TRAP PLANCHIrLK FlIE
1 codify the In the pNmomna eta work an which thin proM is legend.I shall
am employ main y pto say mmarse m or Mn m
amisubjethe Workers'Conten- SEWER-SANITARY-SURM EA.R9 PT. ENERGY IEE
O�`{ intim lay.offalifomie.Date WATER HEATER WIVENTIELECTR
.�
Applicant GRADING FEE
{-+ .Ni NOTICE TO APPLICANT.IL after making this Certificate a Faempkn.yen Nave WATER SYSITlMRBADNG
P y o
booms mbjm io the Wmkces C=Mnmion p iskms of the laha Gde,yrm mum SOIL S FF,F,
{fti7j forthwith comply with such provisions this pamit shall be deemed revoked WATER SERVICE
CONSTRUCITON TENDING AGENCY NEW RESIDENTIAL FLM& SQ.Fn PAID
U Ihvehy aRmthis threi.acawuctia ledingagncY r«tteprf«mence of - IAm ecdpg
U. T-r da work far which thin Fermat is t.wal(Sa.7197.Ci,.C.)
C C.) Isdefa Nora sit,
TOTAL:
ItdeM1 Aram. TOTAL:
y1 aenify tIm 1 has and this applicnioo and vee aha Ha ahwv in0mmaion is BUILDIN a
y anrmr l agree teasingly with all city mal cranky odinaaa undamm law missing m QTY MECHANICAL PERMIT FEE
V buildiregcanaatiagad herebyauthaia apeantdveaofthi.city convention the SEISMI
'' Wnanamtirmnd pegrdy for inspection purpura. PERMIT ISSUANCE
(We)arms se ma,indemnify ad tecP hmleaa ale City or Cu
(We) ELECTRIC FEE
lbibililia•judgmmem,coamudaperaex which may in ay way accrue agatmt said City ALTER OR ADD TO MECH.
I.eaarquma of th g=ilt'of thin pemdt PLUMBING
APPLICANT UNDERSTAND SA .L COMP W RH ALL f 7N- )IM AIR HANDLING UNIT(T O 10AU0 CFM) MECHANIC FEE
SOURCE REGULAR
AIN HANDLING UNIT(OVER IO.gO CFM) CONSTIU
dAp irenl/CmlrmooGio EXHAUST HOOD(WIDUC) NOUSIN ( TI
HA7ARDOU ATE DISCLOSURE
Will den pliicent or forum hieingecaMe[amscar human buamdnu.material HEATING UNIT ITO I olA01O BTU)
a definer)io dre Cupenia Municipl C«le.CM1ryaer 9.12 axl the f4elth inti Safay
Code.Section 25571(e)l HEATING UNIT(OVER 100,g9 BTU)
Oyes 13 No
VENTILATION FAN(SINGLE RESIU) PAID
Wm NcapY
Will dthe.apMtcam«fretum htldtee by the B was,equiir Gu«devkawhich BOILER-COMP CHIP OR 100,000 B7U)
Dist hmadan dr cmmmimim u @Fled by da Bay Ara Air piuliry MaugemeN
} IXwrin7
13 Yen ONO BOILER-COMP(OVER 100.000BTU)
`
1 hve deet the baradag maaida emirtlmlu oda Chapter 6.95 Mth CNt- AIR CONDTIIONER ISSUAN DATE
h.ak Health A Safety Code.Salim 25341,25577 red 7557(.1 uderrteml that if the
loading does iso cuadyhvh mm.the N u ngmrbYmmfy dec, NEW RESIDBN7IAL MECH. $Q.
nfth rtquirtmenu which mat he mm prknn iaance gyo Cemifcea of Occupancy. FT.
i
Owner or wauniad agent live TOTAL: ISSUED BY:
OFFICE