S1679 APPLICANT-TO FILL-IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO NIIILDLNG-ELECTRICAL PL IT NO, 1679
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
ISUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMII'I'Ah DATE
D iR'S NAME: ['HON z: CONTRACTOR'S NAME: LIC NO
kill, yl. NIC CON TROL#
JW ACHISA.E�MIIVIIINFILIC NO ADDRESS. - ❑ ��
CONTAC'L PHONE: BUILDING PERMFF INFO
❑ Consultant Fees Paid by Applicant(Initial) UC ELECT PLUMI� sIECH
LICENSED CON r RACTORS DECLARATION QTY ELECTRIC PERMIT PEE.
I n by P nu m t 1- licensed ti p I co-is l( lag JOB ESCRIPTION
az'Z wIhS i p0(Xl)ofD "on3 nf0eBus IPmfuxiosCde.and my license is RESIDENTIAL:
'C' PERM]I ISSUANCE
Fy-�1y� Infall f 1 effect 'FDWI, ❑KI'I CHIiN REMODEL
6UU License Class Lie.N gPPLh1NCE5-RF,SIDENTIAL A PION ❑PLUMBING RE-PIPE
y Q L Baa Conumcrnr MULTI-UNI' ❑STRUCTURAL
ARCHITFCT'S DECLARATION
yZ IUnderstand my plans shall be used as public records PANELS MODIFICATION
OZ=� UP 10200AMPS El INTERIOR Ll CHIMNEY REPAIR
H O Gernzrd Pm1hy nffinn that 1 oro rUIL from the Con o e C 201-IOW AMPS IMPROVEMENT SWIMMING POOLS
k Ei d.4 followingerasy lanai
OWNER-BUILDER DECLARATION OVER I000AMPS ❑PATH REMODEL/RF.PAIR El DEMOLITION
FY. I hereP uncture :Any l Law for the
n-(Sedipn 7031,5,Rusftaxs and Pn,fmn ode:An I t ❑OTHER All !)II n
Any aI y nraoun Y SIGNS ELEC'fRICAI. V I�a aW
WU.C,of ul(I q :' p n t I II nI demolish, I Y:wcmrc
< prior It)its %lonce,also4 fficapplacentIor Inch Proult tofile 6 d:panlrot SPECIAL CIRCUIT/MISC.
E y
chat he,,I Ip II II p fof C t 't Liceno.Law(Clode)or R 7
"i g (vo e 1hS e nand ID 3 flh R .c dP f :Coda or 'I EMP.METER OR HOLE INST.
W p,p Ci ohm h pt th 1 d N TriosI theII g l pt Anyviolation
P I ,[ l LDG/ADDITION ❑DEMOLITION
'gym Seat 9031,5 by yapplicantf 'pe tsubjectstlapplicantt Ipe alp sf POWER DEVICES f'Nr Ta ❑FOODSERVICE
nm etha I hundred l ID:($500), R vEn '��UIVV
D U 1 I'ub p I h y Ply '11 'g.- 1 I pun SWIMMING TOOL ELECTRIC
E• will) ale work,a,d thea t rcishotintended or nR¢ed for side(Sec 7(44.B n, HER
x'^w
G3 and i f Code TI L t T 1 L 1 t apply t d OUTLETS SWI'CCIIBS-FIXTURES
Property who houlds or improves therecon,and vindec,,their wark larmseffortinough
his own amplo,ce,provided( 't suchamprovehicals aic nor intended or offered fur NEW RESIDENTIAL FLECI:R SQ FT.
sale.If,h wevep the bold' m
g or is; ldwthin< v y of'ore'L(oy the SQ.Irl'.FLOORAREA $ISQ.FC
M1ld Ilk tht d (p a ' gtM1 th fl th ld P [ par ��
pus r,I )
F] c
1 fth finally,y 'I IYCrair"bar,cloth ' d exannahm,to
cii,tract the project(Se]044,Rance,andProfessions CoiThe ColmemrsL-
xeLaw does innately mar—am ofpropeny who builds or isopro<cs hereon,and QTY. PLUMBING PERMIT FEE
who annual for rich projects witha cnnlfroca s)licensed pursannuo the Comenashs
Lice.c Low. PERMIT ISSUANCE
❑ la ,crop under Su. .R&PCforthis ren eon
ALTER-DRAIN&V T-WATER O'A) VALUATION
OwOr �f—
(� )� E ARV ION 13ACK FLNR
yVICH
1hereby'ff under lGahy tip rj Y fah toll deB 'f -
❑lh d ill ''nttneCrn hevte ofC a If f W k Campen� DRAINS- .A,COND.. STORIES TY' CONSTRUCTION
sat on,as provided for by Station 3]W nl the Lem rGMe,fort p f..I a of th
work for wblcb this permit Ls is.u,d. FIX'NRE
1 h 1 Will maintain W k es C p -i Insurance. required by Section
3100.1 he Labor Code fon he per Relocate or the k liar which till'Poull is issued CAS EA ,4OU'I" 4G�ADI
ROUT, APN
My Workers Can,...Iran]asulance care,,and Policy numbm neeCamim: Policy N .: GAS-EAR 4(E.A
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINUUSTRL WAS I'I.INTERCEPTOR
COMPENSATION INSURANCE TIL IN' )IVISION FEES
(Tlm,cctim nemllor be complesdifWepmmjtle faro.,hall dollar,(5100) GREASETRAP
of Ie".) F.
I certify lbw in We sBarourccof theworkforwhieh this perairis issacd,Ishall SEWER-SANITARY-S'IORM EA,2W FT.
not employany person in any n,onnerso ox to become,,abjuct attic Wurkerx'Canpen-
Z nation Laws of California.Date WATT-RHEADIRWIVEN'IYHI,FCTR
ZO Appb,ma I .
y NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should WAIliR SYSTEMl1'REATING
abecome object to the Worker's Compenanion pro .lone of 0e Labor Code,you coup SOIL EL
CII fonhwhh..amply with such rovi,mrs on hie permit eha116e deemed ru..Red. WATER SERVICE
Q
a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Dam Receipt tl
U0 I hereby mora that them ie a construction lendingagency I hevormora ecof
W N the work far which this pemat as issued(Sec,3097,Civ.CJ
TOTAL:
Isndcrs Name
U
Leader Address
�a I rrfydnlh' dthsappl at d.tletht[l b f ion's - BUILDING FBF.
Z) cemor.1'gec tee ply with'll city andcounly ordd state irwsrclmrngho Q;Y. MECHANICAL PERMIT FEE SEISMICFEE -
U Z bull ,1.1nallmillice.and nearby club orze re'reviaremi ourpfd'v ad, care,uP,nthe
above nominated property for inspection purposes. PERMITISSUANCE ELECTRIC FEF
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabllitios,judix,rn.,.,d expenze—hiehmny hardy way accrue almost void City ALTER OR AILD TO MECII. PLUMBING PES
in n,ac e,nce of tb,gaming of this permit
%PPI ICAN'1'UNDERSTANDS AND Wild.COMPLY Wl'N ALI,NON-POINT IR HANDLING UNIT(TO I0E0OCFM) MECHANICAL-PE
SOLI :E REGULATIONS.
1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT 10 TAX
Signam ram Dam I'XHAUST HOOD(WIDUC'I') HWSING MI'I'IG NPEP.
HAZARDO ATE IAhS MISC - li
Wilhbmppllcom arfuwmbuilding nmupam score orhun aalnusn venal HEATING UNIT('fO 100,01-B'TU)
az defined by the Cuptttine Municipal Code.Chapter 9.12.and the Health and Safety
God,.Section 25532(a)) - HEATING UNIT(OVER 1011.. ...or
7Y,. E]No VENTILATION FAN(SINGLE RESID) PAID
IJna Receipt
E!� a it hWill the applahnt or future huildln.a¢vpam use e9uipmmn m devices which BOILER-COMP(3HP OR 1 W,OW B ID)
maenNous aircantan....art,as defined by the Bay A.AlrQuality Mtharlo ant TOTAL.
Dishical BOILER-COMP(OVER I W OW BO)
LJYcx 0 N
�
II" udW h d tial y t' d ChiPt 'f 95 tithe Cal AIR CONDI'I'IONER ISSUANC
4 H a Id &Safe y C d S t :25505 25533' d 25534 I d h d that'!Ne NEW RESIDENTIAL MUCH. SQ.Pp,
buldigd tcurrently M1 ucnam,that it s my responsibility to notify the oeetpant !
ITT he r,9uimnrents which moa be Ism prior a..swan¢of a Cch iflan,of Occurciao, TO
Owner m aml herized it Date ISSUED BY:
OFFICE