S0093 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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UPERTINO BUILDING.-ELECTRICAL PERMIT NO. n
DIVISION APPLICATIONIPERMIT PLUMBING-mECunNlCnl.
BUILDING PROJECT IDENTIEI CATION
1)RHSS: SANITARY NR APPLICATION SUBMITTAL DATE
4-� -q7
f PHONE: 1 ACTOR'S AMP_' LIC
Nh NIC CON'IAul.k
ARCIIIJL'CI'/ENGINEER: LIC NO: AD RFSS:rr,, El
V
CONTACO PHONE.' BUILDING PERMIT INFO
❑ Consultant Fctcs Paid by Applicant(Initial) BLD FJSCT PLUMhtECry
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Iltereny affirmina,Imo lin'med.nde.pmvlsbnstd cnapmr 9 lconnnewing _ JOB DESCRIPTION
�aZ with St bot7wforiumbom 3of Rc BelloCsannd Rnf,ubo Gale.mrd mylicenxc i, RFSIDENTtAL
W O PERMIT ISSUANCE
� in fell ,. �y SFDWL ❑KRCHPN REh10DP1.
QUU I me a 1�e♦ APML CBS-RESIDENTIAL ❑ADDITION El PLUMBING RE PIPE
, Cen
ZQ Dmlrac,«
trey ARCHITECTS DECI.ARAT .N PANELS F1 MULTI-UNIT ❑SIRUCICATY)
zbs2z I undermard my pilo,shall be u'cd re,Public ree«de MUDIIlAT10N
OZ-C UPTO100AMPS ❑IN-rERIOR ❑CHIMNEY REPAIR
1 Entw LoCCe4J Pmfcui«u1 201-I"AMPS IMPROVEMENT 0SWIMNIINGKKIS
'W�j OWNER-BUILDER DECLARATION OVER 10l0AMPS ❑BATH RENIODEIAEPAIR ❑DENIOLff[ON
a Q hereby alEnn one,1 um cxcnmt lmnm IM1,Cumrncmr'x hiccnm Law fnr,he
o.3 d U follmving,.m(,Secucn'10313,B.0 mss end Yndo.viom Grk:Any city m cowly SIGNS ELHCIRICAL �(1TIIER
which nequhes v Mrmil to cewrun.cher,imlrnvc,dcmolidr,m rtPeir any nN[lure
=0I priorto,ui,mao,,e,trHoor imNeapplicrntfor,uchptorrdttofileasignedsvcmcnt SPECIrLLCIRCUITNIS .
9�} tMt he is l,<msed pumuantmthe pmvisiar of the Cnntnemr's License fawhatemer9 r
h C, (comn,rncing with Seetirm"IUMIIof DivieirmJnf,hc lLrimcvurd l4nfex,ionn C,xle)nr 'TEMP.MEIER0 -INST. COMMERCIAL
d X e a' that be i.s excmM iherefmm end,hc lusi,Gr,he dlecN exemption.Any vwifei'm of NEW NhIJGIADDITI(IN ❑DIiMULI'fION
Section by any gjAiinumI« permit
a obje,ov Jr applicant rn
nt to a civil Pelty of POWER DIM [I TENANT ❑FOODSERVICI;
_Zy oat m«e dun five howl Mllan(5500f IMPROVEMENT
f � ❑ hv«vncr d'Ncpmpttty.«my empb>cesw,N wegesuth:ir,nk contpen,etion, SWIMMING RI
y will do the w,rA,mol the s,runua lxrxµmemos]or cRcred f«.mh(5«.704.Busier., ❑OTHER
fa]3 m and 14ofasions Gdc'Itc Cotrucer's Lect,mc Law does not apply to or mwm'of / OUTLETS. -SWITCHEIS-416jp
property who buil,of improves Ihrreon,and do docs such wort him,eN or mawagh
his wn emple,ea lmsided that such impm, aus art n«imcodcd«Mfcml far NEW RESIDENTIAL ELECIR SQ FE
o
,,f,ILh,wner.do building fir impmvement u sold wimm orc year of complm�w.0c SQ.Fir t100R AREA S/SQ.IT.
owner hwdcr will have Ibe buNen of Imving that he did not huild(r improve For put-
P' of sale).
❑1,..M tic fn,Cry.em cxclu,ivcly comwelimg with licen,N cot tim IU TOTAL
.,r.t fed M*1(Sre,7014,Bnvines,tend!Perfes'urs CodC:)INC C«ufstars Lr- r A
,eue lvw does not apply f0 en ow«r of leafemy who builds,r impmsa,hcrCon.and QTY. PLUMBING PERMIT FEE
whmotrxr fee such pmjmw with a c(,mmw,mgs)liceewd pursuant m,hc Comrucnls
License law. PERMIT ISSUANCE
❑I two r.C*1 umkr Sec. .H At PC for,his eaewn
ALTER-DRAIN&VENT-WATER IIIA) VALUATION
(Nner Pune CII y V" NV
WORKER'S COMPENSATION DF.CLARAI ION BACK FI.OW PROTECT.DEVICE s "Lzf1- I 1
jw I y affirm utdca Penally of Nqury cmc of nhc fallwinp dolamnions',
yn Ile,c end will mormon a Ceeificare of C.,to seB-insure fxtW«ie ,Cotpen- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
smion,u prov,ded for by Sectio OIX)of de labor Cade,for the pCrfoo.a c ste the
wrA for which this pemm is issued vFlA-RIRES-1'ER TRM
❑ I have:ud will mainuin Wrkers Comprnsxtion In,manre,as regof ad by Section
3)nllofnhCfled'G.lu,bn,M1c pedmntunaofthc wort for whirl,me,permit in lnwnd, GAS-PA SYSTEM-1 INC.J OUTLETS UCC.CROUP APN
MyWxtp;Cc,22,ewcaVan Imurarre ctmlra«I Policy no
ft!j Carricr'S,/�VL] `- Pettey No.:__ In�(t]_.�I_ GAS-F.A,gYYTEh1-DVIHt e(EA)
CERrincATEOFE\Eh1PTON FROM WORKERS GREASPIINDUSIRLWASTE1NfERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FTES
(nivtclFwrc,'vl nor rte awtplcld lf,he tenni,is for mw nundrul dollars($W) GREASE'TRAI'
«lesxd PIANCIII,CK Il?li
IttnJyfMtinflc pvf«rtmuc efdmw«kf«whichfhi,pmnif i,i.aued.ldWl SEWER-SANITARY-STORM EA.201 FT p�k
rot employ any pt,rso in any manrcr,o ss to bert,rc mbjmt to the W«4rsCmI,cn- ENERGY FEE L
O Z .vadum Laws of calihmm Date WATER HEATER W/VENfII],ECTR GRADING ITE O nppl'rmm
In NOTICE TO APPLICANT If,after maim%Nis Cenif m of Hxcmp mr.YW should WATER SYS ENU REA'1'ING
bm«nC subject to the,W«kcls Cwn ,abvvn provision of the lahor Code.you rust Solis PEI;
Rwh,ith comply with such provisi,ms m this Permit still be essrut revoked. WATER SERVICE
6
UO CON cou.,a'IONLFNDINdo,AGENCY NEW RCSIDINTIALYLMH. SQ.IT PAID Dam µcaiptM
I hertby atfinn,hanhere Is a ttmtrmu,n Ic«ling agsmy fur the pMnmtuwwd
fhc.1 f«which thio grunt,is issued(S¢.JU97.Civ.C.) ," TOTAL_
C) ULemkh Nems
Lcnkr,Addreas TOTAL:
f'�.'.Im W1 certify not I base and this opplicaurm urs]sw¢then me ahsve imarwnlvn h ' BUILDING IPE
Ln r/a] evors, I agrs,e comply with all ,,Y ood uwnty oudirw ,r,ms]state laws'feting to QTY. MECHANICAL PERMIT' FEE r
SEISMIC ITEU Z buihlingcmmurrion.and bnebYeulheiss apmsemat oflhis dry to emtt open the
ebo,cmcmicr U pmpcnY for iny,mio purpmc, PERMIT ISSUANCE
(We)ato emmmss
,indemnify and kr<p hadethe Cit)'of Cupenhw apims 0 IB,ECfT(IC FEE
pra
liabiliticn.ludgmems.<mty and exp:rca which may inany way accrue against sad City ALTER OR ADDTO MIi H.
I'LUN101NG IIiF,
m CANT ofnMRSTANof this pc WILL
mSOUR ERE UNDERSTANDS AND WILL COh1PLY N'I'l11 ALL NON-K)INT AIR HANUIJNG UNIT(TU IU.IXIO CPAU MSCI{q LAICAL FtiE
SOURCE REGULATONS,
AIR HANDLING UNIT(OVER 10,0!1(1 CTbtl CONSTRUCTION TAX s
Signator td A,tiauoC'onmxarc Dam EXHAUST lOOD(W/DUCR HOUSING MITIGATION ITT
HAZARDOUS MATERIALS DISCLOSURE
Will tedapplicant oder.Wiwiog oCctpam vm,«twJlc heard um+tcrial HEATINGUNITCIO10LD)0BTU)
u defined by the Cu,C—M cipal Gale.Clt,fc,9.12,and rhe Health and Safety
Coss,.Section 1_1512o-)aHEATING UNIT(OVER 100.000 BTU)
EJ Y,,_ M, PAID
V13NI'ILA'fION PAN(SINGLE RFSID) Dat, Rcaipt x
I WJI ttrg fi,tun«futue Fuilding,ecupant etc cquiprm «Mo
rltewhich BOILHR-COMP(3HPQR 100,000BTUI
v ,bvardoos au..Inan fiacd by the Hay Arca Air Quality Mt Cncn, —Ty, 0
MOILER-COMP(OVER 100,000 BTU)
❑Y„ Nn
I hoo,read Re Kamrewo,u tt,al rcquiretrncs ruder Ch pl 6.95 of de Cil,- AIR CONDI'f1ONER ISSUANCE
DATE
form.IIdCm&smny Code.Safi 25505,25533 aM 25534.1.6..I"floor if the NEW RESIDENTIAL MECIL SQ.FT / 1
Iviklinp d«s«r rtrnes8lY haveum .Uw it iv my ncspxisiMlitY to rmmfy upwt S/Yn /
,fan, is wmm�nma rut p,;«u.i,wm.',nro eenireat„r
Owner«w orf�wx st O e AL ISSUED BY: C 1„!'""S •�
OFFICE