S1409 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY l
CITY OF CUPERTINO HUH.DINc-ELECrRICAI. I{��`Ir No
BUILDING DIVISION APPLICATION/PERMIT
PLUMBINGPROJE 7l)IDENTICALCAL J 1409
BUILDING PNOJECT IDENTIFICATION
IIUILDING ADDRESS: SANITARY NO. AI'PLICA110N SI1NMITTAL DAIF.
SO
OWNERS NA ' PHONE.. CO CI :S NAV{F� �LIC o
`iOtr+� NIC CUNCHOhN
s ANCHTTECT/ENGINIA_R: LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Conevltant Fm Paid by Applicant(Initial) BLDG F.rCT PLUMB MECH
LICENSM CONTRACTORS DECIARAVON QTY ELE(-TRIC PERMIT FEE
1 bcrthy aBirm Ihm 1 tato licc^ei rods,pmvis'Rru hf Chalxcr 9(canmcocing JOB DESCRIPf10N
{�{aatt�ZO with Slns,c70(XphfDM,r.h3afthe Husims ural Prof6sns Cnle,rodmy license in PERMITISSUANCEi R RID NTIA
F(D1.full frac and elle,' ❑SFUWL ❑KITCHEN REMODEL
aUV Llccnsc Clan lic.X APPLIANCF'_S-RESIDENTIAL El ADDENDS ❑PLUMBING RE-PIPIT
FF..Z w Dare cam tin,
,IQy ❑MULTI-UNIT ❑STRUCTURAL
ARCIII'FECTS DECIARAHON
~-Z 1dastuodo'y'r.Jball Muud y I' blicrrctmis I'ANI:IS MODIFICATION
ZOZm
NC UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F-Nf'W Licensed Prod'si.1 201-1000AMIS IMPROVEMENT ❑SWIMMING PWIS
OWNER-BUILDER DIiCIARATION OVER IPMIAMIS ❑PATH REIODE1JRIA'AIR ❑IIEMOLH'ION
C 6 1 hcrthy aMm'11,nw
a 1 'exempt from rhe CoLao,IJ11c,e for the ❑09NER
%%O a U fours ing rtwm.(Scamp]0313.Ilusimn draftPrafcssiw Cas:Any city a churn, SIGNS III.ECTRICAL
W 3 a h which rryuims a Permit to chnmmG,alter,unfoove,d,othitJ',or repair my siruclum
�.W+��' pri�rm lLr ixwyla,alp+rtyuirex the dpplicmn tixxah,ohoa m Elc n-rignwl inion, SPIzCIALCIRCUITMISC.
ythat M r lkcnred orvaran 1.itis mvidmr of the Chmtaccsr L,en¢law,Chapter 9 COMMERCIAL
h c (cmlmencing wiN Snum]Of10)hf Divisiont Mlbc Borunex aid lhofLisims Ctdc)a TEt1P.METL'R OR Pit-INST.
IY a eC that he k csemp Ihemfrnm aM the Iasis for the alb,,W exempitn.Any vidatim of C1NI7W BI,DCIADDITION EUI ' fOLfrION
-mSSLcE,so]11315 by anylphlOnl fnr a pcnnll 111c,1111O.41,11c:un Aha 1.111".try of POWHR DEVICES ❑T'E'NANT DSERVICE
X nnrc Than toot hundml di(55001 IMPROVEMENT
t=O
F1I.ei oxn'Ilm of the M'Pcny,m mycmPloyen with xagcsuthcirsok rnnrycm..Lim, SWIMMING POOL ELECTRIC '
F wi.ldnthc wmk,and lhcsmOurc is not intendc-,lahtfeted for'ale(Se,7W,Basin, ❑GTIIER
Ea:
3 m and 1'a iom Code:'Etc Cun orLdros Lwco,,Lew docs not apply to an owner of OU'I'LI'IS-SWITCHES-FI%1'UHES
rygcny who builds m iminovcs Merton tiN wM'Mrs such whik baccoffor through
his own eh,Ih,ces,prnviofel Wt such i r,rho.c.oat not Innis al a nRered Rn NEW RESIIJINTIAL ELECHt SQ IT
xak.If,Mwcwr.the huildinghrimpmwncnl ixmld vinhoorc ycurafchn'pldiun lM1tr SQ.19'.FLOOR AREA ESQ.CL
ar-I,r1&r w01 haze Abe bhh eh or proving that he did not build or in'Pmve for pm-
Iwe of time.).
❑Las owner of Nc pntt,ri,am cucludvcly contracting wilh licensed chotlnclm m TOTAL
malmm On p jeer(,a.]TMJ.Bnnio,.wW P hfwnioxu Cldc:lhe Conlmdur'x I.I.
tahns,,lLw des nmopply to an owarhfpnycny who Mtibts or improve trereon.mr! QTY. PLUMBING PERMIT FEE Q q p
wM'mrvxtx fa such prujccu a-hh s caarrctur(s)IiansN purwan w the G'rl,acnYx
I.iccac Taw. PERMIT ISSUANCE
E] Iaon ntPt under Sec. B&P C kxthis mason
a ALTER-DRAIN d VE - 1'r:R IFA) UATIOtj_
°" Dmc 1 ClI
WORKFd S COMPENSATION DECLARATION HACK FLOW PR(TTECI' )ITV i
11IR 21 um,
I Icrthy nlRm'utdox Penally of pttjury me hf Hat fnllnwing Jslnrvtinnx'. k+UCC
❑Ihave mxlwill mainrmneCeniOcute of Ctwent to¢If-imurt Rx Wakds Comprn- DRAINS-FLOOR.ROOF.ARE. STORIES TYPE CONSTRUCTION
r yr
smion, r ph i,h to fm hY '^J]UO M the Isbhr Coda,fa the pMorn'allce hf the
woH for and this P1mdt is arrior, FIST'I]NES-I'I?R TRAP
I have and wW ma If Wtuker'x Compnv``c lnw yuirW it Section
J]OOM molar Code.fo the ,none i.M1rV: ox which lhi it uixwcd GAS-G.SY.SfEA1-I INC.JOIIfI.I:IS OCC.GROUP ANN
Es"
N' an P : y to
vy GAS-FA.SYSII?MUV RH 4(EA)
ERT FICATE OF EX'E" 'ION FROM WORKERS' ORFASF/INDUSHU.WASTE INI'LRCEProR
COMPENSATION INSURANCE BUILDING DIVISION FFF_S
(This aanionn al not br,ohh decd ifthcicnni,iv r,r nc huldmd dllm IS l W) GREASETRAP -- �—
a I".) PIANCHFAK FEE
I c,nify d'y in the rdfwhi.chfthewtrkfawhkh this perm,,,i.csucr,l dtall SEWFA-SANITARY-STORM IIA,2(10 FT.
not employ any ptivm in tiny mmocar o as to Iaume nob-phd to the Wo m'Ctny'en- ENERGY FIA:
O Z wtihn law ul Cdifumiu.Ihm WATER IIIW ITR WNI!NTIELECI'R GRADING 17EI7
Z O APMicart
NOTICE TO APPLICANT.If,uftcr Inning this Certificate of Escroption,ym dnwd WATER SYSTEA VTREATING
(-^ ; haome subFa to the Wsrkds Chrryewtion povidons of a'c Lelmr Ctde.Yoe must SOILS FEE
{a (nnhwhh comply wish moth pmvirioxu a moa lermil droll lvakcnnJ mvkcd.
WATER SERVICE
uZCONSTRUCTIONathion NG AGENCY NEW RFSIDESTIALPIb1B. SRF[ PAID R cip1X
V ,forYdHnnthmooil i is achnumaion kr ding .) fa theperGxntenahf
o F Fcwntk dont, M1lhix tcnnit isnmld(Sct'�JIX)],Civ.C.1
O Enos,',Nwm TOTAL: TOTAL
Irlvki s Addnccs
Ly, fy 1 csxtifY toy I lnvc mad this vppliiminn anJ emrc Ihm Ox:uMnc inOxnutiort it BUILDING Alga
:r h c rat.I agnc to comply wim all city and caoBy oelloa^ocr and unit rows mlying m QTY. MECHANICAL PERMIT FP.E
U Z huildingmnstntcti umlhmbyvuBn'rumrtp nwivevuf6kchymrntcrup ohs, ffiISMIc I'PJ:
mow nlcntiomcd Popc^Y for irr, lion pallmcs. PERMIT ISSUANCE
Wit)ngit).eaw,imRamnify tins] m
kaep hadcas 11'r Goy of Cupenm iagpina ELI!LTRIC M'.
,bdiricz.jtd8mrnlr,nnty and c,,,—,hj,M1Ta,,o wy way acrue aBuilN vaid City ALIUR OR ADD TO MECIL
PLUMPIN Ftili
in chnscqueae of ter r,onrinB of Nis pcnntir.
APPLICA DERV DS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNITITO 10AXICFM) MECHANI ,I
SOUR LATE( S / AIR HANDLINGUNIT(OVER 10,0DICPM)
�/TC l5 OV CONSTRUCfI NTAX
Sigruturchf ApphsanotCrmaacttr Dart EXHAUSTIIDODWIMUCl) HOUSING MI IG ON ITE
HAZARDOUS MATERIALS DISCLOSURE
Will the aPPlicanl or forum huik.ng mcupant atm a hands EanlJnns metrsal HEATING UNIT(TO 100.1000 BTI])
u&Bled by rhe Cupenilw Municipal CMt,Cluper 9.12,and tfe Ilcdrh and Safely
CMc.Szmtm 25532(a)] HEATING UNIT(OVER I00,M)B'IT)
❑Ycs 0N PAID
VpwriLATION FAN(SINGLERILSID) Dye R,�;, It
Will the tipplkam in fum,c building occupant arc equipollent a devices:which
cm^hvrenrdo,air orcro ni x nr tkfitcd by roc Ila,Aro Air Qmlily fOron,cmcnr HOIIFR-Cl)M111'UHP DH Ig1.IMX1 PTU) 'PHIAL'.
D11160 BOILER-COME POVER I00,000 BDO
❑Yes MN.
I Mvc rt;W lloc lwcvrkv,roa,,ials nyuircncros order Owpvr 6,95o]1h:Cnli- AIR CONDITIONER ISSUANCE DATE
fania Health A,Smcty Gdc S Ohsis 25505.25533 and 25571.1 utak.Wrd that if the NEW RESIDIINTIAL MECE SQ.IT.
M1uidivg olhex Ltd cwrntly Mvc n ICII.LN,UuL it ix mY rtsptmdbility to lu'rify rhe rccuptinl
M Etc rtW ilrnrnts which moa he nlet pr'a ro ixwarrc of v Cotit'rwc M(lavlwiy.
Owar«autMxizm agent Mie TGHrAL: ISSUED BY:
OFFICE