S0617 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
4. CITY OF CUPERTINO BUILDING-EI.RCIRCAL PI!RMn'NO.
BUILDING DIVISION APPLICATIONIPERMITBUILDPLUMBING-MECHANICAL C OC
ING PROJECT'IDENTIFICATION J v
BUILDING ADDRESS: SANITARY NO. APPLICN'ION SUBMITTAL DAIF.
�ixU ✓
OWNER'S NAME: PRONG. CIN' A. LIC NO:
NIC CONIRIB.P
:1 4'ARCHrfELT/F.N �INEER: LIC NO: AD[ - S: ❑
CONTACT: PHONL BUILDING PERMIT INI.O
+ � �� ❑ Consultant Fees Paid by Applicant(Initlel) BLIDC HlAddo PLUMBMC❑C[I
1:1 E:1
LICENSBU CONTRACIO I ,CLARATION QTy ELECTRIC PERMIT FBI:
1 haebr affirm ma 1 mm Bal a rl awe,prxvisions of Charier 9(cnnlmeocinc JOB DESCRIPTION
CMZ d15mi.n 7001)ofDivisi.n3.f lh Buaires end R.fc.siom Qdc,und lay license la
WOO �I PERMIT ISSUANCH
F W- full force ard,Ra=t ,FDW'I, ❑KITCHEN RFMODEI.
QFUV LkcLicft
nac�Comr AP%,IANCIS-RI3IDENTIAL ADDITION ❑%LUMPING RE-PIPIT
NQL Thos Cmmxtu ❑h1ULT1-UNIT ❑STRUCTURAL
A HITECTS DECLARA N
Fzc,.z I mdenlend my plans dull Sc u.d at public records PANELS MODIFICATION
rZ-O UPID3IX)AMIS El INTERIOR ❑CHIMNEYREPAIR
F Lw Iicrnmd Pmfcviwul 3111-l"AMPS IMPROVEMENT E]SWIMMING POOLS
I hemb a1Fum thnrN
OWNER-BUILDER cILDIERoDECLARATION mr'.a License for rhe OVER I(WAMPS [INATII RI1.10DILRF.PAIR DEMOLITION
a
k O L U follow mg reason.(Section 7031.5.Basme,%arm Rukssiars CMe:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires'a permit ro cawrvct,.1tv,improve.denlol'uh.a nepar troy micmre
1-u'0g prior,.its issuance.apo re,mral the p4i.for such pmnil In fikosimcdsumm,nt SPECIAL CIRLDIT/MISC. _
IlW fe is licened pu.t,.the provision,of the Comrvnor's License lww(Cheptar9
COMMERCIAL:
�yp0 (c.mmrncing with Sec11m 7")of Division 3 of the B..unit R.fe,Clom Cole) TEMP.ME It OR POLL'INST,
a a C But he is esemp,thcmban tad the hao,for the ellcgul c.acmplin.Any ci.latim.f ❑NEW RLDGIADDITIO.N' ❑DI!I.IOL%ION
XSim Section 7031 J by troy applicantfor a Permit subjects do rMlieeru to a civil penalty N POW'F,R DEVICES OTFNpNT ❑Ir00D SERVICE
FZY ^ot maeb,"rise huredml ddlms(SSXb, IMPROVE.MEST
ESD ❑I.a,.war o(the property.amy embyewith.,
a,with we.as dein sole com,arvaID
ion. SWIMMING OL ELECTRIC ❑OTHER
will do the work,and b,.uu,me u.inlealal or offeral for sak(Sec.71XlT Bmairess
,Wil F and pamrr,im.Calc:The Contractor's License Law does not ap Iy to as owner of OUTLETS-SWITCHES-FIXTURES
M 3- any wba buil,m improves martin.and who it.tach wmk himself or Ihmugb
his Own employes,prdoidrd Ihm slain im ear antes m ml imcMcd or oRcml for NEW RMIDENTIAL ELI!M SO
,ale,If. buildingaimpmv,mrnr i,sold within oris)carof-an icarm the SO.FT. T( A E. SSQ.ET.
.,builder will have the bra en of Imving Thu k did cot build a maromse for pur-
poseofvale.). _ SEP 19 aero
1,ss w.r d'rbe property.trm csclusively.,in,wish licrn.i cm rvctrrn m TOTAL:
v.1 the pmjcet ISa.7041.Business and Pmfexaims Code:)The C.nI m',Li-
ccnsclwwAewepplymanowmafpmpcnywhohuildsmimpovcsnc�rmrr.vW QTY, PLUMBING PERMIT FBBIT Ur WrcHIINU
wllo Ommri r«such project with a cmmY'oara )he vd pnvum In Bn Conuen.r's !�
li=cmc law. 1, PHRMTT ISSUANCE ,3 r
�I oro earngx urWer Sec. .N&P C for thio ruwn
ALTER-DRAIN k VENT-WATER(HA) VALUATION
Owner Dade
WORKERS COMPENSATION DECLARATION BACK FLOW'PROTECT!DEVICE
1 hemby oRma under perWty of perjury ac or the"rowing dcclm.tinn:
❑Inde W will mountain aCenifi,area'Caeemp.sclf-imus fm Wmkn's Cmo,ea- DRAINS-FLOOR.ROOK AREA.COND. STORIES TYPE CONSTRUCTION
talion.as provided firs by Section 37W a da Iaba Code,for ba,peK.e of the
work for which thix permit i.i.ulad. FIX TURES-PER TRAP
❑I have and will nuinaio Worker,Compensation[.0 c,n rcquirN by Scotto
37W of die Lab.rC.de,fata,peKomlmce oflle wvxk for which this permit is ixaaal. GAS-EA.SYST -I INC.JOIff,HM OCC,GROUP APN
My Wraker.Compenaetim Imuumr carrier and Policy number oR:
Cori PolicyNo.: GAS-PA.SYS*T -OVER4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIAS'UINDU.STRL WASTE.INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This smim rnsd not be cnng8elnl ifthe permit is forme hurWed dolly ($IIXI) GREYSF TRAP
a kssJ IYANCIIIiCK THE
Icmify that inthe peKmnamc.f the wink fmwhich ddsp< ni.iusllal.l II SEWER-SANITARY-STORM F.A.31X1 FT.
cot cmpMy any rein in am,rtumar 10 - Ila W C pan- ENERGY FLT!
Oz Lotion Tawsof Califs .Dmc - WATER HATER W'/VENT/ELI:LTR GRADING PER
Z O Applicant
h NOTICE TO APPLICANT:Tf,aBer coiling the Crnif re f f cmplkm,you dmuld WAFER SYS'TEMO-REYrONG
"" become subjm m Ibe Wohn's Canpem.dao pmvisiom rhe IaAra Conk,yea moor SOU-S%'Y,
Wfrathwith molply with slsch govi.aion.or this pe,mits Ibedeem,drevol:cd. WATER SERVICE
Q
7 z CONSTRUCDON LENDING AGENCY NEW HI?SIUFNTIAI.YIJMN. SQ 17.1 PAID Dal, RcaiplN
I bereFY inn that them is•mnatmetim Icndine age^cy for da per(mmuac.f
the work for which W s Permit is is.uM(Sec.ANI.Civ.C.) T(ITAL
O (✓ Lander.Name
V Icrukls ArLlmsa TOTAL
L9 BUILDING FEE
11 1 cem y tied 1 have mad this appli,6rim cold Marc IW the.hove inbxnu0on ix
fA camct.I agree to comply with all city and county ordinanm and state laws rclming m' QTY. MSCI IANICAL PERMIT IFTai
(..1 Zhuilding conurvaim.end Fcmby truOuKm mprcanmtives of this till mwmularn the SEISMIC FEE
.Inv,-mcnliaad progeny fn in.paciim retread. PL'RMfIISSUANCE
ELECTRIC ITE(Wpgr
aee m wive,indmn
eify aa
nd kap harmless the Cil'otCupmlin.rEadi
Iiobilidcs.judgment.mvsand eapenseswhich may in any way trams against said City ALTER OR AUUTO MF,CII.
PLUMBING ITS
in nICAN ce the grantingof thioparnit.
APPLICANT UNNDERSTANDS AND WILL COMPLY 'TT1 AINT AIH HANDLING UNIT OU 101,031 CIMI MIiCIIANICA1.IrIJ1
SOURCE REGULATIONS. 1)' y AIR HANDLING UNI'FIOVI:R 111,1,X1 CFM) CONSfHUCDUN'I'AX
Signatmc.fApplicanhC.nlrnaa Data / EXHAUSTHOODOVIDUCT) HOUSING MITIGATION FEE
HA]ARUO MATERIALS JKLOSURE
Wdiffirapplinaraf mhuilding�upontMn iwl ndkhmunlnv.mri
nlool (HA'rINGUNIT('IOl(XJXX0H'I'U)
av rkf d by the Coperi mnkipal Co&,Chapler 9.I2,and the Ilcalth naI Sufav
Calc.Scrol.n 25532(a)p HEATING UNIT(OVER I Xr(NX)BTU)
p Yca ❑N. PAID -
VINrIIA'rl(INFAN(SINOhl1RI?SIU) Uwc Rec,iPM
Will the appllednln frame Fuilding ncopanl once rynlgnem car dnvitt+which BOILER-COMPOHPOR I00dXIBI'U)
emit b yar0,ns air rimami119nt as ck inN by the lay Ana Air Orchly Mmugemenl 'I OTAI,:
DI'mad? BO LER-COMP(OVER I00JXX)ItI'U)
oy- 0 N
Itwvc rwd the hoounknn macriWe IxuN,r ChyXcr h95 of IIS L'alt- AIRCONIPHIONER ISSUANCE DATE
fmnia A-11h&Sandy Cork,Saaiom'3551)5,25.53)old259W.1 mndanyThal IIIbm NEW HCSIUHNT'IAI,MLGII. SQ.PI'.
building tire.cot cumnBy heviceluwnL dwn it"my mPnsihilitymnNlfy th Wcru9-/B^Q 032
vpnnt 7 /
.f the raryimment which mvsd hu mel prim In amanee.f o Cal Ifnate of(kcmpew)`.
(twiner or aulMrciecJ egcnt Ilam 101.At,: ISSUI!D BY:
OFFICE