S1037 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECruu:nt, PERMIT No.
APPLICATIONIPERMIT "'UDIRING.VILCIiANICAL '1 03�]
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION S S 1 I
BUILDING ADDRESS: /,,y SANITARY NO. APPLICATION SUBMITT'AI.DATE
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9 �I PHONE CONIit CfOR'S NAME" I.IC NO (�•�
OWN / QUO/jG/e J/ Ob-8 -�/ e af<� Nfc coNxDL«
ARCH T NGINECR: LIC NO. ADDRESS: - _ / ❑ �A`
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COMA PHONE' to1���4 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ECT PLUMB h1LCH
r iv Ile_ .Cr/f e-473--t?`7 '
LICENSED CONTRACTOR'S DECLARATION QTyi— K
ELECTRIC PERMIT Fl?E JOB DESCRIPTION
I h<rtby efBlm men 1.licm,ao]uodu Provision,,Of Cli 9 fcomnxming Zwecton .ardmylies cll 1p In ISSUANCE WL ❑KITCHEN REMODI9,
r= rdIrWtt.meSttt. e/yQUU Eir.cI • 1.k.♦ NCES-RISIDINTIN, ADDEPION ❑PLUMNINGREI'll'C
Z LL1 Delc CtmlworARCHITECTS DECLARATION MULTI-UNIT ❑STRUCTURALS MOUIIlCAT1ON
ZO'-Z I unJcmmnl my Plan,sM1.11 W uxd dx puhlc mttrdx
OZ- 2IX)Ah115 ❑IN'ITRIOR ❑CHIMNEY RFT'AIR
F-I:tLW Licensed Pml.irmb M)AMPS IMPROVEMENT E]SWIMMING POO SC �JOWNER BUILDER DL'CIARATION '.. "MES ❑BATH REMODELIREPAIR ❑EFhioi.ITION9a=Q I hcmby of red Thal 1 and ucmp Irom thu CoNNcmr's Meds,Law for IM1c2 U falhnvine lean.(Section 70lI3,Nuxim,,.aid 1'ndeoice,C d,,:Any cty ne wumY FLECIBICAl. ❑OTHIiR
hich rtgainv a I%'.mlit hl onnurucL:Jler.ilnpinv<.drordixn,nr repair any strut.. P A n
rion i,o Iv 4 Ih (pl hp III fl gld�lcment L C I RCIJ I'U/ ISC.MITIC fc< YI IMI I a n• ITh L t I« I 1 (Chlper9(con rk lh Vec1 71NMB t D " i fIw If J IM t 4 COJcI W MITER lIR IY)LE INSI'.e p{ that he is exeopt Ihcrelrom wvl mu Iwxlw r r mu auegm camp gym.Any Vlmmbn or uEMOLI9Iory
Sechnn 9031.5 by any^IIPGcml Grc a .mil odhkcIs to,appleum to a civil penalty of R DEVICES T ' ❑h'ooD SeuvlelinX tmre than rive hualral dnllur,0S50(b. Mtf��hlrMING IDOL EuicrRIC ❑OTHER Vf, fl 1'IV
I.. well du dx wn,V:,arW the wwemrt is notmomdd rruHO<d for salt(Sts.70Lb Huaine,
qv
and Profusions Code:TComru'mr'.v licence Use Axs Ilse applY m an owns,Of OUTLET'S-SWITCHES-EIXTUNIS
pm OOy at wilds m impmVc'Ilxrton,and wMl dlx.such welt himxlf Or Wwl
his own employ.,pmmidul Ihm such inllrrwcm[nlx arc not matioded m offend for NEW RESIUBNTIAL ELIiCfR SQ Pf.
-It.If.howor—,rostraIk wiliin«Irimpmvemem ix sold widhirmt,yeuofeampcli ifs � FT FL(�RA� 3/SQ.I'T'.
builder will have dm WN<n IMI M proving he did rd wild or inlpove for par-
pox Of csle:)�
0 I,m ovoI Of the p^Pe^y and escimostly clmauvng with Iic<m<d Cmlr.Ctw3 to r
corse.,the pmjcm(S<e.70 1.Busilxas amt Pmfcadons Code:)The Cmmilmors
vc law Jrca ml apply tommmcr of pgxrtywW Wilds vx impmvcs lbC(Nn.and QT)(. PLUMBING PERMIT FEE
winbobs is forwent pmjttH wdN acaur,etulO licensed pinuaru in the Caarxvor's
Lienee Lit, PERMIT ISSUANCE
01uncscmpt mist .H L P C for Thi.rca
ALTER-DRAIN k VENT-WATER(EAI VALUATION
Owetr DNc
WORKERS COMPINSATION DERATION BACK FLOW PRJECf.DEVICE 2a
1 hereby ill ned older pendly o!.fCmn one of tw fMlowing W-lom'ions:
❑IMve uWwill mailMain.Cedlf ate of ClmxnuOsdGinwrt fm Wlxter's Cnmpco- DRAINS-FLWR.NOOF.ARI'A.COND. STORIES TYPECONSTRUCTION
swim,m provided fn by Scelilm 091X1 of IM1c I,Mx Costs,for the Eceflmnuce of IW
work for which this permlt ix i.vucd. FIX71URIS-PER TRAP
lj; Gt sed will merm,in Workers.Conn mmdiun lits,a rtgaved by Stetimi
37000fthc laver Cak,Rn the put'Ilmwrc,eflhcwork limit U,,writ is iswcd. GAS-EA.SYSTEM-I INC.J OUHLIN OCC,GROUP APN
My Warkc�' +ypcns9pjsal InwrjMu. Id Polity rummer mu -
Cerlicr: �s"'0 '. � I'olicYNo,: GAS-FI..SY.SD:h1 OVERJ11i\I
CURTIFICATHOITFAEN11"HONFROM WORKERSGREASIJINUUSTRI,WASDiI NIERCE19UR
COMIHNSATION INSURANCE BUILDING DIVISION EF.ES
(This union neOd not w mmplctttl iflhc pmmit is foram hdndtcd dollars(SI00) GREASE 7'RAI'
orlu'eJ PIANCHFAK FEE
I ,nify died inthe P=dumrlm<otlw work forwhich thiepemOul isilsuol.I J,11 SEWER-SANITARY-SIUBM IA.200 PI'.
not cmoy tiny pcm In y neammr so ux In Wcvnx xtthj,,l al Ise WOAo cnmpn- IiN1iNGY FEE
pman
ZZ canon laws of Culdomiu.Dine WATER HUNTR WNLINTIIflXCIA GRADING FEE
Apple=(
NOTICE DD APPLICANT If.alto making this CIldrI a tit E-ollemn,Yu sl ould WATER SYS'1'IUrtfFRUA9)N . SOU-S FEE
(~ beton,subjem m NC Workers Canpemullon pmvisionw of Ise law,Calc,you roue
OG fonhwithoomP,with...b prevision,Irlhis Nimaehull be danlel rtwlw. WATER S17RVICE
WD
Z MINHN
'RUCON LEDING AGENCY NEW RESIDENT IN.PUl B. SQ IT. PAID
Dam Naxipp
I hemby dBlm lluu mto,is aeualuction sending agcrey fee 00,peHnrstrel or
4. O dx wmk fw which this Permit is boud(Stt.3097.Civ,C.)
F-' LNdu'n Name TOTAL:
0
Yds iAdrlrtx• BUILDING
W I omei fy that l Mvc Rad tE,.,,Beed cm and.lal<tMl the also,le—im Is
V) cmrcct.Iegrtc In comply with.I1 dry and c.my ordimmes old I=low 1-1-61 On TY. MECHANICAL PERMIT FEE SEISS
V z Wilding mnsauniarn.mllxrtby.udxxizc mprcxtvarivcrM dda city to cNtt upon the I�
'- .hove lrcminrcd pmPeny for inyxetim purposes. PERMIT ISSUANCE ELECTRIC FFE
Ove)1,eem sax,ilWemdfy and kttp bumkss tk city MCuperum ag,iml
Ii.bilitics.Itdyrelus.mN.s and csPcnscs which may in^ny'^TY accrue vgeitw sed Cry ALTER OR ADD TO MECH. PLUMBING
in eonxque.of the gruuing of thi,permit.
APPLICA UNDERSTANDS AND WIL P WITH ALL NON- IN AIR HANDLING UNIT(TU 10.005CEM) MECFL\M AL FEE
SOUR GULATJtO'
/b 6 AIR HANDLING UNIT OVER 10.11(10 CITD CONSTRUCTION F
Sigtlwmof APpl' adr.cta Dax MHAUST HOOD UVMUCT) HOUSINGMEEGATi0,'FEE
HAZARDOUS MATERIA SUISCLOSURE
Will dlc applicant nr fmurt Wilding rccvpmlBlore or boodle hvnNau•mucrial HEATING UNIT(TO I KEN)BTU)
.s defnal by IIx Cupenino Municipal QMk,CTape,912,utd the HedO clod S.fay
Crete,Smiled 255320.)7 H13ATING UNIT IOVIiH IIp.IM(I HTO)
El Y. 7 N PAID
VENTHATION PAN(SINGIL RESID) D.ta Rttciil
Will the Wi hart or Thum Wilding ocm,rad ux egalpm<m or device.which BOIhF,R-COMP OIII'OR 1(X),(XX)H'1'U)
unit hdus air ulmmnimms as de0tud by Ise Bay Arca Air Quality Manam
geent TOTAL
Lh.,e�W
BOILER-COMP(OVER 100.0001)'IU)
Fl No
rtW IM1c bmtnluv nmlmmisv,mmnantx amler Cha,,695of the Cull- AIR CONDHIONER I��/E���
&,,ety Gdc,timions 1,"11,2.5533,n1553J.I ualcrNM IMI Hot, NEW RESIUIIIJTIALMIGII. SQ.171nM curlenlly have a teat.dell it Ix Illy mv,P)SIlhlldy m Nilly Ise cobt,anln em,which snot W ext prkr m is.wa.e of a Ccnifxde Mbori"agent Dve ISSUED BY:
OFFICE
PUBLIC WORKS DEPT.
CITY OF CUPERTNO
i
TO: Christy, City of Cupertino
Karen, Building Department
FRONL Kevin Rieden. Public Works Department
The follo�cing grade has been siened off:
Address Permit Date
M 711 �fiss ��✓