S0693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT rvo.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING—MECHANICAL S 0693
BUILDING PROJECT IDEM'IFICATH)N
BUILDING ADDRESS �J SANITARY NO. APPLICATION SUBh11TTA 1.DATE
o r]/� �✓45'54K I /IZ f 1 9 -3 ��o'q�
OWN LlI MBG /, / PHO E: ACT`RS NA C LIC NO.
6 /��G 0 NIC CONTROL
OA 11 INFS$:CS a Y` LIC NO'. AD ISS: ❑
COM, Cf. /Vv/ PHONE: BUILDING PERMIT INPo_ .
�LD(,I /1 EqI ��O E:1.ConsWlam Fees Paid by Applicant(Initial) Bu�)G-7 E PI MECH�
lIILLL��� �f l l -` b-✓
LICENSED C NTRACTORS DECLARATION Q'PY ELECTR IC PERMIT FEE
1 hprtny ammo that I an;cense.!oder provl,mos cfCmamm 9 c'm"Kr.:Ins _ JOB DESCRIPTION
,O„XZO with Section 91X0).1'Torsion 3n41he Ruslrxxxend Profexsiimz Cak.uml my fiecnsc ix
qen
full force and,,Reit PERMIT ISSUANCE WL [D KITCHEN kli\fODlil.
�UZV License Cbau Lie& APPI.IANCBS-RESIDENTIAL El ADDITION CPLUh1BING RE-PITE
Q W Dam C.ntracmr C MULTI-UNIT C SI'RUCTUKAI,
A' ARCHITECT'S DECLARATION
ZO�rZ lumknmmd my plan xhsall he uud as public neardc IANLIS MODIFICATION
OZ—O UPTOn)AMPS [I INTERIOR CCHIMNEY REPAIR
�4LW Lievised Pmrasimwl 201-11100AMPS IMPROVEMENT' CSWIMMING POOPS
6 1 herthY nlDrm thatNFam BesemPF amtnx«'s Licemue Law to Umc OVER 1000AMPS R DECLAItATION ❑BATH RfR1UOif lYF,�R C DI.MOLITI(IN
X O i V following rrassn.(.Seclbn]01316.Basins,,.and Pmtcasi.ns CMe:Any city a county SIGNS ELECTRICAL ❑OTHER r M
W 3 which rites a permit to ewtmct alter,impose,dem"Rok"rePuir any Rmcturc a�aa�eap
I�'u•�
prior to its imuee,also rcuims Bit,applicant for such pemul to file v signed"Cosenn SPECIAL CIRCUITAI1SC. IMI-11
f se that M is licrnW lwuanum tic prnsisims d the Cmeetemis Liecnc l,ve(Chapter 9 --
r� COMMERCIAL
�p('Q (mmmrncing with Section]000)01'Uivisimlolthe BusirKss wool Rofc.uionNCWcla TEMP.METER OR POLE INS'E Q��Y p1�pf11pfJ
a a c K Ilw tK is esemq Bierefrom aM the hasis 1'w th elkgN eumpim.AnY violuioa of O MVur Cfl � D 5 ICI:
Xie 4. Section]031,5 by anyapplicwt fm a permit subjects the applicem to&civil PI of DEMOLMON
POWER DEVICES
l„ZY rams mite then lisp hundred ch laa(S!5000. IMPROVE?,IFNT
O DLea mmwrcruf dK fxyeny,or my employm with wage as their wk pmmlenwniun. SWIMMING POOL ELECTRIC C1 OTHER
d, wmlldOthcw..k,and the Arvcmum is nor interdecOr Offered for rude(See70cW.Ilmimu
13 amt Prdeemons Cock:The COnlmchNN License law docs nor aptly to an tomer of OIIT-S. -SWTTCHF_S-FTXTURF_S
his own whO huiws a ImMnn rchn,amt who dues e p wak M1W tr of lhnmgh
his own ow,,c r p.rvfin lhm such impnrvmrcnu art ret inKrrof rr Ofrmpd for NIiW RESIDENTIAL EfECTH SQ Ff.
sale If,M1mmwpxT.lhe building mK imptiavcnem lv old within one ycm Of cmnyction.lhp SQ.PI'.FLOOR AREA SAU.IaC
owner-Ismider will hmc the houSir of ptnv'Kg mat he did not heild ur improve tort per w O
tic dsele.L _L7 �—
rojeel Sm.70M,stnrom,,and eumracdng Cod :)The
Cummou', m ( AI
cen,c]-t de pml'cl(See.91FtJ,Nuaircnr and Aofcssims Code:)The Cnnlrseds Li
.ensu WwJoas my WWcj+�y'muaownsndpropcny wbo codiph imti'mecomnn,anl QTY. PLUMBING PERMIT FEE
wbo antrnts for m jEsjecta mmroc (s)Iianswl Wrvwnnnlhe C�ntracnRx
Lice.¢law. e} / �(� PERMIT ISSUANCE
❑lumesempu TS "1
1 per �.B&PC.fur thATTER-DRAIN&VENT-WATER(IDO VALUAI'HIS
Our
• �/ WORKIiR'S COMPINSATION DECIARATIO f BACK FLOW PROTEGE DEVICE
lbya iuramMmltYdPetiuD..fd fol in steel isms:
hcre
❑?have said will mAntalr a Certificate d Comrnt to self-insure for Wnkcr's COmper- 1 INS-FLOOR.ROOF.AREA.COND.. STORIES TYPE.CONS IKUCIION
sa on,as provided 1'.n by Seetiam 3700 d be,labor,Code,fm Bre perfamuee Of
wok fm which Nis permit k orsoi TURFS-PER TRAP
I have and will Kalinin.Worker'.C.nµrnsmmh 1 in b
3tt10ofthalabnr Code.fmmarlienmenadlJlf�. permit isi',mv! GAS-EA.SYSTFDT I INC.a OVII.GTS WCGROUP ar APN
My Workcls Coma
peatim Insurance
curler a d��f(tl is nu ve. 1
Carrkc Policy Ni CAS-FA.SYSIIN-0\'ER a(HA)
CIiRTIFICATF.OF EXENIMON FROM WORKERSGRIASFIINDUSTRLWA.SDi INERCEMUIR
COMPESSSAIION INSURANCE BUILDING DIVISION MILS
(Thovoction ncsdmm Me.mplctW if NcperminishKomchuWreJdnllun(511X) GREASETRAP
a Ipu.l PIANCI{ECK FEE
I certify that In the Perfarnure,nflhe wok for which this permit is osmerl,Ichri SEWER-SANITARY-STORM EA.2W FI'.
as mnpluy any trnon in any mmnci r 1 ae K Meat aunu n
hjccme Whrx
e 'Con'to i'NIJIGY IEE
ZZ Nation Iowa of Crlihmla Duro WATER??DATER WAENTIF,LECIB GRADING FEE
0 ApPlicrou
N NOTICE'DOAPPLICANf:IL aver nmking this Ccnifirnle or Facmmiim,ynm Jmuld WATER SYSTEM(rREATING SOILS FEE
l-� fornmh mord m the tanker's Comtpenr this provi ha dole lal.mr Culp,you mull
a
forthwith potrmlY with such mrrvisinnsamiN pemdn shall kJsnKJ revoked. WATER SERVICE
W
7 Z CONSTRUCTION LENDING AGENCY NEW RF_SIUINTAL Pll SQ.Fr. PAID
I berebyeffirm than dKe,is.0—lion ksJingegcnry forthe pcffammcc of teReceipt
LUL. the wM fa which this pent.Issued(Sec.3041,Civ.C.)
Q F' Lender's Nuns TOTAL
L) I<Mels Adokecs
1 1 anify thn 1 here read this app!ii mon sad starve that informant.re above infoantm is BUILD E
.. N moat.I spa tu errantly with all city and county mdi.s and Ovate(haws reb0^g m QTY MECHANICAL PERMIT FEE SPJSS ��
U Z building cousuunion.end thereby eudoriae d this ely Or enter-Pin Rte
'"" pbovc nlmp.limrnKal Pont for inxpccdon mupxcs. PERMIT ISSUANCE ELEC C
(We)agree 1O save,indemnify end keep harmless Ibe City of C.Penim against
Iiabilitin.juJgmi pats sM cape ves which may in any way accrue It.add City ALTERORADDTOMECH. PLUMBING
in omagnwae Oft granting d this permin.
APPLIC NT UN ERSTANDSAWIL COMPLY WITH ALI NO POINT AIR IIANDLING UNIT(TO 10.(KKI CPM) MECHANICAL 'E
SOUR 'REG'ATIQN S. /� f Alk BANDI.INGUNIT(OVI?k IB.IXUCINm
Z(, a.✓L CONSTRUCTIONSignvtmeotA IicanVCummdm ate BXHAUSTHOOD(WNUCT) HOIISINGMITIGATHI EE
IIA%ARI%)US MATERIALS DISCLOSURE
WIP dic vppl kmn or future buildingoavPwntsnnre or handle by iwrimmrinl ill?ATING UNIT(TO 00,000 BTU)
v Jct incpJ by the Cuper im Manicifial Gwb.Llmapter 9.12,and the health std Safety
Cam,Section 25532(.)? 11El'INC,ON[T(OVER H C.00V BTU)
(oycx 7 N VENTILATION FAN(SINGLE RF_SID) PAID pure Nn<i
Wi11 the applesun a future bulldioe.pcapam use cquipmcnl Or dericea which• HOEER-COMP OHP OR 100.000 IT U)emit haXaN.us air commnitvaatN as defined by Be Bay Arcs Air Quality Marogcmem TOTAL:
Diann? BOILER-COMP(OVER 100.000 BTU)
C]Yes ONO
I have read the,hvanboms mntcrials requimmits unto Chapter,h 95 of the Cdi AIR CONDMONER ISSUANCE DATE
fomis Ileald,&Safety Code Sectims 35(15.3533 and 353$.1 mdosam&I Jml if the NEW RTISIDENIIAL MECH. SQ.ET.
Wiwi"docs ren csmen0y base a tenser.that it is my nnponsih0ity to notify the evev reant
M de reclairmrc.0 wbicb math he ren prior no 1.a.CenifKere of(XYvpuKy.
" VA
Ow'nsrorauth rirN.yput Date _ ISSUED BY:
OFFICE