S3210 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIALDING-ELECTRICAL PER\yIT No
BUILDING DIVISION APPLICATION/PERNOT PLUNIBFNG.\IF.CIIANICAL SJ 3210
RGILDING PRUjRCr IUEYI'IFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
to l i�� � l`al.e_ Ge. a,x v
OWNER'S AM_h:: PIIONE' CONTRACTORS NAMB: LIC NO:
Q • �C �c �g_ .7 NIC 'ONIHfII.N
.ARCIETEC!ENG tK: LIC O: J ADDRESS: ❑
CONTACT: PHO BUIL ING PERMIT INFO
❑ CDtiond ai l Ftxs Paid by Applicant(Initial) xl,lK FIECT PIAMB Simi
❑ ❑ ❑
LICE!,SED CONTRACTORS DECIARATION Q'1-Y ELECTRIC P13KMIT FEE
I hcrcby,affirm fl d 1 am Iicrnrcd unkr proof'olns of CUP"9(connencing JOB DESCRIPTION
0�7 wdb Scedma7(]00)n Givi,im.3.fpc Buxircsxnnd Nofe.siorF Code.viW mylieenseis R SIDS
WOO PERMIT ISSUANCE.
CSF in full fma stilleffect. ❑SFDWL ❑KITCHEN RUIODEL
¢7uUl [)a"—.0. Contrxtc. APPLIANCES-RESIDENE'IAL ❑ADDITION (3 PLUMBING RE-PIPE
�n¢y ❑MULTI-UNIT ❑STRUCDIRAI.
AHCIIITECTS DECLARATION
�,5 y I',\NI:I ti MUDIIlCAT1ON
707—.7. undcmlanJ myplans droll be uttJ as ptthllc mrrtJx
DI'TO IIXIAMPS [I INTERIOR ❑CIIINNI3Y REPACK
is=;W Licemcd imnwinnal 1111-10110AMPS IMPROVEMENT [I SWINIMING POOIS
OWNER BUILDER DECLARATION OVER 000AMPS ❑BATH REMODEIIRF-PAIR ❑DE.SOLECON
C W E hcrcby affirm that I am moors,nom the Cunrmctors I
I.ianu �w for the t
OU¢ OTHER ADD �fSI - .wlttroo bl
S fdl omit
(S t n 7031 5 B rd Nuf li Cock c y city w caunr) SIGNS ELECTRICAL
3 LL which regi pc t t u t Iter mpm h cm t 1 ... ml structure FSO pfmh c y m poli ( mnsf rtt fl .gsW(CItlemcnr SPCCIAI.CIRCUITMISC.
pude I' s<dly rt tlKl+n -+� fm C tract fila 1 wlChnpicr9 COMMERCIAL
W C (con nascing'a'th4ulm](1fXdofDlv'slon 3 oftla.Basil andPnf ar.s Codc)rr U:MI MI]T'R OR POLE INST.
Sat be isn xe n tit,troon nmoet rhe Ilea-for the dlcgM cxctnption.Any vlumtion of ❑NEW BIAXi/ADDITION ❑DIiNIOLI'I'ION
Y yapP pemail sunjatx the QW11canuo v civil pc100y of POWHR UEVICF_S 11 IT ❑IRR)D SE RVICE
Fly not marc man fivc hoo,md dollun(5500d. IMPROVEMFI.T
_¢ to ofapt pmperoy,or my employm with wage.,as then"I cumPctwiiun, SWI NTMI NG POOL ELECTRIC ❑OTTER
�F.O ill do the cork.and the swemre is trotimarr4l o offal for sale(Sire.]O1J,Bmir
W Pmft siom Calc:Tac Crmtfsmrs Liana I,w dscs nm apply to x nater of OUII.ITS-SN'RCHES-FlN"NRIS
a 3_ prope ry war builds or imlrmvcs Jana,mw who duce loch word,hill m tamagn
his own emplovce.,pnwint put xteh impnorrolde an sari i oca ll m ml'ercd Gt for NEW RESIDFNGAL ELECSQ FT.
sale.If,nuwcvcniha molding or mptnwnenl ie sold within ore y®r ofcomplviart tlw SQ.IT II.GOR A R FA S/SQ.Fr.
cobaiWel will min:tae.hard-of Exnnng that nc d'nl int build n i.npmw fir pur-
po,e of sale). TOTAL:
1,ss wrcr of One ,I oro ndusircly contracting with licamad enoolocvrs to
amrvet pe project(Sm.]Dm.Basirtrn end Peohmsiurs Calc:)The Cntttm:m
etis IT-
cuxLvwtkcanaepplymanowraofPgcnywMhuilthoimltTvasthemm,std QTY, PLUMBING PERMIT FEE
who mann fa such Isojms with s e.ndO Uccos vl ptuauam to the Ceranicuis"
Licemx I'w. PERMIT ISSUANCE
❑Iain exemptr 'c. .R&P C for tail orison
AUGER-DRAIN&VIM-WA IER(EA) �VALUATION
WWORK] ' D
COM%N. 'ION .CIAHATION HACK MAW I'RGTECl'.LF R'17
1 handy el onj rower pe ndfiC d'perjury au:of the final for dee.Erminnx:
❑In.sw undwill main by Si Ccnificuc of Conr<nuo Ylf-itnut its,It ah Co of fh- UKAINS-FLUOR,RfI(IP.ARI!A,COND. ,NpORI� TYPIi CO.V,SIRUCTION
s IL f es pmvlJN for by Section J]DO of pc I�t.rr Code,for tic perfonunx of tfe
workos,dicatai.[mainland
i,,amt crkce IlN"rURES-PER TRAP
I haft and,ix ttmintsin Woh t,Compertamitm Ifor shi ss required by S.aml.
J]Ip of the lnUn Gde,lanae prrfnmunenf the sant for which this pemtit is issued. GAS-IA.SYSTFAf-I INC.NOVII.ETfS OCC.CROUP AP6
My Waters Coon,ofrmiot Enmrmwe canner and!Policy member arse
Cumin Polly NM o.. GAS-IIA.SYSTEOVER q IIA)
CER'1'1171CA113 OF EXFSIITION FROM WORKERS' 'RCCPfOR
COMPENSA'I'[ON INSURANCE BUILDING DIVISION FEES
Una,cairn teed m.ba ctrnplia t dhepmnit u for oe hmwfl JulWn(511 C RAP
m ksx) YLANCHECK FEE
lanifypui in the pccforman c the work for w hichilin,mrmit ixi.ssal.l I mu-SAN ARY-STT) 1 ._200 FE
tw me bi,any Poon in any nmnm-r tt ss m bccomc oubject to the Words-Com ENERGY 1171:
',� mtitm laws of Celilnmis.lAre
O O nppl'tan, I 1 . n' GRADING 112E
Z) NOTICE TO AI'PLICAN'll 11,vftec making tale Cenificale of Exemption.yin shoo 'At Elf SYS'I' M/TREATIM
Z) SOILS 11717
FK 7 1 sit,
M:mvc auon,fit tic WA,,,lCongcn,this ptnvt hal of the I:Jrs sok1 Yaw mu
RrtNwirh comply with sucM1 pmvieionxntaie p[mrildwll bcdttmcd rcrnkcJ. WATER SERVICE
z CONSTRUCTION LENDING AGENCY SQ.FT. jPAI['D port tai Ihermy eifimt tMf theca is a casimetion trading ayenry fa tie poftrmenec ofU� fhewM for which this permit is issued lice.3097,Civ.C.) TULetder's Name.Lemdrn'x AMmae 'NOTALI ect ify that I Wve mud this aplication and state then the shove intmnmlnn is DING HEcarrot.I ogmaI i'ly w fliall dry and anrtmy nrd'tnattasatw vmclnws rdmingn' QTY. MECHANICAL PERMIT PEE IC FEE ZaNtvc-.mumrd pmfcny roc irs,clitm Furpw,'. PERMIT ISSUANCE(We.)egma In vf<,laceal and kaep fwmrk+rite.City of Captain aicainu IH1e Ili
IiebJities.jWgtmns.maysad uprnsn which muyinany way nesueogmnu said City ALOM OR ADD TO IdECH, PLUMBING 1193
n emu.Irene of tk Knowing of this permit.
APPLICANT UNDERS'IA NDS AND WILL CONI PLY WGT[ALL NON-POINT A IR I CANDLING UNIT CTO I whin CFTQ MECHANICAL HE
SOURCE RP U 'PIONS.
ello AIH tIANDLINC UNIT(OV ER 10.0C%.D [ONti TNUC"ON
' TAX
Signmumn(Aplih oorsomr ITne IDUAUSI'i IOOD(W/DUCI'd I IOUS I NO M I FIGAI'ION FEE
n"IAAI S RDOUS MATCH DISCLOSURE
Willthe applicwl n Wilding ding occultismvo
u a m hadtr hvenhus mmcrial HRVLNC UNIT(TO 100,00 111111
Jana 1 the Cupeniro Mueinlml Cede.Cltaptn 9.11.s1Jc Ilcalth sN Sefny
C ciio
a,dc.San M532(.)? IIL'AfING UNIT(OVER EIXLIXXI NTD)
VENTILATION FAN(SINGLE HESID) PAID Uma HaeipN
• WIItW vpplicam or furore building iecupwn use aquipmcnt or tkvia,which BOd.ER-COMP(511P OR 00,nX)CRU
emit hururdom air cuntwnu as de
inanfncd ny thin[luy A.Air Quvlay Mal hent 'Fly I.:
DisviO? 1/ UOILIiR-COMP((OVER H0,000 LU
E]Ycs
I base.fowl Je b,,M macriae,oc,anenw uttdcr Chs ocrh95 of tfe Cali- AIR CONDITIONER ISSUANCE DATE
fortis,._...m&Safely C NI5.25533 url 2553!.1 tau if flc NEW RESIDE\TIAL MECIL SQ.FT. / �
ortax,gdm Jy�cetrn , it is my mi^^wbiliry nnrif� g
of the mcnt li bet cofsC
Owner fir a Wxrimd agcitt dote TOTAL: ISSUED 13Y'.
OFFICE