S1241 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAL PESIT NO. 12 41
BUILDING UIVISK)N APPLICATIONIPERMIT
PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATIOS
BUILDINCADDRF_SS: SANITARY NO. APPLICATION SUBMITTAL DATE'
2o�sa vG - 1 Dn . Zr
O 'NEB NAh1E: PHONE: CQ G ORS N,V.1E: v N' EJC NO: i� NC COSIROLI,
ADDRESS: ❑
CONIAcT: 1 lNE H DINC PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLl ' ELECT PLUMB MECH
Q c"_ r ❑ ❑ ❑
ICiLSBD 'O RACTOH'S DI:CI.ARAI'ION QTY Ej,ECI'RIC PERMIT FEE
lwrony dr mw I an,Fwnsd ardtt Im,v..hm.of Chiq,xr 9(cmmrnc., JOB DESCRIPTION
Z with Sctlitm71X10pd nrsion3oflhcBmilrrs and Prnfuni do,ud my liccnuls RESIDENTIAL:
WOO PERMITISSU NCE!
V in full Lrce ar,J eRni{a ❑$IUWI. ❑KITCHEN RIiA10DFa.
la-.VV I�ccnm 1-� APPLIANCES-RESIDNTIAL ❑ADDET[ON ❑PLUMBING RIi-PIPIT
tnQa Ihlc Conwc ❑MULThUNIT ❑STRUCPURAI.
Z O7,n RCHITE LA
N PANELS
MODIFlCATION
rX-Z lu my plans. wN. s UP TO MAMPS
OZ-� ❑INTERIOR ❑CHIAI6EY REPAIR
p-t!s F' . rnscdl ,w.l 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I000AMP\ ❑BATH REMODE,IIREPAIR ❑DEMOLITION
Q I herthy.frim,that I am esemp from dte Cmaaclur'.License Lew for 0te
K 3 i Uc. fullnmine reumn.(ScOwn 7031,5.Bta,mco roll Pmfe.dms Code:Any eaor toxicity SIGNS ELECTRICAL ❑QDIER
W LL y which teyuirc.a permit to eomstmel,ahtt,improve,dcorot h,or repair any Vrecton,
pre t t '. a al " theapplicantf such pcn ii fl igtRJ mtament SPECIAL CIRCLE FIMISC.
gp y tial hu ,�Euratoml th l IIheC Vacs r l I (Cliaple,9
l^y.C�� (cu R 'mScl 7000)of Division J fth 11 : nil f 0xic)or TEMP,METER OR POLL'INST. COMMERCIAL ter'
a a c e him be ,pt Iherel andma back f Ion II pnl A y Ice nn of ❑NEW BLDCJN)DITION Ia1DIiMOLffION
SccI,n7NI5bynnvapplicantfnfap.n, tsubjeetsth, Iplwtteo.vllrnulty of 1'OWIiH UI:VICES 17!NANT /❑-FOODSERVICE
i n,re thmt live h ndnd ih,l tem(3500).
La,owmrotmc -n MI'ROVIiMI?NT
`Q ❑ pep Xtr my employee.with wu6e-,nr lMir wde emnpcn,allnn. SWIMMING 19x)1 I!LI!CI'RIC ❑pTNAN
w
will doOwwosk,aolllm nrucmi,iHut immod,ouUnal l i,rsac(See 7Ufa.Bmirca
3- and Profcsomv Code:The Conllacux'c License law dors rex apply It,an ovmcr of OU FI-SW ITCHES-IIX'I'URES
prottenr who haid,o,mpmvc,Iher rm,,nd whin mc,with work himself or mmagh
his own employee,,provided Our neh impnrcemems m:not intended ox offered for NEW RESIDENTIAL EJECR SQ Cr
sale.If,
M1oratt.Ihe buidin6„simpmvttrrnli.roll wiminnno year of a,mplelion.the SQ.FT.FLOOR AREA I.T.1lSQ.
eo uitsi will have dr hunkn of proving lhas he dW mit tuiW tx ilnpm,e Rr pur-
Fl 1 ofvlcJ.
❑ L v wxr d'the propmy,em ems,,'.mil svmmnine with Ii Thm Ctortmetox Io TOL\IL
r.Tw01e . pplyonto.Bosir of endaywho mo Cock:)Tl,e C,tibentd,nd
ccmclawdoes,t, rrtich pymmowncof.m'(ywlmoses]pmimpmvheconn n.md QTY. PLUMBING PERMIT FEE
whin mno-xto Brc tech pvjeets with a convvctla(x)IittmN pursuant e,the Convans,r's
License law. PERMIT ISSUANCE!
❑ I am cacmp under Sec. ,B A P C far this rcami
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dene / O
WORKER'S COM of
, yonION Dfine followiRAI ng HACK[LOW PHUITiCI',UEVICfi Jvl
a Ihad ulnnn fair,undcr penahynf of Com"ilnflbcl in l-roma following oncluaWorkIr Cie
❑on,aspool,dclI..binaCcn 3700of me LatorCoda,fo,c Lx Wrtomm ,cotthe IlRA1NS-Yl1KIR,W)01(AREA,COND, SFOR �S TYPE CONtifRUL'fION
wino,, r pmvldd fur mSCCI nn]70X1 o(thc LUMr C,dq for the pdimlwnre of the
walk have
will maintain
i. sal¢J. FIXTIIRIS-I'IiH'fHAI'
❑ 1 have uLa will maintain Wntkof's Canpenmlim Imuchnore.hi as his Fer by tieminn
1700MOr IaMr Codc.fo the perRrmancc ofthc work fox which thio pcm,ilumarred. GAS-EA.SVSIl1M-I INCA UVfLEFS OCC.CROUP AI'N
My Ciotti
r p w , umna cid Policy u
C ]iq.�„Ja.—-I,.,No cort: O E.A.GAS- SY\Tp.sTovE1 i(uA)
1 CERTI A 01:EXEMPTION FRO IW R(I:RS
COMPS ATION INSURANCE GREASUINOU.S BE WASE 1NILR(7EPIOR BUILDING DIVISION FEES
(This,LLIIIIII nrW notbo cdifine pcmir afro tm hmdnedddlar,151001 GREA.ST:TRAP
m k+v) PIANCIiI!CK ITE
la0ifythv Teles K ed'Jr wokfowhichlhis pemdl is inial, shod SEWER-SANDARY-STORM E.A.2M FT.
mtemployenyprrson i wy role eo In 'C ENERGY LIE
O Z .-tion law �"' WATi;R HEATER WIVEN M.ECTR GRAVING ITE
zO Allicm ,a e
In NOT ICE! :IC a wr ma - t this Ce I' nen.You,maid WATER SYSTI!M77R EATING
[-� ? b,c n s saseel w ma Woo,e.Com ion prov sine,of the Jabot Code,you must SOILS ITE
WIonbwilh comply with such prnvisio :w Nis pari hu Jwnted rendaJ. WATER SERVICE!
Q
uz 'to hIRULTIDN LENDING AGENCY NEW RI!SIDIiNfIAl.1'hMI1. SQ.IT. PAID DW RcwiptN
V O 1lrrtbrnlrmi,Fcon,e ix,c (,Som,m lwdmg ng,rrr lbr lM:Ixrronnatwe of
nr work br ween lnix pcm,il i.i., esre.A)97,Ci,.e.)
W. Le,.e..Name
TorAl.:
Wboder',Add,- TOTAL: BUILDING ITE
0. I mnify ten I have neat this epplica ion and nine Incl the above inf rnwiun is
F' N cornet.I acne m amply with W city ud cmery andioarea cid stem laws mladng to QTY MECHANICAL PERMIT FEE
U Z buildiri"nonaracliw.and herby amdmnxe oTrcanulives of this city to enter upun dr SEISMIC ILG
obove-memie ed pyrny for inspection popes,,,. PERMIT ISSUANCE,
(W'c).fli to MM idemoify xiIJ keep hams ale City of Col'sidrlo.Raine ELECTRIC FEE
liuliliun.joillic ,cwsedcapen,os which they in any way acrnse.Eun,1 and City ALTER OR ADD TO ME!CI I.
PLUMBING fTF.
A APPLICANT
Nod RSTAN SthisD WILL
APPLICANT UNDERSTANDS AND W'ILh COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TU 10(1(111 CITD
MECHANICAL ELi
SOURCEREGULATIONS.
AIR HANDLING UNITIOVER 10,00X1 CFM) CONSTRUCTION TAX
Siynmute of ApplicanVConaector Dale EXHAUST HOOD(WIDUCO HOUSING MITIGATION FEE
IIALARDOUS MATRHIAI S DISCLOSURE!
Will the applxam cit fwme buildingocupunl nam or hndlc harmthus moterial HIKI INC,ON IT CID IIXI.(XX)If IU)
as tefin,rl by dr CeFerfen Mmi c,ro Cods,Clulper 1)12,anti be Health and Sale'y
Osk.S,wtion 153921x)7 IIL!ATINO 11Nl'1'IDV HH I IXLIXXI H'I'lJ)
❑yes F-1 No PAID
VIiNfIIAfION FAN(SINGLIiNESID) lam R.,Ep,
Will Ibe upplicron tr fxmm bonding acculunl use am,nrm or Jokes which
emit bmardox,air comamirems ac defineil by dr Bay Ara Air(polity MmoRemu,t BOILER-COME'hill'OR IIXLIXXI H'IU) FEB TOTAL:
f
'I EB,vicl:' No BOILER-COMPIUVIiH IIq.gXI BTU) ([IILINV
\
❑yes ❑
1 Mvc red Jc M»vJau rmwials ncquimnrnt+luv)n I_lmiser n 93 of the Celi-
AIR CONDITIONER ISSUANCE DATE
form.health R Sickly Coe.Sections n5(15,n533 was!351,.1 urdm
eco il that if Etc AI
NEW RESIDENTIAL ECII. SQ.FT ` 1 2—— 1Y
buikling dos rot currently have a tenor,.that it is my reynroihilily to notify the occupant
of Ik f,eircreems which must be ort prix mInownes a of a Ccm1wae of Occopoi T
Owners au11KK1]Ld agent Date TOTAL: ISSUF.DBY: ' s'
OFFICE