S1905 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEcTRICAI. FIUpITND, 1905
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING,-MECHANICAL VC
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ��� /� S,\NI'TARY NO. APPLICATION SUHMII'IAI,DATE
OWNEN'S NAME: PHONE CO, ACTOR'S NAME LI NO:
a / NIC CONTROL
\� ARCHITI:CTIENGINEER: LIC NO: AU) 155: ❑
CONTACT: � PHONE: BUILDING PERMIT INFO
/
/ e ❑ Consullo"I Fars Paid by Applicant(Initial) BLD ELL❑CI1'I,UMB MUCH
LICPNS CO ACTORS DECLARATION rJ(/G QTY ELECTRIC PERMIT FEE
I�e ,,tffimt am liaenw d make Provisitms of Clwper 9 heormatcFaeIng JOB DESCRIPTION
OCO win Snvon T100)mDivisi n3dthe Bn.in�..trod tfir•�tnNct dmy liccmcis RPSIDF.NTIAI:
+{1 O PERMD'ISSUANCE
IA
in fall lecexN w ❑SFDWL ❑KITCHEN KEMODB1.
<UW Dar,se.-' Lieg APPLIANCES-NESIDLNTIAL OAUDITION ❑VLUMBING RI:PIPE
�naa ume Contranta
F>y ANCHITECI'S OECLAR y PANTIE OMUI.TI-UNR ❑MODCNRAL
! ; I u t pima etull be u.d as Puhlic recnrtt. MODII9CAT10N
.".1 UP TO 200 AMPS pZ El INTERIOR
❑ IMI
iccnNN Rafm.iaml 2UI-11pAM1 'S iFPRQVFMiNT SWIMMING INDOLS
yf;
OWNER-BUILDER DECLARATION OVER IDMIAMIS ❑RATAREMODEL(REPA1R [I DEMOLITION
C W Q I hereby affirm Inas 1 am exemp from the Cont—mr's Lh —fur the
K O i U following lemon.(Sceliom 7031.5.Businw on I Irof¢dmxu Crtle:AnE eily«eoumy SIGNS ELECTRICAL ❑OTHER
4]3y�; which rcyw¢v v Xnaril In cunvlixl,alor. nrolie
,improve.Jch,«rcpvt any wwrt
uc
"iO� pnmtnip moance.aon neyonu the afTicant forsuch Wmiilit)rile a signel.aumnwnt SPECIALCIRCUEDMISC.
tam leislkanwd pummmaomcloo,ki vd tWCemracler's Licenw luw(ChaptmH
p(QD ICoxttmcrcinex'ith&ctitn](M1111 o(Divirim3oflhc BmimcoaNProfcniunnCNc)a 'TEMP MISILR OR IVLIi INST.
a a e C then he is eXempt therefrom aM the III for Ib,WIegN exellrpnon.Ary rioW ion d
[IN tlLDCJADDRION ❑DEMOLITION
�:�'y Scclion7(r3lJ by ane apMicam for a pcmtit naNan,E,.,Or,. civil pc.try d POWER DEVICES ANT ❑FOOD SERVICE
=4Hol more loan five hutmred d llvn($A)A, IMPROVEMENT
t ownetm the lnlll rty,mmy cotployces w oh Fair stole nnnlenw(nn, SWIMMING Pt X)L ELECTRIC
CCCh will Mt the vnxk,oMEc mmear,i.v exxmlc"deJnfoRcnd I,,.1t,(See7194,Brite.cv OTHER
amt Frofcsrdenv Coitlb,,Com r,,mrIs Liccnw I v,des not apply to an..of OUTLETS-SWITCHES-FIXTURES
1'rWeny wW Wilda or intimae thco,ma,Inc!wtw dnen.wen word:himwlfa Uvough
he;own employee.,pnwiJN thin such impmrctrena.arc nut imenvlN or offered for NEW RE\IDIXFIAL[IEC"R SQ FT.
sale.IL lntwcvca the buildingmximlmwcnanimutld withinmeyew of nrmpletitxt,Ibc SQ. RARER SJSQ.FI'.
—Im Me,will ba"lIn,Mmint of proving tMt nu did not 1aim mx imlaum fa mar-
ptacofulc.l
as o . Z
a1, wncr of Ie.Iemmtfven, c¢ludvely cenllerting with licecwd n amebmM9 a to TOTAL
� cn Bret the Purjun(Sec.]Dm.Bmrcia a Profesv:w Code:)Ts CantslN.Id-
(`(� cerin law des not apply,to III pmpcnY win buiMls or improve thereon.and QTY. PLUMBING PERMIT FEE
whocomraen hx sane pmjaw whhunnlmcnx(s)IlmnrN fm.mtolllc Cnomao ry
\iw Geenw maw. VE3 MIT ISSUANCE
\7 ❑I an escmp made,See. .B R P C for lnia mown
i ALTER-DRAIN&VENT-WATER(EA) VALUATION
ON'ner Dmc
WORKER'S COMPENSATION DECLARATION BACK Flaw PROTECT.DEVICE •GnDI,�)./
M Mmby alfirot meehr,rad,ofp piryn of foe Nfllowing dedamtnnm
Ilwn mad will mvinmin aCertifcutuJCnnwnl In self-in,wre far Wmxkcr's ConnI DRAINS-FLOOR.ROOF,AREA,COND' STORIE-S TYPE CONS'IkUC ION
mtinn,ozpmv' fa by Searin o79000 of the Ichor Coln.IF thmtanc
e p ofoof me, O
—k I IMt permit ix d rooFIXTURES-"TRAP
ve
aN will mainamn WaYcr's Corntcnvmion Insuraree,ss required by Scmiee
3]IMI"fthe,Wh«Cede.hrthe Perfumunce ufthe work Fewnich this lemon is issued GAS-IA.SYSTEM-I INC.v OUTLETS OCC GROUP AI'N.
My Wuht currier unit Ril ky
Cartier: olie,N'�: CAS-IA.SYSTEFI-OVI!RJ(IA)
CERTHICA IFEX EMVIION IItOM ORKF,RS' GRFASI%INDUSTRL W'ASTL'INTERCIiI'IY)R
COMPENSATION INSURANCE BUILDING DIVISION F£FS
Mi,wwrien reed.N,cm lmN ifthe perenh ,for maw hamnad"I.(SIM) GREASETRAP
) YIANCHECK FEE.lcwv.l
Icrnify that in the perlixntnnce of lie work tr w1n,ht iv Email ip pnred.inhull /CEWRR-SANI9AR ' R .\.K
rot cmplo)'eoYJ y terwvst M1jc 'atcn'Cumpcm IL'IJtGY FEE
( WATER HEATER WIVTNI'Fit FCIR
z Oil GRADING FEE
NOTICF L Eafte mWi co F;X pian,ynu sfeuld WAI'F.R SYS I'EM/fRW3'ING
H Fttame suhjcn at Thu Wmtds Cmmlocnxwiw pnrviaiunX of m da Cah:,ymIn must 5011
WIe.hwnm,omFly withtech pmvmuns or Ola Eennhrlwll mel revoked. WA'DiRSERVICE Ll 3
Q
a CONSTRUCUON LENDINGA d1tCY NEW'RIlT
iti1DlflALI'LMB. S6.FE PAID
= 'Z Thereby aifimtlM1ut then iaaNnnstraCfiat lc Wing ngrncY for the perftmnarce of ) ,/,mss n �yG1111
meigl
Wme wxk for which this p rl Ia is.wcd Sec.3041,Cot.C.) kl [1/47. X� �-/L� A TOTAL:
O V 1<ndcr'x Nanta _
0U Lemdf'.AJtlrtas fY111i111N6F}I:'-.'n
y 1 ccnify that I have need this agtlicalun aN amc tial the afnve information is ts.v
F-' N coreca.l agrtc to eemply with N city and county ordinmasa,1 sera laws slating to QTY. MECHANICAL PFRMIT FEF
VZ Wildingnaorr ,mad hereby authorix mtrtcanuives drINcity In entreUpon the SEISMIC FIFE
alhu"norniorwd pmpcny fec inspection pu"wsn. PERMIT'ISSUANCE
(Wu)ag,m m so,q imkornmfy aml 4avp Mnnlesa m City of Caen,ayuinet ELIICIRIC FILE
liffiiliticsjwdgmcntN nes eN CXprnsc which may in any wey ae.c.,imetull City ALTER OR ADD TO MlzCILPLUMPING IiE
O
in cwnwq, aeoftlr primingofthi,Le.it. t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NOK-POINT AIR HANDLING UNIT CFO 10.000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNI T(OVER 10,DX)CPM) CONSTRUCTION FAX
Sigmtmrtof AppliceMCnmmctm Umu EXHAUST FOOD(WIIUM I IOUSINGMITIGATION FEE
IIA]ARDOUS MATERIALS DISCLOSURE
WilllhcepplicumtrfwurehuilJinyv[c�itpant yore tr luNlc x..+nMtun material HEATING UNIT(TO 1011,01111 BTU)
uv Rfi d by tI Cupeninu Maniciryl�G''idu,Chaffer 9.12,ned the Health ural Safety
Cede,Seen 1195321 N'! L_J/'/ IIEA'I'ING UNIT(OVER la).0X)BTUI
�Ycv VFMILvTON FAN(SINGLE RESID) PAID
IMtc Rccclpi If
Will cs on"mom i forme Willing mecupaB tu�y A equipment at M ns which
tooenulhvaNwr kir<unwmirwus ns mN by the Bay Arta Air Quality Muwgcmrnt POILT:N-COMP(IilP OR 10B.f100 BUT) TOTAL.
Di.FGG1 BOE.17R-COMP(OVER 100,UM)B9U)
]V
I M1ave n®d de haaadaas mamas Fromm x mI CTupm 6.Y5 d IIc Cali- AIR CONDITIONER ISSUANCE,DATE
famla Hrnith A Scbay CNe,Scerinas 25505.255]3 and 2553].1 uNcrvanvl that Joe NEW RESIDENTIAL MECIL SQ.FT. —7 —
/-J ��.� d O
Wildingdias teteumnJyhavc..F.that it.myns,anutlity moonfy the—F,rm G-
of be rnryirtmenl which mum M net pnm In Luuwmc of a CceliEavte of l kv'ulvnry.
owrer or vudldN agcm D. TOTAL: ISSUED BY: S I?t Q 1
OFFICE