S3007 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 CNO 3007 0 0 7
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL `
r--BUILDING PROJECT IDENTIFICATION
BUILDING ADUHESS.. SANI'fAHY NO. APPLICN'[ON SUBMITTAL DATE
2U o jo � - 2_
OW, R'S NAME IONS CO ACf 1ME IJC NO:
` NIC CONTROL If
Clif' BIJGINEER: 1L 9{]DI�I'S ,I ❑
CON�Tr�yj' KfN ,(r I'IIONG / ( V BUILDING PERMIT INFO
E] Consultant Fars Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
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J ❑ Lal ❑ ®-,
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 ncrtnr my.mal I am hern�d adN m,kiots.fchpw 9(oa-M Mo., JOB UFSCRIPTION
DMZwnh uTtitm 9gX1).m Divi.i.n3.nne Boil xa,l Vo,Fahm,Ctde,endmy lircllwia RESIDENTIAL
{ OO VERMI'I'ISSUANCE
Ny full frac md,Roel. ❑SFDWI. ❑KITCHEN REMODEL
�U� Ixrnsc Clow crb APPLIANCES-RESIDINI'IAL ❑AUDITION ❑PLUMBING RIS PIPE
Q W6 Goa Cwl nm
Fnz c d t ` S IR Moog PANELS ❑MULTI-UNR El STRUCTURAL
MODIFICATION
Oz•-o UP TO 2(q AMPS El INTERIOR El CHIMNEY REPAIR
F.4G o'cwsiona 201-IIXXIAMPS IMPROVEMENT []SWIMMINGPO0IS
�2g , / NIiN-BUILD DECLARATION OVER lgX1AS11'S [I HAITI REMODEL/REPAIR 0DEMOLITION
C 1,Q I hereby ufGmt IMI 1 em exnnln from me Comlectnr'x Liceno,I,aw Gv me
K 3 6 U following Town.(Sntion'1031.5,BaunnNP .w
a d .fcmv CNe:Any m,o county SIGNS FHCTRICAL OTHER
W LL which rtquires a form t I.cmwrvct,eller,impi Jemobi .oc rt 11 any s Ima
I"1='fig fnnamiu ommro .Iolryuims me apPliew ho vah Pnmil to EkesignN,onemem SPBCIALCIRCUITIMUK].
IMI M is liecnud puruwnl to the provisions of the Comtnunvr'n L'Icmn Li.(CMpter9
4100 Immmencing wilM1 Section 9gMllnf Division Jof the Huvilw.vs nod Not"o)"Citic)nr 'FIiMP,METER OR DOLE INST
apx� a mm he ,oxrntpt Therefrom and IIw Mi,0n bonoleg,d cxcmpdon.Any violation of BILlipeDDITTON ❑DEMOLITION
Scefma 70315 by any aflPMno fix a tMot suhjnD 1ho-1pli1unl to u civil PMnIIYM POWER DEVICES 13 ❑FOODSERVICE
m' MI marc then f vc Mndred dal Ims($500).
�?Q ❑L as win al the lnopeny,a my empkryces with weBss u lMir ink n,M, ,az m SWIMMING POOL ELECTRIC MPROVII 17
It will doth—k.and mc.Bm,luml inkdeloc.ff dfmsak(S .1DU.Rosillw ER
5�
a 3� ari114ofminnn Calc:The CnnlmceiG Licrns law dna not apply to w ovner of , OltII.LTS-SWITCHES-FlXTlIRF_S
pmpeny who Mils or improv.IMrton,and who d.n.tech work himself,x IbnmgM1
ho—cngduycn,pmvidN Ilm sMh Intprovcmcme'on M.immd d on olTaml for NEW RESIDFNfIAL ELBCTR SQ IT.
salt.ITMnmer,IM building of iml.nvmrcntis Md wilhlo m¢Yemof canlplmitxL the SQ.IT Il,(IOR AREA LSQ.PI'.
m-boiklerwi11 Mve ILC h nofprovingt lhedidnotMildwimpnweRxpn-
pom ar vk.),
n I,as msxr of the P rty,em exclusimly innimicting wim IiccnseJ coumctrxa to 'T AL: �O
msuuct me p foot(S«.9014.Bmioexs ad Profcssiuu Cde:)The ComMuM's Li-
amwwdtty notopPlymun.wovof pmpcny wbt MilJ.voimpravn lh -oo.mil QTY. PLUMBING PERMIT FEE
wim nnlmts bn sizh proi owlmnu(MoKox(sl llcmtrd lmrwant In the Cow MO( II
License law. $NMI'C ISSUANCIi
I.1ioM1NtMcr See .B&PCRxmis rte
A. A, �VPNT-W'ATER(13A1 VALUARON
WORKER'S COMPENSATION DECLARATION BA'
K ' IiCf.DEVICE �O
1 Mrehy atTnm unJlr pewlly of pmjmy alre M the tiilluwing dnlanlitme
IhavemdwillnwimainaCmdnic:dc.f Cummiillo.mll-insurcfnr Woher's Cnlmcn- DHAI . 1(R (R)P,ARI?A,COND' SILIRIES 1YPI?CONSCHIICfION
.moan,es pnrviJeJ Rn by Scclian 371X1 of Ile LtMn Gdc,lar IM perGmuwec of IM
work fm which this pmmn lv im H. FINL URES-PER'I'KAP
❑1 Mvr ed will maintain Worlcr's CoitaMsmion ImtMM,e.as ri,pfl,ol by Scelion
3700.!IM labor Cdt.for de feRomlarce of the w mr which mis lcrmit isis.d. GAS-FA.SY97ti.LIN (ICC,GROUP APN
My Wmioe'a Compensmion Imarmme carrier and P.Iky number art: / ,
Cartier: PMIcy No.: GAS-EA.SYS F VERBA i7-.
CIiKI'IFICATE OF hXIiMPIBON FROM WORKERS' GHIASI%INDII. 'ASfG INTIiNCIYrIY)H �/
COMPENSATION INSURANCE BUU1i DIVISION FEES
(Thlswmiun nrcdttm he mntpincd if lbc pcmtil is Rx nnc huNtrnl ddlun(SI WI GRIASETRAP O
.Tics) PIANCHI:CK HE
Lttmfymvinllrcpmfomlarcc oflbe work for whkh mix Penrvl is u .I sMII SEWER-SANIT -STORM F.A.M)FT.
not eroony any Fern in my mann) so m to ba wb;ecl to de Workm'Conten- EVLRGY FF.I: 3
O Z intim laws of Cxlifomia.Dann W'XTER HEATERrffiLECTR GRADING IPI:
C) A,I.nt
NOTICE TO APW.ICASM IL if M.MGng MS Cwif.in—rF-acmFtion,you WnNd WA'1'17R SYSTEMM IN'
hccorc.wh ran the W.mcPx Com psnxa un Gf ll c Iadn Cask,ymust sou-S IFF
µ pruvisiunFo
fuMwim ntmfJY with such prnvisitms or mis Pcmul droll he Jccmcd rtvotcd. WATER SERVICE
= Z CONSTRUCTION LENDING AGIliCt' NIiW NFSIDLNTAI.I'LA18. SUIT PAID O lk mipU
U O I Mrtby dRmt lMl on,i is a cmnnl.Y0 lending agrncr rm dte perfvmune.r
tM work No wmcn mix Ommil m«+I�d fate 3m-r,Coe.c.)
F' 1.tndcrs Nmle 'roTAI.:
UI<tder.Admn.. 'HYI'AL:
>. a eun.l 'F Ja
W 12 7
1 cenify But 1 have reed Nix epPlicotion aid wNc IhN the.hove inGlmmlion Iv
F' N mrtcaLlvgra t.comPlr wim en city amt rnumy oNivmcs and sole kwx rd.Gng le QTY. MECUANICAL PERMIT FEE
U Z bnikfilpt tmslmctiam.aM hmcbyawboi rtWcmmafi—ofdiscitymcmcfupm do SEISM
eMvc-Ircntimd Prtleny fm nopi loin tai m . 11:RMTTISSUANCE
(We)ago.m mvq indemnify mId k ,Mm1ka the City of Cuomino again. ELE C
I'nbilitin,judgnema,mauenJ expmse�which maY in any way uccme a8aind atd City AIJERORADD'fUMICII.
*ER'"SnA'ZJ'N'
e llAlx pennil) PLUMBIN('ll?C
TA W I MPLY WITH ALL NO -POINT AIR BANDIJNG UNI'Tfro IQlpl1 CPMI FIECIIANI <-cF, p ST10N. NR HANDLING UNIT(OVER I0.000CFM) ON ToU' 0117
n,Co tar ( Dale FiXHAUST GOOD(WIDUC) I IOUSING MITIGATION FEE
IIA BOGUS MAIALS DISCLOSURE
W,IIIhca,lii,mn, wmMildll cupanl setmmluudlc M'raNwwinalMal B EA'UNGUNIT CIO 100,IX011OU)
m&fire by tnc Cupenino Municipal Cde.CMPkr 9.12,and ILC Hcwllh and S.lOy
Cade.Section 3532(x)^ HEATING UNIT(OVER 1110,000 BTU)
oYa VIMI LVOON FAN(S INGLE RESID) PAID
Dint N«fila a
Will io,m,applicant m future Willing occupant y A rya t,QQ In JM.mi which
emit h:vuJuus vie cammninmm as JeOteJ by the Bny Arcl An Quullry MowgemmMl Bf11Ll?R-COMP pIIP(1H IW.IXU BTUI
D"on"? TOTAL
�Ycr No ❑OILIiH-COMI'[OVER IOII,gp H'IL1
I love real de M1armJo,a mabM,iE myuimmM.,tinder Chafor695 of me Cm- AIH(:ONDTIIONI:R ISSU NC• ATE
fania Hcnm&Sammy Code.Semiolm 35115.25533 and 2553.1.l anderumd thin if lie NEW RISIDENTIAI,MECIL SQ.IT.
Meiling do«not OM,moly MVC a RtwnL IMI i1 k my rtarymsiNlity to n0my IM occvpont V
a!Bic"Minmems whithon.Mot Di in m i.of o Cmtillime of Octni cy.
OwoermmIhonrdagrnl Dine TA ISSUED BY:
0FFICE