S3333 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,CFRICAL Ill No
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 3333
BUILDING PROJECT IDENTIFiCITIUN
HUILDINGADURFSS: / SANITARY NO. APPLICATION SUBMITTAL DATE
eo JOZ3VA a
OWN NAM , IIONIi: NN}'kACI'U AM LIC NO.
� NIC CONTROL
• ARC CF V GINEER: LIC NO ADDRESS: ❑ O <
GNrncr: PHONI;- BUILDING PERMIT INFO'
G 0,6_t5)&1
B /� ❑ Consultant Fen Paid by Applicant(Initial) BLDG EI-ECT
P UMJ�� Mimi
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LICENSED CONE 'rolls DECI RATION QTY ELECTRIC PERMIT FEE
I hertny ufirm mal l am h.cn soder pmvidons m'Chapter 9(cnnncrcma JOB DESCRIPTION
with Seel..]WO)of Oi,i,.3 of the Bmire.0 utd I4afunions Code amt my license is RESIDENTIAL:
'Op I'IiRMI'T ISSUANCE ❑SPOWL ❑KI'fCHENREMODI?I,
:R
fol hxce and Ikea.
UU Liccnv Claa Loc.«
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b.F. U I'LIANCI?S-HESIUFNTIAh ❑ADDITION OI'hUMBIFG RF.-PII'li
N 6 W I>atc Cammmor
ARCHMIC1'S DECLARATION ❑MULTI-UNIT ❑MTRUCNRAL
F O w PANI31 ti MODIFICATION
zonz luodcrvaud my plena shall he uxUss Public rcr«ds
OZ-� UD 10210 AMP5 CINTERIOR C3 CHIMNEY REPAIR
W Liccnxd Professional 201-1010AMPS IMPROVEMENT C)SWIMMING POOLS
OWNER-K 6 I hereby affimo mal 1 am BeaelmtpLGomEOac Cmoact«'s I.iccnx law f«the OVER 1000AMPS ❑BATH REMO EEI/REPAIR [I DEMOLITION
KO a U following . Section]011.5.Husil s red Pmfcssiann Coats.An ❑OTHER
fol rtvon ( Y co,Y«coon Y SIGNS IiLIiCFRICAL
3 tl which rr4mru ti permit In C shuel,oast,in,ptOva Jelrailiit a«rcpair ratty structure
,F]�O
firm the., irwarcqub+rrc to belMoppticunl fur salol Pcmtinnti,r,i,aw harmirm SPECIAL CIRCUI'C/MISC.
Ihatbc�cing wtl Cumm�l vtlhn of Disinnz ofihcr,Monica;LlI Poof ka(Oapu9 _
,L hal(cobe a,, Section
r,o and m besi,for rb me aged e.ss alai Pndcsinns ation or 'DiMP,MHI'F.H(lN POh13INS'1',
a p; hal he is uempl Ilmrtfrtml anJ me hssin f«me alleged eaeonptlim,rally vlulmion of — ADDITION ❑DEMOLITION
Sec-tion]0315 by tiny.pplkunl for a permit suhjxothe applicant to a civil penally of POWER DEVICES iNANT [I FWD SERVICE
m nor awls than fisc huodrtd"Iers(SS001.
IMPROVEMENT
�SpQ ❑I.sswmcrof the proprny.txmycmphryeeswim urges asllleirsale otxnpensaliarL SWIMMING 1'WLELECTHIC BOTHER
�1... will Jn llC w«t,and lhcHrvclureemlinvml l«oRcrtJ fnrsak(.Sec.]DN.Buurles.
and Profe.asions Code:Tor Commame,Ldcenx Idw dors ran apply to an twrtr o Of/T1.ITS-SWITCHES-FIXTURES
Ixrpcny wow builds or improves mcrem.cane who doe.such work himscR«Ihmueh
his own employm,provved Lha such iro,Prm ,,am not inteadN«oBcrN for NEW RESIDENTIAL.ELEC SQ FF
sale.If.however,Inti building or improvement is sold within ore year ofcrmrplaion,dc SQ.FT.FLOOR AREA SSQ.BT.
nr-milder will have dro huNen of proving that he did rad Mudd or ilnpmvc for per-
,aif,
-ower.ldn of Nes P'Trn&a adusivdy c muaaing with licensedc mlrxlom m 'f L:
m,me,In, av=c'1(Sec.911W.Hmhcss unit Itofiessicers Cou,,.or CumtucmrI Li-
n,law docs no,.pply m an owr000f prrgcny wow Wild,or impmvcs lMmm.aM QTY, PI-UMBING PF,RAII'IFEE
whoetmtrana for each Prmne sVmmorma(s)Iiama,dponwasolmah,Co nsclnrz
c^x Vw' PERMIT ISSUANCE
lemu .It KP Cbmi.
AI TT:H-DRAIN&VENT-WATER IIAI VALUAFIUN
ownrr Darr OD 06
WORnder of perATION DECLARATION HACK FLOW PROTECT.DEVICIi
I
by
ofiimt under tynf perjury ore of the fMlwing declarations:
loaves ural will mainmi %.col ficmc of Conunno xlf-inwm Grc WoAcr's Cooper- DRAINS-ILWN.ROO . 'OND. STONI TYPE CONSTHIJCI'ION
.lion,as Provided for by k'Ilnn 39(X1 of the Lehr Crdc,fill Ill,IA'rnanwnre of IMG
work for which this tomtit is ivacd. LIKE URLS—PI: 1'
I have it will rrainmin WnAcr'.Colnpcnaalkn Insfomnce.ax,,mrd by Scclmr,
3700ofmc Lelo-Codc,f«Ibe per4mnaresofthi,work f«whkh this lcrmil is iswed. GAS-IA.SYS'1 C.000-GJ: OCC.GROUP APN
MywUr sCmn nwion Inwmncty crane Policynam cart: '
Cam¢ Pdiry No.: GAS-IA.SYSIti O J
CERTIFICATI?OF EXEMPTION FROM WORKERS' GHFASI%INDUSTR 'ASTF,INTI:RCI:ITOR
COMPENSATION INSURANCE UILDING DMESION FEES
(Thu.vino w.vl wrhe<ompinNifine prrmit is fororc numLed Allan 151110) GREASE TRAP
or Is,,) PLAN C 'TE
1¢nHylhminlhclwMitmmrcmfibcwm*f�r whichmispcmoitisikwN.lanai SE 17X-SANITARY .21X119'.
inploy unY prmn unYn nu nn uz to nccone mby_n la lbs Work,,Ccro,r- ENI ( O
Z salon laws of Cdi4wli.,l e"i, WAIT EE 11 TATER WN17N'CIIiLfCIX
O Applicant GN FIE
NOTICE TO APPLICANT:If,alter nuking This Ci,mirale ill faanpinn,you should WAIT:R SYSTIJABI EATING
tanto a subjm m Ih[W okRa Compenaauon pno—on,of rhe laho Code,you must
o-, forthwith comply wiW wch provisions or this permit Nall be dccmcd rcvokcd. WATIN SERVICE
11 CONSTRUCTION LFNDLNG AGENCY NEW RIiSIDIiYT1AL PLMB. SQ.FE PAID
7 Z Ddlc Rncip N
UO 1 herebyich do Ihmoo,i iso d(Socvion leaO.Cie.agercyfor the pcdlmruree of
the w«t f«which this pcmlit is is«e(Sow.Jf19].Civ.C.)
C) F" I<nikr's Name TOT§AL
y� U IsnJcrs Addmca 'TOTAL:
1 ccnify Ines I love mW Ibis;pWlicatitm aN stale tii the atone Inloodurian Is BUILDING FE 3V] narrect.lagreelU ccmply wlmall city and county arboxcc.and slate laws mloling 0' QTY. MECHANICAL PERM 11' FEEU Zbuilding crmvtrunioo.and burehymmraris rtpr,rlrts,,of this city to enter upon meSIiISMiC/ MIRMH'ISSUANCE it
(Wg ag.m sae.indceni fyeel lacy lesmatesa thecoy.fCupcninoagaim, Q ELECTRICALTER OR ADD TO MECH. PLUM
in coman,ma,,of me grmung of mu prrmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTT(T010d)(IUC'PM)SOURCE REGULATIONS MECHA ALPrP
AIN HANDLING UNIT(OVER 10,0011 CFM) CON. H
'LON TAX
Signature of Applamiu Cominclnr [)me 1X IIAUtiF HOOD(WIDU(T) IIOI151NG, CATION IIiE
HAZARDOUS MRI'ERIAIS DISCLOSURIi
Will the applleum nr fmnru MIIIJing xcup-em nolo or handle harmrkwx nwlenal HIA'1'INC,UNIT('10 IW,IX)(I H'1'U)
as d-fin ed by dac Capcmno Marici Ctx1c,Clwper 11.12 wd m, lcdtn wit Salcey
Ct.k,Sodom 25532(.)] MISTING UNIT(OVER 100,000 It FU)
❑Yes Nu VINTHATION FAN(SINGLI:RESIDE PAID
Dae Rcacipr g
Will the applicwx or future building occupam u.c ryuipmcnt«devices which
emit hvudeuz air contaminants as dcfinedi by the 5,Arra Air Quality Marmgerui BOII.ER-COMP(3HP OR I00,100 BTL) T 1
EI I to
Di.arin] BOILER-COMET,(OVER 110.100 BULB
pr C/
I have mad the hvnnlius nomeridx In foods,Clo. G.95of the Cal i- A I k CONDITI LINER ISSUANCE DATE.
nxluimrwn yacr Q
Retia llculmKSWcJ�CNc,S' SSUI i 25533 onJ2553lfit, o ad,11 motif IL- NIiW HLSIUIiNfIA1,MECl1. SO 17,
nnilding d'caoay� my ha Ic hot it is oily res pipnibililyln orally lM CRvvlwtl ( /
of, reyuuc is 'hlCllm u n IU iswarcc UftiC 'Iifif9lC UfjO)IYn�let
(purer«sum Nagcm
Doli, T L ISSUED BY:
OFFICE