S3924 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECfIUCAI. PERMIT NO.
BUILDING DIVISION APPLICATIONMERNUT PLUMBING-MECHANICAL. S 3924
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE;
VN SONAM1E: //''_�yyf���II PHONE: COLS R C It E: UC NO:
NIC 9 C�7O/MJ/IOLY
��i ,GINEF,R: n LIC I: U ' F_S�I f,J� ✓�� ❑ ! f
C NTACT 'f/sTCJ✓✓1 RISE BUILDING PERMIT INFO
L ❑ Conmlulnt Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(� ❑ ❑
LICENSED 'D FRAC OR:S DECLARATION QTY ELECTRIC PERMIT FEE
I lereby calm Nv T an,m time p ovisimu of Chaptc,9(eamsrcnc e, JOB DESCRIPTION
°�Z with Smion]lO0)MDirision? fthe Busi.aM Rofessi.Cale,and my license is -
OO PERMIT ISSUANCE RESIDENTIAL
,�F in full forte ad cRat ❑SI'DWL ❑KITCHEN REMODEL
:RUL Lnamsc Class Lic.Y APPLIANCES-RESTDENTTAL []ADDITION ❑PLUAIBINGRE-PIPE
FZ W� Date CnnIIKBr
V1Q M 3LTSIl1[CLARAI'ION ❑MULTI-0NIT ❑STRUCTURAL
ZOyZ t . I used as public record. .PANELS MODIIICATION
OZ—a 9 UP T0200AMP5 El INTERIOR ❑CHIMNEYRETMR
Q=1]w IJccn f l 20140MAMPS IMPROVEMEYf SWIMMING POOLS
y OW U exempt
from
m the CoATION OVER❑ AMPS ❑BATH REMODEUREPAIR ❑DFJNOLITION
6 I hm000,Ilion that I m Bempt s an the Cssions Ys License Law f«the
k O L U fallowing auto.(.Scminn ILA Business old Ikofcasians Geo:Any city m musty SI IiLECGHCAL C1 MITER
3 �te which retire,t pencil to con„trust,at,,improve,dennlish,«relulf any suucturt
�LL0-1 prior to its i.aunnce.ido,msuims the applicant lin such,annum flea,i'aini temenl SPE , C /Af LSC
fly then he is Itemast crasam to the Provisions of 0a,Coovamors Lemce La% Chepm9
WE5 C, (ammurcrcing with StationItOM)of Division J ofthe Business and Pmfcasians Codcl« TEM P.At POLE INST. COMMERCIAL
d e K that he is saempt Nsteft«t aN tM hioas for tie WRycd cssmpievi Any vidstim of ❑ EW COMMERCIAL
EMOLUION
LL• Section 7031.5 by any opplieont for a gamut subjects the aMiicam to a civil penalty of POWER DEVICES
�y ANT ❑FOOD SERVICE
F, C, nm more
owasn Ovehundred
tarty.oarsyempl. IMPROVEMENT
=Q QLas,the asnfthe OR,.,mmyempoyees wiNwages ax0e(Secvole compensation. SWIMMING PUOLI]JiCTRIC
E ° w;nda the w«k,,nd Nesmelarc i,amt matmea«aRe,W r«wels«.]a.w.Bus. ❑OTHER
ud Profession,Coda:The Convector',Usama,Lew ease,not appy to en owner of OUTLJTfS-SWITCHES-FIXTURES
pnaPaty win Isuild,or improsc,thnwn,surd who rRes such work himself or thmueh
his own empLwms,provided that such improvements are not inandal or offe¢d for NEW RESIDENTIAL ELF,CfR SQ Ff
sale If.however,the Wilding orimprovement is mild within oon year ofcotoaddicn,the SQ.F..FLOOR AREA ySQ.FP
wne,builder will have its,human of proving tlwt M did not Wild ox imprna fu par
pom of sale.).
❑L u oyer M Ne progeny,sum earhaively amntrxtiog with linnsed amntxtms to T �111//YI
curmunact ale I+oject ISee.7144.Business aM Pcolessiau Code:)The Co.=,.,,V- - 12-0034
serve Law does am apply m unowan ofpopery who Wilds or improve theme,and QTY. P ,PERMIT .FEE
who a mere s for such projems with a cwvaeloy(y licensed putwum w w
the Conlmr's
I"en,r Lw. PERMIT ISS ANCF. 67
❑Itorn e,surn cr Sec. ,B&P C for thus reason
Date
ALTER-DRAIN VFM-WATER VALUATION
nn
WORKER'S COMPENSATION DECLARATION BACK FLOW P E E CE -3 /r0 'lam O
I tereby affirm uMcr penalty of perjury me of the fulloving dalamtlarve ll
DRAINS-11,008. F, ,C ). SNRT 'M,CONSTRUCTION
aduce,as provided for by Scctiom 37M of the Ichorde
Co ,for the perfommarcc of the
work f«which Nis panda is ismcd. FI%TU RES-PER TRAP
❑ 1 have end will nainain Workers Cau,cnattimt Inmates,a re,uimi by Section
?]W astthe Mbar Code.fm the perfvnwrce of Nc wmk f«ulrich this pemtit i,ia,uM. GAS-EA.SYSTEM-I INC.4 OUTHAT1S
OCC.GROUP APN
My l4'mAefs Cumpensatinm Inmrmue artier end yPolic,N.:number art:
Carrier. Policy No.: GAS-EA,SYSTEM-OVI!R4( �
CEiII FCOEEXEMPTION FROM WORKERS10—Mc
COMPENSATION INSURANCE
GREASPIINDU.STRLINIE CE f BUILDING DIVISION FEES
Gros section lava be complaed ifthe prnnit u for arc huMmlddWs(SIM) GREASE TR ^J
eve ass.) PLANCFiECK FEE ....7
1 unify that N ate any mea rce of tk wak f«which t I.permit is issue.I fall
not employ any pawn in any manna w a m cone,subject to Ih[W«Lerx'Comtism. SLIM; -SANITARY-STORM LA.21N1 ET ANERGY'EE
Z ,z satins law,of Cullfomia.hate ATER IEiATER WNENI IBLECIR
Applicant GRADING ITE
rn NOIICP.TO APPLICANT:If,after making this Ccnif re d'Eaemleim,yon sMuld WATER SYSIEMOREAUNG -
(-' become subject to are Wadi Canprnsetioe novicims m(d,c Iuabar Code,you must SOILS LIZ
forthwith comply withsuch'evi,iaru«Thu permit”"be deemed revaked. WATER SERVICE.
= z CONSIRII(TIOK LENDING AGENCY NEW RESIUPNTIAL%,Atli. SQ.Ff. PAID
L) 0 Ihemhy o0.that them isec«mmctim lending agency lin lM lenfomanea of Da¢ RacipM
It P the wak fix which Nis pemtil is ivsuN(Sec.3197,Civ.C)
C) U t<Mcfs Name TOTAL:
Lcodcls AJdress TOTAL
y 1 ccrify that I have rid this application and swte dist the,bone infomation i, BUILDING FEE
m rocmrl.T,gus,mcomply with m1 city and armyun inrrcc,and soa laws relating ,, QTY, MECHANICAL PERMIT FEE
U z, twilding<tnaructiam and hereby uu0vim reprewmatives of Nis city wetter upon tM1a SEISMICITE
above-tMmluned property,for inspection purymcs. PERMIT ISSUANCEa�
(Wed Von,to save,irdcmnify cad kcap harmless the City of Cupertino,agsuimt r r V ELECTRIC FEE
liabilities.jwlgnents.amus and expenses%hick may in any way accru against mid City ALTER OR A DO TO MECH.
conse,uenauddeagnm Mthis pemdt. PLUMBING FEE
APPLIC 'UAND WILL COMPLY WITH AEI. O PRINT AIR HANDLING UNIT(11)10,01111 CIM)
SOU E O
MECHANICALFPE O
f fl. i'
/t. AIR HANDLING UNIT OVER 10'"CFM) CONSTRUCTION TAX
Sigrc App icanVC u CC EXHAUST HOOD(WDUCI')
H )US MATERIALS DISCLOSURE HOUSING MGIGATTON LLE
Kill the upplic t future Wildingmcv iume« icharardmn,mv al HEATING UNHU'D LINA"BTU)
e,de0nal by aha Cupe - n Mtmicipal Code,Cholxer 9.12,and alta Ileulth and Safety
Coda Sermon 25532(a)" HFAI'INC,UNIT(OVER I00,MO BTU)
o YVPNfLAT0N PAN SINGLE RESIDI PAID
Data Rcacipt0
Will de applicant arfaturt WiWingoanpomuwc iP m«des which BOILER-COMP IMP OR 100.000 BTU)
emit h=., ,dins air commuwnss as retinal by ale Bay Arta Air Quality Mawgement TA
Di nicl^
LJ Yes BOII,1?R-COMP(OV ER IW.000Bin)
AIR CONDITIONER
I have usual Na hvmrLw - ,�uhcemru under CTaplcr695 of de Cdi- ` ISSUANCE DATE
tomo Heats aY 503.45533 and 2551E 1 aNeauncl tit if ale NEW RESIDENTIAL MECH. SQ.Fr
buildingth het 4 that it is my mxvied day tomdfyt «,lynnl ` r
of c ono matinee of a Calif [ ey.
o- a -Te
Owoeror -Wagent 4Z 1 ¢ TTA ISSUEDBY:
OFFICE