27454 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING RI PER.MITND. 27454
APPLICATION/PERMIT PING PROD-MRCnA H"ICA
BUILDING DIVISION BUILDING PROJECT IUFNTIFlCATIrIN
BUILDING ADDRESS w�f/1 SANITARY NO. APPLICATIONSUBMITTALDATE`\1 LOT# l� lJJ`.LJS
WNt _ C( t0O�IG�` NIC CONNTRROLL#
ARCIIIITCTJFNGINEER: L 1V�SS; (lam . ❑
CONTACT; PHONe: Ql'Y ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ti��/1I x�DOcr —E
d / PERMIT ISSUANCE �. RY,
LICENSED ONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Ip-
pz7 1hcrtbyam
ffirthatIamemed
licuru fid rwf..fChapn9(,omoo cin,wish JOB DESCRIPTION
�00 Section 7")a Divi Sof theBu and Proll iov Codc,and my E«nse u N PANEL
V.aF full fo ,,mdeQect. Lic.N UPTOMAMPS
-
vFi Date Conrraa« 201-1000 AMPS
7 FONZ� ARCHf1ECTSDECLARATION OVER IOW AMPS SQ.PT.FLOOR AREA S/SQ.ET.
OZ—❑ Iurst ,urd my plena shLl be u>m M Nur,Morris.
p o,t w SIGNS ELECTRICAL
aIJccn.d Pndcssimsl
OWNER-BUILDER DGIION SIALCIRCUR/MISC.
ryx,O�U hmchy eflirm that 1 wt excmp front,he he CumCinouc,ur's I'fiCLitany Isw for the
WE C,.a (dlowing mau�m(Sec,ion]031.5.Buune+a and Prufeuivm Ctdc:Any city or awnty TEMP.MEIFR OR TOLE INST.
E J which mluinn a pcmut to ccrstnct,alis,mr rnve.dcmoliah,or mpeir any strunune
Ct2a� prim to lis I...].is,Iuu s the applicant ferauch pnmit to flea aignRd".1 POWER DEVICES
CDO that he is lies Npurrunt to the inwinkas of the Contranor'a Licrnse Law(Chngcr
d' 9(commu,ning wth Smdm 7M)of Divwon 3 of the Rusua aN Pr
inofcvimn CadgWIMMING POOL EIFFCIRIC c) VALUAI] r
.'9_'y or that Ma xemp, firuom and tk basis fsr the alleged exrcoo .Any violation Gll
tKQ Section]031.3 by my aFpi k,mt for a rrsita *u the applicant to a civil p onty of ITTLETS-SWITCHES-nmumS Q
C Iwt tmrt thin fin hmdncd dollar($3(10). NLRV RPSIDINHAL ELECIR _SQ.FT.
❑ I,asOw,nrofNepmpeny,ormyemployaswiNwag we irsolecrompe uml. STORIES TYPF.0 N
d3� will Jo Oc work,Cci Is, m,intLic mUwJo f«sak(Sec.to
Bta�s
and rty whim. Code:The Cmtlho tore Liceran Lew doer or elgly,o an owner o,
popcnywhn Wildsmimpmvnlhrm�n.eMwhoMnauch wakhirtecUarNmughhf. FICC.GROUP RES.UNITS
wn emPloyxr,pmvWM duroverompovemcnumcrucy ardedocofferW therw.Ir,
however,theruc t1w for Impo,cosirieo, withinoneyear of«mplaion.lheowner-
.1c.). ill hove the huden of moving Ihet he did no,buil)mimpmve fm WIry><e Or
elc.).
❑ Luwmrorllsc Property,em ucbdvclycmhanin iN li Conlnmonto QTY. PLUMBING PERMIT FEE hl D pl'N
connruct the pcjen(S«.](H4,Bonn.aM 1'rof C The Contractor's
Ii."wdannotapplytoanownnofpopcnyw ild,arim vn Oerem,aM MJMIT ISSUANCE
who cour.fci pmjecuwiNacantnnmfa)'cm c,ocAnnt the Conlnnor',
licrnsc Law. ALTLIR-DRAIN A%'ENT-WATER(HA) FEE SUMMARY
❑ I am eaaopt utdn Sec ,BRP or this reason BACK FLOW PR ICP, SANITARYOUTSIDE N
Owrcr WORKMAN ENSATION DECLARATION DRAINS-FL R.ROOF,ARFA,CO SCHOOLTAX YET# N
❑ Ihertby affirm thNl aaniOcNe ofrnnxNwslf-itswrt,mvc tide of RECEIPT#
wonted cmmpensaf atan«meerninalp mxTUR PER TRAP
opy lhamf(Sec.JS00,Lab C, hich PARK fCE
I nm all nnlgoyds oder thio prnniv GAS. A.SYSTEM-1 INC a OU7DXTS ECEIn#
licy# BUIL14PNGDIVISI Il1ES
C"n'. C E.A.SYSTEM OVER (FA) PLANCIIECK EFF.
❑ CcnTwdcopyisle byfumishcd. 11 1 IL
❑ Ccnieedcupyir Rle with cit cu GRPASPIINDU, L :RCEI'ITNt GRADING II:F
CERTIFICA OFIDE NFROM WORKERS GRE- SHTRAP SOILS ILL
CO PFNSATI SURANCE
(Itua,cctivnlcd mth ctcdif 'tis fm mch dNlus(51 W) SEWER-SA Y-STORM EA. FNF
a kaa)
IccnifythNinthc perf a cfdcwcrkfcrsih 's pvmituissvd,IslWl WA \TiRW/VPN /EL
nm cmpby any poor in any sn v m ,ubjw,o Ne Wohens PAID
z Comµ+uasian Lawnof California Ne A S O On R,c 0
a
O NOTICE,TO APPLICANT:If,after, thi,Ccnif aof Exio rl ,you should NE FS AL SQ. TOTAL
V] Mmrm aobject to the Wokela Cmnp ism pmriaimu of the Labm Cori you muv
a fmhwith corply with such pnvlsiom m lhls l it mill M ciccmcd mvo4d. BUILDING T
PL.
�] CONSTRUCTION LENDING AGENCY
SEISMIC 'EP.
Vz Ihctchy tuff Out there is a mtutnti lending agmy for the penfourroar f
Q the wtxk for which this pcmut is ivucd(Sn.3097,Cid.C) TOTAL ELF IC ITE
IcldcrS Nems
OF I<ndvl A,11o. On. MECIIANINLPWMIT FEE RU ING FEE
V I aruty tout I here read this application u,d note that the above information is
MECI [CAL FEE
>_ Li1 «nen.Iagtcen oncounty mnanuu
only with all city and Jiand...�.law,nAm'to PERMITISSUANCIE '
U Zw
huiding«mtrunmr,.and hertby eud,miae Rprm ,s,a of in.6ty 1.enter upon tic CON UCTIONTAX
ebe- mid I Tarty for ioapnnioo ImToan. ALTER OR ADD TO MECH.
jlwbill
e) to save,indnmJy m,d kttp humlev the City of Cuprn'uw egi.e
x, enu,anus Hdex which yinanyweyunmee .rid City AIR HANDLING IINTT(TO IO,IXiOCF )
of the tin or permit.
Al AIR IIANDLING UNff(OVER 10,(MUM)
Si rvn Appy n untnnor P" ate E%HAUSTHOOD(WIDUC ) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT[TO I(C."BTU) WA Rcccir#
Will the srfdw Cupian,mo Morribudding occupan,ume«handleo,Hinnlau,matfety HEATING UNIT(OVFR IW,BW BTU) TO
ril
ea defnad M the Cupvdnro Mwicipal Code,Cluper 9.12,aM the Health W Safety
Code,Stcucm 23332(11)'
❑Y. ❑No VFMlLAT10N FANSRESID)
ISSUA E DATE
tlOILER-COMP CHP OR 1 W.000 RN) pp
Will theapplicmum(wunebuilding by t1s,Bay Arin it mdcvicnwhichanit P N D
•h•ardoua air«mamirwu n defmM by Oe Bay Arp Air Quality Maeagnnn,t BOILER-COMP(OVER 1 W.I100 BTU)
DisWcR
❑Y. ❑No NEW RESIDENTIAL MECH.—SQ,FT.
)nide ri the ova cko,,menriex reyoirtments undkr Chnmr 6.93 of to, FEB 1995
Culihim la Hall,k Safely CoM.Sections 25303,25.133 a a 123334. 1 uod rurl that
Ifthe building dace not currently have anoint,the,i,lsmy.,nunbiliryto nwtify the CITY
rtcupwt of the ICGoiremrnu which on"he met pnm to i..of a C ficin e of V 1 ' V
fk""wwy. .
Ownar«autlwrislegrntDate ISSUED .
OF I