S0660 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDIN'(:-ELECTRICO, Pf 11TN0
BUILDING DIVISION APPLICATIONMERMIT P11Uh1flING-M4'C11ANICAI. 0660
tlUILDING PROJECT umviTFICATION
SANITARY NU. APPLICATION'SUBMHMAL DATE
RUILDINC ADIlRFSS: J
2a- f,�L /ZtzA) Ar- Ito
OWNER'S NAME: PHONE. CO RACUIR'$NAME LIC NO: N� CONROLX
VtCHITEC(ENGINEER: -LICNO: f,�S.^� o ❑
cONrncT: PHONE: BUILDING PENMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLJOAfIUN QTY ELECTRIC PERMIT FII
1 Ilcrcby affirm shut I am Boned muter pnnwms of Chaprw 9(mom to& JOB DFSCRIPTION
UZ wIh Sedio.70Sll of Divieian S ofdm Has-miss unA Pndclat Rdc,rrdoly J,c,,wi, RFNI� DFNTIAL
w o z PERMIT'ISSUANCE
�,O full 17 onde t. 6 ❑SFDWI. El KITCHEN
F. coffee Clan• IJcXqS
N'I'LIANCES-RIiSIDIlTI'IAI. ❑AIIDU'ION UMHING RIiPIPIi
0� Uafc Cunfrvcmr
N Q a ARCHITECTS Df;CLARATION ❑MULTI-UNIT STRUCTURAL
PANIH S MODIPICAGON
t-=Z I uNosmM my plan.,shall lit,LLral as public oxcmln
OZ-'� UPTO2- AMPS []INTERIOR ❑CHIMNEYREPAIR
H�tW utm,,ed Nofeusioral 201-1SXIAMPS IMPROVEMENT SWIMMING PO(aIS
gs 5@ ` OWNER BUIIJ)ER DECLARATION OVER IDq)AMP5 ❑BATH RFMODELRIPAIR ❑DEMOLITION
K Q 1 hereby affirm that I am exempt from the Conuacim,1J Lew far She
F.Ow 0.U foll—m,ovum.(.Semiom 9"31.5,Buxincrs and Norc,,ionn Codc:Any city cr Homy SIGNS ELECTRICAL SER
LL3 LL which rryuirts a panus m mnvwc6 dart.imprn.e,dcmalidl mpo,reany urocmrt
C
1- ) Sisim m itsisuumrtpp
mce.Nsryio,the ulicenl for permit such peit to file a sigrarl wm
teem SPF,CIALCIRCUNFNISC.
QY K tfathis l'cxnsd pwsuant In de provirirn ofthc CnntanYs ticrnw Law lClyprcr9 COMMERCIAL
,. C (cam in6 wish Section 701)(1 of Division 3 M free Busineca sod Pmfessiors Cadc)of TEMP.METER OR POLF,INSL
a y a Ihol he is ceemq Ill,,i mn uld the basis for tlr alleged c..olu i,n,Any violuminn of ❑NEW BLDGJADDHHON ❑UI:MOL1'1'ION
¢Xl lith. Sectior703"byany elMlicmt forapmmit wbjms lheepilicam toucivil letakYof POWER DEVICES EITFNANf ❑FOODSERVICE
nu more thsn fvc hunmle ldollars(SNXH. IMPROVEMIl.T
=QDl.as vwrcrof Oe lrsSeny.mmYemploymwith wages os thcirsolccanpenwtior. SWIMMING POOL T:LECI'RIC ❑OTHER
p. will do the work.and the nocno,k rens imenxled or offered for sale(Sec.7044.Busiress
C
and Prafcoboo,Calc:Too Cummicnr'x Liccnrc lyw doc,std apply to un owner M Gll'1'I.IHS-SWITCIIIS-ITXTUNI'S
Pnycny whu Wilds or improves therm,and who toes wch work hinmush or through NEW RISIUI;NTIAI.FSELTR SQ I"f.
his nwm emMoysxn provided Thal.wch improvements arc dol inlrnkd nr oReml for FT.II.00BAR. S)SQ,IT.
.Is If,huwccr,He homing or imprvvcnem is sold within me year ofmmspletion,de
vrer-hihler will b fh Nmlcn of moving than he did rwt huild-impm.s f-par- O
pose of w2l.J. TOTAL pr„D
1,as owner of the property,am exclushely comrrHng with licensed mnuxtas m
xms mn Ise pirmoct(sec.T(Ifl.Husircas end Itofexirxss CaRJ Tim Gntmcnr's Li- lJr
ams Law dues not apply man owrer of popery who Wills or improver frcreon.and PLUMBING PERMIT FE' urtKr�N/''
who comoifrroKh psujens"as commcto(a)licensed prsrtmn 10 the Cairo fors ^ kV
Lkenx Law, PERMIT ISSUANCE {y'
1 am eacmm under Sec. .B&P C fr a this mum
ALTIiR-DRAIN&WN'-WAD!R(IA) VALUATION
Ow er Dye
• WORKERSCOMfiNSAT10N DECIANATION BACK FLOW PR(lDiCf UF,VICI!
l hnby vff udm powhy al'perjury me of the Emlhwing lkdwwinns:
❑Ihavc ydwill maiwina Ccrtifcue MCamcm to self-Oswe fm Worker's Cmnpcn- DRAINS-FLOOR,ROOF ARFJr,COND. STORIES TYPE CIINSTRUCTION
see aM will maim Seelliun 39Uf1 off W Ichor Cede,fm the pcHonsmvtee of the
syr prnvded for by
work In xwrich thu permh k issual. FIX'NRFS-PER TRAP
cin Wtr4Yx Cumpenswitm Inunarec,ns rewired by Saipan
191X1 ofthcldxr Code.for the prrfamr Hees of Oe wtrt for which thixprnnit is LarusrL GAS-EA.SYSfI!M1t-I INCA OU'I1.FTS OCC GROUP AIN
My Wmrkds C rsi i Iwuvre Pdiry mhr
Carrier, G � I'niky No.o re 7� GAS-IIA.SYSIENLOVER 4111)
Cli IIHC lE Olt E%I:MPIION FTXOlf WORKCRS' GRP.ISFJINDUSTRI,WASTP.INTI3RCEPIDR
COMPGNSATION INSURANCE BUILDING DIVISION 1EES
Ilhiv section Heol notWcnnpinN if Oe perosit is for nnc hundssst Jmdlun 1511X1) GREASI!TRAP
PIANCHF.CK ltii
a Icsa.)
Icrnify shot in the perfanuna of Ocwrk hmrwhich thispemsit ixicsud.l Jwll SEWI!R-SANITARY-SIY)RM I!A.28114.
std empby vnY Pemm�in anY nnatver w as to recnnc subject to Je Wukeri Canpcn- CNIRGY IPE
Z smitnlcaws.fcalift ie Dale WATER HEATER WNENTO!LECIR GRADING IIS
z ASiplicam t
NOTICE TO APPLICANT:If,aflm nuking this Certifcve of Exeff",you aNwM WATER SYSTfW`U EATING SOILS FTI?
Fes' become whjmt m the W'xkers Compensation provixions of the ISNsr Cale,pow must
m-„
forthwith comply withsuch muvisimns or this pemdl i be deemed revoked. WATER SERVICE
az CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PI-MH. SQ.IT, AID
I herebydl'sms then lhre is attsuwclimn lessirg'I fa the pedamarxc M Date RecciprX
U �P-m tlw work fnfwhich this coat ie'Nmol[S<r.3(rO.Civ.C.)
OU fenders Name TOTAL
WLodn's Addreu BUILDING ITS
y 1 serif,that I lwvc read Ibis ap,4icWi,,n mad note that the al imomwtium is
!n mrrml.l apsem comply with ell city and marry uNimmi and smm how,refining ba QTY, MECHANICAL PER MIT FFR SEISMIC SIT..
U orldmItOmmouctiws.uml bmth,authoize repry nmtivu oflhie city memo apo the
vbnse-mmtiorcJ progeny for inspection Purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,lmlcmnify and keep haw�bx One City MCupemim against
bud,litie,jadgsrcnts,emus and eq'ensu,which may in any way came ug mm,wd Ciry ALTEKORADDTOMECH. PLUMBING IFC
in con equence or the gmmim,of this permit.
fAIPPIACANTU EANDS AND WILL COMPLY WITH ALL NON-POINT AIRIIANDI,INGUNI'I'(1 )10,gpCFM1 OURCE RE S. AIR HANDLING UNIT(OVER I U,IX)O CIM) CONSTRUCHON'fAX
ngmlart ofAWlic"Con vee EKHAUSTIOODIWITyUCD :1)
GAnON ITE
HAZARXZUS MAIti DISCLOSURE
WI11h awksal offooc Wilding oetapmltflart m luridk hwolum llubefid HEAT]NG UNfr(To IWOOD BTU)
s deblcd by the Cupmmn Municipal Coda Churn 9,12,uM the Health wd SMyy
ass.Salimo 25532(a)9 [WAS UNIT(OVER IIX11XI0 BTU7
❑Yes C]No VENTILATION PAN(SINGLE RI-SID) ate NnciptN -
Will use applicam or future Wiwn occupant use equipment or device which
Wmil bxuadaPOII.I:N-CAMP IJIIP ON Ifp.gXl BTU)
u air worm ccom,as dcfnd by the Huy Amo Air Q- ,1aMiami BOILER
UirtrkB BOILER-COMP(OVER 100.000 BTU) _
C]yes 171 No
I Sri,and lie fourar n mwcniab rtyuimenl.under Chapter 6.95 of de,Cali- AIR CONDITIONER ISSUANCE DATE
formic 1I&Safety Gdc.Smims 25.005,25533 mol 255M.1 umdwuad that if tut NEW RESIDENTIAL MUCH. SQ.lel'.
hojim't docs sot.1,have a IrnanN.thw is in my icspmtdbiliry Sanctity t e rxsalmnl
M lh r.quirtmenfs which moat h nes prior m iswurec ole Crnifcve M Oavryxy.
Owns m.fWriad nem Dwe TOTAL: ISSUED BY:
OFFICE