30072 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECITtICAL PERMIT NO. 30072
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRGSS: SANITARY NO. APPLICATION SUBMITTAL DATE.
2003O 02-- PA-httl, G \�7 q6
OW .R'S
�ANAME PHONE Cp11LomroeL
TRACIORS NAME J
WC CONTROL#OC NO:
ROUTE rENGINEERLIC NO "i
F{ �� C-r• SRX1��l.yT� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consuluent Fees Paid by Applicant(Initial) BLDG ELE yLUMg xLICINSED CONTRACTOR:S DECLARATION - QTY ELECTRIC PERMIT FEE ❑ '�/L,Q(`
l Ieteby amrm IMt 1 nm rtcmrvW nmlm pavidana ar ennpmr 9 mamtneneto, J4 DESCRIPTION
0i�2
m OL I'
RESIDENTIAL
�df � PERMIT ISSUANCE
DatUe� � gyh 0 SCOWL
El KITCHEN REMODF.
APPLIANCES
❑ADDITION El PLUMBING RE-PIPE
�y ARCHHE,CTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z Fp Yi I undnvtend mY pen,ahNl be ud u ptblle renmk PANFl S + MODIFICATION
OZI- UP TO Mp AMPS ❑INTERIOR DCHIMNEY REPAIR
<w,$.u� Lunnne Ponfesaiatal p1-HIprLAMPS - IMPROVEMENT
tY Yr�-t OWNER-BUILDERDECLARATIONhe RATION OVER DMOAMPS D BATH REAIODEIIREPAIR El DEMOLITION
`a U I hctewo.(See that 1 ant.Hump front the Cmvas Cud Liceme law for the
%3 a U fdbwing ream.(Schon]OJI3.Busirev arrd Prt(easimrs Code,:Any ntY a rnumY SIGNS ELLCfRICAL ❑OTHER
ul µ�I'! whkM1 o int a pennn m cnnvmn,alter,improve,dccmli,dl,or%-*r uny awnw: I
�H Prier to iN iawsntt.also raquim ON,appliant for Wch p,mnt to file a signal„a amwr SPF.CIALCIRCUTCAUSC.
that he is licertwdpramnt to the Orviuors trite Ctno,coms Lieena,Lww(Clot"co
�1p0 (commencing with Section 7")tt Divixion3of the llusimis and Profnaicrart Code)or TEMP.METER OR POLE INSE COMMERCIAL
e. n Ther he is cxcln,t ftinfourn earl the buil for de alleged eacmption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
YYYIII 4• Section 7031 5 by any applicant for a Ictmit subject,the aprt m a civil Penalty of POWER DEVICES [I TENANT D FOOD SERVICE
y oro ma,door five hunbd dollar.($501
(] I,azuwrcrnf Ne prop:nY,amY rmpluym wilM1 wegoulheir wle ctmpemmim, SWIMMING POOL ELECTRIC IMPROVFLIENT
will dr Ne work,arM lie.ra isoq int,MNeroRcsW for We(Sea.]DW,Rurenea ❑OTHER
t�]3 final Rofe.uiovv Code,Tie Contr icter's Liccme law doe i nn appy It en owner of ounCETS-SWITCIiiS-rixTuRri
Propcny who build,a it,tr a arrmm,ani no Jree'uch work himrelf m tMmgh
his own employee,provided doct such in,rata.art vat Imendnl or ofeml for NEW RESIDENTIAL ELF. S
uk.lf.M1nwever,tM builJingaimptvetnemix wld within mcyeu tl completion,tM1e SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have de huNen of proving drat Ile did not build or ittgnove far pur-
pose,of vale). p
D I,m owner tf me roproti am exclusively cmuucting with Iicaneed mntmcmrs n, JY - i�
corwrun the pori(See.'1(Iu,Business end Pmfeaaiau Code:)The Conlrwtar'a Li-
e a Low dreanmapply It,.. rofpmpmywhohuddxorira,Peithemm..6 QTY. PLUMBING PERMIT EE JUN 17
who,ontracu far wch pmjau with•contmctvr(s)Beamed pursuant w tie Camrenofs
Leave Taw' PERMIT ISSUANCE 1996
D I em cxcmp underlie. -.B A PC fee III, son (+111a
Owner Date ALTER-DRAIN A VFW-WATER(EA) vUtVALUATION
WORKER'SCOMPENSATIONDECLkRATION BACK FLOW PROTECT.DEVICE
I herebyalr uMer pemlty of perjury role of th followingdeclaatirms: _
❑ Ihave aal will common o Cmificae ofCommnt to self-more for Wakeh Canpen- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPECONSTRUCTION
solar,a povidul for by Secr on J]W of the lobar Cale.Tor the pa fvrtwes M the ,
work For which Nie pcmrit lx i..a& FIXTURES-PER TRAP
❑ 1 loco,mM.ill maintain WorkeO,Compensuiat Ins.,m tryulrel by Senior
3]I ftleeklrbar CCetpdgc.yfm�lJM1vewp{cprraryrt�wt rpz�(tf Pte wink rm whkb.nttl PolicyJt�his pemtit i.ieeced. GAS-EA.SYSTEM-I INC.4 OIITLEI'S OCC.GROUP APN
CemicrWork` ul"Q"tfYly� U1C161 oy No.; R GAS-HA.SYSTEM OVER 4(IA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEZINDU4fRl.WASfP LNTERCI l`Toit
Thi seaim need nm hecmrpnedd he permit a for me hunm,di&II n($IN)) BUILDING DIVISION FEES
m ) GREASE TRAP
1 ttnifY mat in the icrfmnertceof the wtnk far wM1ich els M,ANCHECK HE
pe Workiesued.IshWl SEWER-SANITARY-STORM EA.IW PIC
rot employ any pnvrn in any manner w ue to h<otrc wbjecr to the Wakm'Camprn. ENERGY FEE
O z I.Litt o(Califanie.Date WATER HEATER WN2VDELECIR
Z O Applicant GRADING FEE
N NOTICE, bj APP LICANT:If,Carr making his Certifleam of Esabor oo)w hould
n,t WATER SYSIE.WIREATING
a ; become acomp y it Worker Compeor tio, atmit tors tr the Inbar Calc,You moot SOILS FEE
aQ forthwith comply with such provisions or to,pmnit stlill be dccmM rtvokW. WATER SERVICE.
:Dz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.ET. PAID
U O Iheal,emrm tM1u there iso...i. for the Perfwnlmlaaf Dae Rev<iqx
F" the wont!ar whkh thi+pe.I iv ioned(See.9097,Civ.CJ
OL,acele Neuse TOTAL:
{DLI 1<Mn'a Atltlresa TOTAL:
gy I etrtify lhm I have marl this application and anteth t the above iaC.ion is BUILDING FEE
y mnectl agree m campy with all cry and cowry cordm tm aw oatle law,relmag on QTY. MECHANICAL PERMIT FEE
V Z building consourtitn,erd berety emhorim tepresntetivo of Itis city to enter cpm the SEISMIC HE
aMve-mentinnm pwpeny lar ivpacoco purpeea.
(Wq agree to uve.iwemrJ(y anti keep handeu the City n(Cuprdim ageing PERMITISSUANCE IiLECTRIC FF.E
Iiebilities,juJgmemF
in of theggrantrow ing M this permit.and apeva which may in any way moue egainv.viJ Cry ALTER OR ADD TO MECH.
cmrcqucnrc PLUMBING HE
APPLICANT I,1NDERSTkNDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,M)CFM)
UR�G.I G A MECHANICAL.FET:
+(/f�/L/•�'�� 6-t`1-9b AIR HANDLING UNIT(OVER IO,(Np CFM) CONSTRUCTION TAX
Slgnaor, ranl/Cmaxta Date EXUCO
EXHAUST HOOD(W/DHOUSINGMITIGATION FEE
t HAZARDOUS MATERIALS DISCLOSURE.
Will to applicant a Lot bu"ng accopent store or barWle berardous mavial HEATING UNIT(TO 100,000 BTI)
u defird by IM Cupertino Municipal Coale.Cheper 9,12,amt the Health ural Solely
Code,Section 25513(.)] HEATING UND'(OVER 100,000 BTU)
❑Vas ❑No VENILLAUON FAN(SINGLE RFSID) PAID
Date Receipt
Will dre applicant m furore budding ineby the B y A ea Airnem or rlcvica which BOILER-COMP CUP OR 100,000 BTU)
.emit M1vudws e'v cmtamiranu m defird by the Bay Area Air QualilY Management
DiTOTAL:
/ sttictYtt ❑No BOILER-COMP(OVER 10O. irru)
Iluverul We Maerdvu mareriela rtyuimrcnea tvtder t]tapm 6.95 Mthe Gli- AIR CONDITIONER
ISSUANCE DATE
I. II®IN&Safely CWe,Section s 25505,255 iJ'25 34 tuakrxanJ IMI if tlw NEW RESIDEN DAL MECH. SQ.F1'.
ouiwng doesnora,nnalyhove ateam,theit ismyresof.C'i0ty Ite,of the rccupwt
of dre rtquirerrreou which muv be mn pia to issuance of a CmlOawe of IJccupercy. - '
Owns m au0wnaed agent Dae ISSUED BY:
OFFICE