30156 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE'SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, 30156
BUILDING DIVISION APPLICATIONIPERNUT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION'
BUILDIN�RESS SANITARY NO. APPLICATION SUBMITTAL BAD
OWN ;S NAME�94 � / PII[)N J� CU ALTOR:SNAM LIC NO:
Jr S (/L7 NIC COItfROL Y
RCHfILCUEA(UINEER: LIC NO: ADDREU
CONTACT: PHONE: 7 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BIJ)G Elt PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 hmby affirm Thr 1 on u,onsol under Movi.im.ofCpep,r 9(er r meneing JOB DPSCRI ION
Ia00Z wiNSeclkrn]t0111 of Diviurm3ofJe Bmirec..rd Nofa.ia,Conon,and my licennc is PERMIT ISSUANCE RESIDENTIAL
UU In�fdl force cRm 3fi UU Ixx I� ❑SFDWL ❑KITCHEN REMODEL
If AI'I'LIANCIiti-REST UINI'IAL
Za1 W Date � J CiNlmelor ❑ADDITION PLUMBING RE-PIPE
Fay
ARCHITECTS DECLARATION /✓ Ins PANELS OMULTI-UNIT ❑STRUCTURAL
OZV—n'Z Iundcrvevl mY Pluu ilWlhuneJmpublic recaNn UP'li)2fX1AMPS MODIFICATION
c VJ-'R� I.icmud Pmfatianl ❑INTERIOR ❑CHIMNEY REPAIR
gx�- OWNER-BUIIJ)E DECLARATION JB1-I(OOAMPS IMPROVEMENT
❑�=Q 1 hereby affirm Ih•t I of exempt Boothe Cmischrra Lict ase Lew for the OVER I000AMPS ❑BATH REMOl E�lljs❑DEMOLITION
x 3 G.F trAwwing reuxiro.(Sa+lm 7031.5.Budneu and Prufmma,Coda:Any easy m oram, SIGNS ELECTRICAL ❑OTHER e/'r/r�P
4F LL O to whch Ieyuira a permit 0 mmant t.filer.uyrtove,dermli h,or retain any wixwrt �O I, G
yg pn«mion imuerce,dw us,l Ne agrlicenr for ouch pemduo rile a signed mommm SPECIAL CIRCUUDMISC.
vWvW11Y Nds he is nomaci ponuummthe pmvisinnn of the Cnnlmnm'n Loans,Law(CTapto9
aGO� (mmmmcing with Secdm]0f0)of lhvim 5iSof lhetaand Buls Pmfemiara CUJe)on TEMP.METER OR POLE INST. COMMERCIAL
a E eC Nm he u eaemq therefrom Wnot,psis f«Ne allegd acmpti^n.Any vioWion of
LL S¢tion T)3136 my applirdsu f«a oNt wFjccln Nc epplicent luacisil ❑NEWRLDG/ADDITION ❑FOODS TON
RVI
Y a penally of POWER DEVICES IMPROV ❑FOODSERVICE
F_Z_mY
one moee than five huNrttl Nrlluu(gNlO). IMPROVEMENT
6 0Lmowncr^fthc pmpeny.rr myrstim cert N.ffeemufien rule co .Buss ion. SWIMMING POOL ELECTRIC
pf�� will doth W.C. -le o, une ismllnlcdd«oa, to for sal.,,, nI an
C1 OTHER
LLl mad bt,sit. CukL Tic Cas,ther aUccmoluesfire.nmapplymlf owner of OVI'IJ?fS-SWRCHF_S-FIXTURES
p'o,so who bunny or Impiovea Nercon,and who Jon such work himclf m Nwugh
his own tmrser.h,provided Thar such improveoamu th bar iye,vr d or offered f« NEW RFSIUIl.'TIAL GIJ:CIR 50 FT.
baiter buil -rwill have the loo iminvvcmcm Bi mill did n tbiarofcon,ve for lh SO.FI'.FLUOR AREA S/Sf].FT.
baiter will have the buNcn o(pmving N➢I h did nasi build«impmrc for pur-
pmt of ale.).
I,uowner of the(firSon.
7( amexclusively ginfir-ng wishfThi,CcmudoorI .- TOTAL;
eense La Nees mel(.Sic.]Ily to an wn,Ba,r ofa nal ty who
buts d,or i The Cunhereon,Li-
n«luwdoaevo oppmeannwner om aorywhbssej too imam the Ccrcm,vml QTY. PLUMBING PERMIT FEE
who cmaxu f«such projav wish.conwnor[a)luenscd plmuem ro th Cmaamo/a
IJttme Law. PERMIT ISSUANCE
❑ I emamnpt under Sec. ,B&PC f«this rtaan
Owmr Dolc ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby affirm ludas penalty of perjury ante of the following JaWrcdcmx.
❑Ihavead soil mainuine Crnirimm ofComatlobaB-inure fmµ'urkeh Cvmpeo DRAINS-FL(%)R,ROOF AREA,COND,
union.u pm.idd for by Sstim 3]0(1 of the Labor Code,for the pemmmsnc,e of Its, STORIFS TYPE CONSTRUCTION
work f«which this ort,is roa ,. FlXTURFS-PER TRAP s
1 love and will maimaia kers worCoro en a m I umarlcs.m mryirnl by Saloon
3700oflle labor Code,(«fix find mnceofth workfor which this permit ie i.uud. GAS-EA SYSTEM-I INC.4 OUTLETS
OCC.GROUP APN
Ce rider. C^mpenwlion aum
Inneecamicrstdolic
Py numhraR:
Cartier. PaBCY No.: OAS-E.A.ST,STEA1-0VER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GRBASUINDUSTRLWASTF.INTI:RCIi
(Thinx boa no
bb] he,romplerd ifihpmnll U f-.-hoalnd Jollan ISI W) - BUILDING DIVISION FEES
of leans.)l eeGREASETRAP
PLANCHF,CK FEE
nifY tom in the perf«mentt ofrhewvk f«which lMs permit iniwrd.l ahWl SI?WIiR-
nnl cruPloy any pemm in any nlannm to SANITARY-S'I ORM FA.300 IT.
cI fie Workcrk Cmlptn- ENERGY FEE
Z .anion Lat"ofC
0 Applxalt t% }tkc�M1 o'I.c y ' µ'ATEA HFATIiR wNENDEI.ECIR , O
L 1 y p GRADINOFEE
Z y
NOTICE TOAPPLICAMier's;If. om,,rakition this CetioiWe of N..attour Cody uman WATFRSY.SIIJN/ TING ' - -
� ; ha'ons subjetl m 0e Watcr't Cnmpcn.balinn pmviainm of the tub,r Code.you Inuat SOILS HE
� .. foMwiN rnmplY with such pwvislauathie permit WilhdauN revokaL WATER SERVICE
Da ° UL 10 la4
7z CONSTRUCTION LENDING AGENCY' NF.W NESIDBNIIAL PhMB. SU.FT EAIU
V 0 1 bereby affirm than them ieacomwucdoo lerxling egmcy for de pMomlmtt of rll` Due kTgtpIII
D. rh wah for w ch thin pcmdl is iswnl(Sec.309].Civ.C.)
0 Lodds N. s' CUf Cf1111YV TOTN.:
Lent e,Achlo,, TO'f
0. 1 certify Bud 1 hese read Nis"motion and ands,than the Yro.e iof«mmim u BUILDING FEE
fn a .lyrettoc«nplywiNOicilynMcamtymLwtce sulclewamlenngm Qry, MECHANICAL PERMIT FEE.
V buildingcaulmmion,aml hcrthy nmhnnrc rtpracnmlivcx of this city m,mcr upm the SEISMIC FEE
above-mendmed popen,fir imapcnim purposes. PERMIT ISSUANCE
(WO a gree to bane,indemnify and kap ban %to City M Cupertim egaimn ELECTRIC FEE
IiaM1lluies,judgmenu.coneand deepans whkh may m my arty mane against sill Cry ALTER OR ADD TO MECH.
in nmacqucrccnf lhegromm'nfihi,permit. PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNLI TO 10,030 CISH
SOURC GUlf ATIONS.�� /�II MECHANICAL FEF,
�✓J//_ _ nT1.1 7— Jf1� AIR I IANDLINGUNUT OVER no,gq CFM) CONSTRUCTIONTAX
Siputme of App�m lh¢Y omit!/V I��NJ[Ul // /��I//� EXHAUST HOOD(WNUCq HOUSING MITIGATION FFD
HAZARDOUS MATERIALS DISCLOSURE
Will lhapplicantor future Wdcfim,aecupanl.Imc or hlmJlclwuJmr mmcrial BATING UNIT TO 100.000 BTU)
m defirld by the Cupertino,Municipal Code,Chn ter 9.12 and Use HaIN and Safuy
Code,Secdm M532(a)1 HEATING UNIT(OVER 100,000 BTU)
❑Ya ❑N^ 6
VENTILATION PAN(SINGLE RESID) PAID
wll th,applieuru or furore Wilding otmpam me equipment m devices which
emit hainrNes it cmlamimnt,in,defined by the Bay Area At,Qudily Menegemenl BOILER-COMP OHP OR 100,000 BTU)
UisncC TOTAL
❑Ya ON. BOILER-COMP(OVER 100.0I0BTU) . u
I have rad rW h...dnu Tnicrialx noprn eon under Chaloner 6.95 of the Crib AIR CONDITIONER ISSUANCE DATE
Tania HeaIN&Sefery Curie,Satiom 25505,25533 and 25534.1 unlaNard that Bthe NEW RESIDENTIAL MECH. Sp.FT.
Will rlgdoe,mon cmrendywrc•tm•" dlds it in mynmpmaibilu,on mrify he,mm W,
Mfie reyuimtenu whichmuv be andpas«to i.cwenc ofe Certif eof(ksupvney44,.
Oaxr«wBo,nad,germ Data TOTAL ISSUED BY:
OFFICE