31464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /I64
/I
BUILDING DIVISION APPIACATION/PFRNUT PLUMBING.MecnANICAL 314
BUILDING PROJECT IDENTIFICATION til
flU1LDING ADDRESS: SANITARY NO APPLICATION SUBMITPAL DATE
P/f712J C�
OW R'S NAME:
i"r :
-371v i,rr; E"��fPEPLUMBER ��4 e CON RDI..
RCHM!C`UI INFER: LIC NO: qp
i
CONfACI': PHONE: K)�SF�, CA 9511BUILDING PERMIT INFO
(IAS7111u11�Fees Paid by Applicant(Initial) BLDG ELECT Uh MELD
LICENSED CONTRACTORS DECLARATION - ❑ ❑ ❑
1 hereby eff [,at 1.m limnni time transitionsof Chupc 9(cmtrscttci QTY ELECTRIC PERMIT FEE
nT JOB DESCRIPTION
IDCZ withll oiteimil )m(Diviaim JMth<B.,m.x.nd Pmra.imu Cis,e,en mylirrvei. RESIDENTIAL
F W O u full fac<.ml eJ�ep PERMR ISSUANCE
tVR tiacve Clan L.J/yzx Con. ?71 F1 ADDITION
❑KRCHEN RE-P EL
,uw Omc fie.rJ:7�L! Caumctnr APPLIANCES-RCSIOEMOAL ❑ADDI770N ❑PLUMBING REMODEL
1„.>v1y ARCIIDECTS DE TION PANES ❑MULTI-UNIT ❑STRUCTURAL.
02%1' run de, mwralur
myple .hbeupat rcmcu .MODIFICATION
r^Fq,O Lkemcd Proreatonal UPTO 30(lAMPS ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION IBI-I(KIIAMPS 11PROVEMFM
yryCC Iy�•�6� I hereby.ff.Bw I w excmp from Ne Cmtr.ctoe,License law fa Ne OVER 1810 AMPS ATH REMODEVRFPAIR DEM ,fT10N
>(3Lu fdlnwing treson.(Section]0115,Busioccr aM Mnlcainm Cak:My city nr munty SIGNS EhECBICAL CAT
4417 O{'T whkb requlm.permit to cmurvcl.Iter,improve,drnnlirh,m reptir mY atnrcove
Aria to it.iuwn'e,also taryirn din epplicam(or sixh permit to file a uynd Wlcment SPECIAL CIRCUIT/MISC.
that he is lien e l pusuam to the provisiau of the Conteamofs License law fCnepty 9
00 (aarmnrrrctng with Sstim]00(B oflXriaim Jnf Nc BuirmWPro(etiwa Cmc)m TEMP.METER OR POIE INST COMMERCIAL
that he is exempt therefrom end the tusis for Nc allege)excmpt'a.,.Any violation of ❑NEW BLMADDTTION ❑DEMOLITION
iLLCI 4y Seetim 703"by my.pplicant for a peanut subjects the applicant to a civil petulty M PUATR DEVICES � 7NANT El FOOD SERVICE
not more Nm fisc humral dollar.(SSIXB.
�Q ❑I,uvwa<Udr pnperty,amY emPbYca with waaeudrir Wecurmpcwtim. SWIMMING POOL ELECTRIC IMPROVEMENT
will clothe week,am dsar ,toe,is M iner,clm aof(erd Rusale(See.](WL Btuinems t COTHER
a .m I'rufeniau Cmc:Thr Connscle"a Lcmuc Isw does mm apply to.n owner of OUTLETS-SWITCHIS-FLXTURFS
his own wm baud:a intlnom thoacara ,r who done,n cat himself« Bu<uSM1
his own emPloyaa;pmvMm than such impnrvemcmn ere not intcmal or oRcrm for NEN'RESIDENTIAL EI.ECTR SO FT. F�F1,pp R1,A
ulc lf.mwerer.the,building or improvement is add wthw oa ye ,fmmpfii,dr SQ. F) /•S 1 � SISQ,FT
mer-builder will have 0e buNat of pficO,that he did rut build or improve for pm- t' N
pose of sale.).
E 1,ea owner or be property,am exelceo,ely coinruning with licauai contractors to TOTAL:
emorri Br fw*d(See.]84,.Busiaa..nd Profariaw Cme,Thr Gt.timet<:.U. DEC 16 1996
cem.e Law clan M apply to an owner N Pra mm,who Wilds or mo hese tbismoo," QTY, PLUMBING PERMIT FEE
who contracts for wsh pnjma wan.a n.,oris)licemam N....athe Cootnctora
L ee.l-aw.
❑I em excmp timer Sec. ,B&P C for this reason PFJIMRISSUANCE CI I Y Ur .,urr n l"lu
Owar Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
�IWOR KER'S COMPENSATION DECLARATION BACK FLT. IC
OW PROTECT DEVE r
I herel'yefirm urdn'nalty of erjury exsor thc folbwing Orclveiom:
❑Iluvc.mwlltramam eCatihewe ofC,auetmslf-Inure fm Wwkeh Cvmlrn- DRAINS-FLOOR,ROOFARTiACOND.
satim,u pi,vidN for by tiortim 3700 of the Isom Corte,for the perfonrenx ache - STORIES TYPE CONSTRUCTION
for which Nia pami.u iuuM FIXTURES-PER TRAP
w I hove am will maintain Wakels Cmtpenwtiun Inwmms,as squirm by Section
J of /yr Cuk,fa Jr c."
u"Nfict("poo,ia.atai GAS-EA.SYSTEM-1 INC.4 O(M- S OCC GROUP APN
r My Work 6•t ^m.P�L arria.nd Polk \(Lr •M
Cartier. Y�` Policy Nu.. GAS-EA.SYSTEM-0VER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPDIR BUILDING DIVISION FEES
CITU setim nml oat bec»mpleted if the Parini,u for ane W coral ddlau(SIM)
a tea) GRP.ASETRAP
YLANCfiECK FEE
lemony Nato the paf<mursenl the wakfa whijeois pmWalkessum,INalSEWER-SANITARY-STORM EA.200 FT.
cork emgloY.nY person unsay nuette or u to Ircvrrre subjct to dr Wakrni Comm-- ENERGY FEF:
Z nan a.of Cnldomiu.Dote O
� tioL . WATPRf{EATFA W/VENT/H.ECIR / GRADING FEE
O Applicant
Vj NOTICE TD A JCAM':If.after mating Nir Certificate of Exemption,ymM
nvtMl • WATER SY.SIFJd/I1tEA'fING
F becroce, t .to the Warkels C r pro,himu of the Labor Cale,youoi
most SOILS FEE
Q
forthwith comply with etch Proem.or Nis Pmnit.ball be deemed swkm. WAI`1R SERVICE
ow
7Z CONSBUCIONIENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
U O Ihaeby arum Nat ihuei.awnetrumitm lendin�vgcaYfa the perRrmtirwe ur Date Recap#
G. the work fa whiaN NH Permit is iasuecl(Sec.3097,Civ,C.)
01 I<odeY1 Nates r TOTAL
V L-mlcr"Ack] TOTAL
�" y I ani(Y the 1 have ted thin ytplicafion.nd state Nu Ne above iefom.tim u BUILDING PER
(ncatect,I agree to comply with all city.m courtly im inmce,,ared state laws relating to QTY. MECHANICAL PERMIT FEE
LJ Z boildim6m eat nor m e b u hone pro nwi eafNucity toe pw dr SEISMICFEE
e Wvctamimm proper y for iupttYim purpm'a'. ,
(We)agra to uses irdnrtnify e,1 kcp hvmka the City M Cupemirio vgeiw PERMIT ISSUANCE ELECTRIC FEE
Ii Wilities.lWpans,.emexpemaes which may in any way rxmc.Sairist said City ALTERORADDTOMECIL
n cor atel of'he gestin,of Nia permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND W"COMPLY WITH ALL NON-POINT qIR HANDLING UNIT TO10,000 CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNTT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatmc of AppliannC,immmr Uam EXHAUST HOOD(WMUCr) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future Wilding occupom stere or Vi h.,.rdrus material HEATING UNIT CM lyf"HM)
u defiant by the Cupmttho Mueicipal Cate,CMI,9.12 erW Ne Health em Safny
Cod,.Swim 255740? HEATING UNIT(OVER 1(10,(1110 BTU)
F]Yea F-1 No
' VFNTIIATIONFAN(SINGLE RFSm) PAID
I
Will the applicant or future building o<etipanl are eyuipment tr deices which Date Receipt N
mvnd
it houa m
air ctamiamts as Rfce]l by the Bay Area w
Air Quality Mgttnem BOILER-COMP OHP OR PA."BTU)
�Diatfic,' IOTA
❑Ye E]No BOILER-COMP(OVER I W.DXI BTU)
I have rail the 6 tficI.15 mwcneh Chapter AIR CONEFTIONER ISSUANCE DATE
m,u 533 naoma 6.95 nl the if ra,
fami.Hu1N&Score Cucle.Sstimu 35505,235JJ and 255}1.I uedewrth ttmt if the NEW RESIDENTIAL MECH. SQ.IT
of
don rotcuwhich have atennitortl1 ismyeofa CilitymreofYth< ency.
Or dr rcyumrrrnb Which mw W net pram b isuurwc of a Crnif.:we olOaulsmry.
Ownerarau0mrpla.ent Dote TOTAL ISSUED BY:
\\) OFFICE