30154 APPLICANTTO
L I BUILDING
INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
TYOF CUPERT ELECTRICAL PERMIT Na.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30154
BUILDING PROJECT IDENTIFICATION
BUILDINGAUDRISS: SANITARY NO. APPLICATION SUBMITTAL DATE
l�3 F t e le L '7-4q 6
OWNf 'S NAME P O E COI A OR'g r E
'` �1 .4 - �` NIC , CONTROL#
%RCHITECH PFR: LIC NO: ADDRESS:
Ks-
CONTACT PHONE: BUILDING PERMIT INFO
rv':ss,s4 . ZI7 ❑ Consultant Fees Paid by Applicant HniHd) BLDG ELECT PLUMB MECH
LICENSED CONTRACTURS DECLARATION QTY ELECTRIC PERMIT TEE Was" ❑
1 I Iy afnnn mat 1 am ran-U order rovimor,or Ch,on,9(co mmcocing JOB DESCRIPTION
�
with Sution]1]00)of DlvHin 3 of the Busi.and Profwions Cdr ad my Hearne u� nfulI foae ad of PIRMIT ISSUANCE RESIDENTIAL
�UU Liam 'Cls Li<.x \� ❑SFDWL [I KITCHEN RE-P[PI.
I..Za y) gle Cwvaclu r�. APPLIANCES-RFSIDFMIAI, ❑ADDITION C3 PLUMBING RE-PIPE
g.7h ARCHITECTS DG TIO ❑MULTI-UNIT ❑STRUCTURAL
Z I undcawnd m Ica Nall be we0 as bli,Icc nL.' PANELS
OZ yp W UPTD 200 AMPS MODIFICATION
F sL u�i Isenum Pmfnsional ❑INTPRCR ❑CHIMNEY REPAIR
.] 2111-IM)AMPS IMPROVEMENT
OwNEno tolPR DECLARATION OVER IWOAMPS D BATH REMODEUREPAIR DDENOLMON
C)LL Q 1 hereby x(Drm 11.e.emPr fmm the Gnnlr.clC s LIcn.4 Isw for the
iy(�a V following mans..(Station tt ]OILS,Basirvas aid l d1stio li Code:Any city'.cwnty SIGNS T:IFCTRICAL ❑OTHER 1 1_. - ��
W 3 LL vFa's which requirta a it to ctinurucl.alltt,imprvve.IkmoluM1,w repair ony roucmrt S!kY�
Prlaml%iaslunce.alw laryinn the applicad for such pemdl to Ek•signed scale rrt SPECIAL CIRCUIT/MISC.
�y that Na is licnmd pulsionttotfe provisins of the Controcnr's L eanw Law(C],aPrtt 9
Mcon
�CO (nnmuncing wish Satlon]IXNII Cf Uivuin JuftheNnirt¢s and Rofeuions Cak)or TEM P.METER OR POLE INST. COMMERCIAL
d y m y Thu Ie is eaemp Ihaboal m and!de,basis fm cd the dlegc.acmpina Any violative of DNEW BLDG/ADDITION ❑DEMOLITION
uXl LL Section 70313 by any upplicwl for. iYiil,ohy,s,be a,icvnlm.civil pclarly of. POWER DEVICES
FZON., oat more than Its,humid dollar El TENANT El FOOD SERVICE
Q Dl,aaowoen of dr Fol on rry empoy.a with wages as Neil sole compenemion, SWIMMINGPOOLELECTRIC IMPROVEMENT
mm
will do the work,and the urucis as int d d or offend (Sl
o.orc(S .]IWi,Busircvs DOTHER
a rd Prof.iau Coda:Tie Corunc'ler"Liansc Law Jon not apply to an owntcr of OUTLETS—SWITCHFS—FIXTURES
d 3- pfopeny who builds a imgovn Ih4ae,ad who don wary work himself m through
his own ar,loyat,,pnrvidal was smh imtimvenoants on,.innoc on ofir l for NEW RESIDENTIAL ELECDt SQ EL
sale If,however.the baklins,,on orxnetu is"it withio ala:year ofconapletin,the SQ.FT.FLOOR AREA VISQ.IT.
vena-huikkr will have the bindcn o(pmving dui ht did ml build or imProve for For. GU 0
pas,a of sole.).
❑ 1,n owner of Ik tis scny,am esdusively nnwclin8 with Ilcensdl mnnxlon or TOTAL JUL O 9
calurvn do pmj,.(Sea.]DW.Rel and Pmfrnina Calc:)The Conuannr's V- •996 +
lo-
crisis,larcor m
e w da nutility an owner of propnny who builds or impel themm,ud QTY. PLUMBING PERMIT FEE
whoe.hoscls for teach Frejecit with.cuntr.clefs)licrnad plma.nl s9 the CrsmracluJa
CE Ur
rc l am until uMcr Sec. ,B&PC Son Ibis revon PERMIT ISSUAN �Urtnl)ryU
Owner Dom ALTER-DRAIN&VENT-WATER(EA) VALUATION
' WORKER S COMPENSATION DECIARATION BACK FLOW PROTECT.DEVICE
I bya(f urdcr penally of Penjory as;oflhe following JecYrations:
D DRAINS-FLUOR,RUMP.AREA.COND. STORIES TYPE CONSTRUCTION
.lion,se,povickd for by Salim 37M of We fall Code.for Ne Prrfomurce of tic
work for which this Pvmil is'.,...n. FIXTURES-PER TRAP
D 1 have aid will maintain Wader's Compcnwlion In.surnnce,m rcquimd by Scrim
3700ofthc labor Coda,falba rarfomlantcc of Re work fntwhich thispcmul is issuM GAS-EA.SYSTEM-1 INC.d OUTLETS
OCC.GROUP APN
my Weil Conlperwtian Insurance carrier ollPolity camber are:
Canicc Policy No.: GAS-G.SYSTEM OVER d(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPFIJSATION INSURANCE GRFASIMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ITFS
(This,athrn r.edr.R be nmlNndif Ne pcmlit it hn one hurWcJ dollns(SITU) GRPISE TRAP
or kss') PLANCHECK FEE
I eenify this,in rhe perfantanx oflhc work for which this omit is usaaL l draft SIIVBR-SANITARY-STORM IA.20II FT.
mm pmwm
ney ' y n �}y� orrc suAjar to the Workers'Cooapen- FE
Jy ENERGY E
Z O cation
ao f C 'f .♦♦ m M I`I WATER HEATER WATNT ELECTRA,lkGRADING FL+B
In NOTICETOAI'1'L ANT (Itt nwking this Ccniflcatc or Escrrlplion:ym stlwlJ WATER SYSTEM/IREKHNG
haeane sabjal to the Waders Crmpenwi®Provisions of Uc lab9r Coda.you ntns SOILS FEE
fonhwith can iy with such sol ciauo,do,Poolshall he deemed ncvokcd. WATER SERVICE -
a0
7z CONSTRUCTION LENDING AGENCY NEW RISIDENTIAI.PLN B. SQ.FT PAID
I for which
llml hlorrali issuauwe,IVO,tling.gcllry R.the perr9rmenre Cf Dam R M
�� IM cart for which this permiluiuud(See,IVO,Civ.C.1
F" landeYs Name
U 1 adcf'a Address TOTAL: TOTAL:
yI cnify bi I have read thu a,Tl ion i nd,Isle Owl the above infmnmsion is BUDDING FEE
N carnrcl.I agrte to cmnlRy worth all ally and coutgy antinarcn sd.we law nelwing m QTY. MECHANICAL PERMIT FEE
C„)IZ, Wilding cor.res, n,ural hereby euthoriee mpr ools—fdia city tocntcr upmlM1e SIJSMIC ITE
'ebco,n.tioned property for inspection purposes. PERMIT ISSUANCE
(We).gnce to mve,indeouufy aM keep harMen the Cly of Cupertino agdnss ELECTRIC FEF.
liubilitim,judl costs odespemea which nay in any w.y.ecrueagnino veld City ALTER O0.AT]U TO MECH.th con.)ucnaeo gwllirlgM this panus PLUMBING FEE
APPLICANT T d ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(KU CFM) _
OUR C REG .ATIONS. MECHANICAL ITE '
G A AIRHANDLINGUNT] VEA IB"CFM) CONSTRUCI]ONTAX
Signwm of Aptilic m noococ 1 1 Dale BXHAUSf HOODUKDUCT9 HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will fill ,fcantafummbudding arvWl urxe nrhadtiharanlous material HEATING UNIT(TO IOO,IUO BTU)
as defined by the Cupertino Municipal C dn.L)wper 9,12,'vd the Health and Story
Code,Seniors 15532(.)^ HEATING UNIT(OVER iM."BN)
oyes PAID
VENTILATION PAN(SINGLE RESID) Dam Reaip#
WII therdous applKnlaftuurt building ca,by umult llba Bay Ansa AirQnear litydill gmnt BOILER-COMP CHP OR IM.000 BTU)
hveNuas air cnntamivnls an dcfirod by the Ray Art.Air Quality Menagcmrns
ITsOrl'l TOTAL:
DYa 14 No BOILER-COMP(OVER IW.fUO BTU) ,
have rrml try Hmarrkws m"'•ruD resBoramns uoda AIR CONDITIONER ISSUANCE DATE
ChHtmr 6.Y5 of the if Ina
famin Health& fcry Clafe.Sarilms 23ha,it 25533 old 25511.L to on lartd that if de NEW RESIDENTIAL MECH. SQ.FT.
M1uild,,inlryggfpduuan I rraul'r,
havovtervutL until is my rnpnisihililymrrolify the arvlwu '
�ru'rnr airt i ;Ih rtn Riamivt�y�l Of/CasrifamcM Dly TOTAL:
ISSUED BY:
OFFICE