29791 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BIIH.DING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERD1IT PLUMBING-MECHANICAL / 1
BUILDING PROJECT 979IDENTIFICATION L9/ 9
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
1�y2 ?44 u� <18,� (-t IA.%
NER:SNA _ PHONEi C'UNTRAC'IUR'S NAME: LIC NO:
NIC CONTROL,
ARCHIIIiCI'/ENGINEER: LIC NO: ADDRESS: . ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FI ECT PLUMB MECH
2K ❑ ❑ ❑
LICENSED CONTRACTOR'S DE0,ARAIION Q'I'Y ELECTRIC PERMIT TEE
I hertby eBirm that I an liamed aider Pmvisims M Charon 9lcot000erelc, JOB DESCRIPTION
OOZOwiN Section 7Wr Division 3 of Nness an
e Business Profession,Cade.ad my lic.is PERMIT ISSUANCE L
RESIDENTIA
to full farce and effna. ❑
ySFT)WL ❑KITCHEN REMODEL
U
UW Data Class-Iic.N
1
�QData—Can vxta APPLIANCES-RESIDCNIIAL ❑ADDRION ❑PLUMBING RE-PIPE
P,�rn ARCHITECTS DECLARATION PAN pLS ❑MULTI-UNIT ' ❑S'IRUCI'URAL
z p 7J. I undersmmi my plw shall Ne used es public recalls MODIFICATION
OZ O UPTO200AMFS ❑INTERIORUMNEY REPAIR
Limud Professional 201-IgX1AMP5 IMPROVEMENT
Y� DOWNER-BUILDER DITCLARATION
Pf 1 hereby Jfrm that l am exempt from the Contracmrs Liccusc Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
k 3 L U following realm.(Section 70313.Bun.and Prafsuoam Cris:Any airy or cwntY SIGNS ELECTRICAL 0OAR
lal a which rtyuirw a Permit m n,c,um ,alter,impnrve,denmli.h,a rated,any urvewre
��O pwrm iu isuun<,also rryuirtslhe apMica,n la such pexvurmfkosipmisuretnent SPECIALCIRCUR/MISC.
fE5Y INIkuBcemN pursuant to tk pmvisivnsof WeCmtranafx licrns<law(Clrepta9
W PJ 00y (canmrrcing wish Scctiun 7lXX))af Divisiun3aftk Nu,incss surd l'rofcsritm.Codd or TEMP METER OR POLEINSf. COMMERCIAL:
a e 4
but k in excmyt Jrrefmm and the basis for the alleged!escmptitn Any violation of ❑NEW BLED ADDITION ❑DEMOLITION
_1+•
Section 7031.5 by any applinm fa a fiscal subjects Jrc alai dant to a civil peruahy of POWER DEVICES
} u []TENANT ❑FOOD SERVICE
nnt Nan foe M1urbduls,, 53X).
L' IMPROVEMENT
f G I]Leauwmsnf the drapery,arm mar mucyea wiNwego av Nei ride c ,Btaires, SWIMMING POOL ELECTRIC
will d,Ne woh,and din,stnetmtis anti Liam,Law
vele(Sec.TNI,B of ❑QTHER
t�iT 3 utl Profewaru Code:TM Cwvecui,Liana Lew Jas eta apply to an axes,of OUTLETS-SWIT(2HES-FIXTURES
L hi,me,why wilds ear videll th Nmenn,and wlm dost each work hi di or of Brough -
W own etvployee.,Provided Nat such imp is sol w arc rot ineMM a dfnnl fa NEW RESIDENTIAL F.LECTR SQ FT.
owrc Lon"ever,do Wilding arimptmvrneni hat he dNinaeyeor improve Rw k SQ.FT.FLOOR AREA 55Q.Ff.
nwneof seildu will have the huNcn M moving Nat he did rat build or improve Da par- T
you sea sok).
❑I.aowar of Brepropeny,aBh,io,sisalymd contractingo,Es, ,Coda:icensad schounich.h.Cwbmatt&,L,- TOTAL s
nswntkes nor (sec.91141,Bueircas se, Rwhotne Co drJ'IMeamrnnurx Li- n^�
Genu taw rias mX appiymon owrcrof pmpeny who buildsaimpmva thnrnn.std Ql'Y. PLUMBING PERMIT FEE AP O
who .fasuch ri
such pmjecu uiNernurecnor(s)licen.iputwvnt toc Commix x Ff
licrnsc law.sumPERMIT ISSUANCE �X
I sexempt uals, ,B&P C or dais reasonC// l.... ���
Oemcr Data ALTER-DRAIN&VENT-WATER(EA) 'NAEUATIO�'
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hacby effort a pet ty of perjury me of rte following deals diom:
•Fl Ihavc std will mninuin eCcrtif roof Comenno ulGinsvre fa WakdaC mPcn- DRAINS-FLOOR,ROOF,AREA,COND. SfORIIS TYPE CONSI'RUCI'ION
.motion,us provided for by Nation 37M of tk lalwr CmL:,for Ne serfomucce of the
wort for which Nis pcmtit is iswcd. FIXTURES-PER TRAP
1 Mvc std will maimain Workers Compcnetion haureocc,is rtquired by Saction
3TXl of the lobe, c,for be a vice ofthework iLrwhkh this mmrir is ivwcd. GAS-EA.SYSTEM-IINC.JOUT1.EIF OCC.GROUP ANN
M
y rid s t 'sur surd Poli.,number eR:
v LLL r s /e 0.y NO.: GAS-EA,SYSIEMdOVERJ(G)
CEKIIFlC OMPE EXEMPTION FROM WORKIJIS'
COMPENSATION INSURANCE GRIASFIINDU.STRL WASTE INTERCIJ't'OR
fDri,section reed ren k completed iftk permit u faorc Wohned"Wit(Si m BUILDINGDIVISIONVM-
a less) GRIsASE TRAP PLANCHECK IEE
Isenlfy Nwin the pertiomena of do wmkfnr whish Nin lennit is lam M.Isbell SEWER-SANITARY-STORM EA.200 FT.
notcroony any pars set in say roomer w a,w rcubjec
bccorat to the Waken Courpen- ENERGY FEE
Z ution laws of Califoma De
zO Applicant WATER HEATER WNF.NT/ELI;CUt GRADING FEF.
aN NOTICE TO APPLICANT:If,otter mvkirrg Nh Cmtifcwe of Enemptiom You should WATER SYSIEMRREATING -
; Iseco e,subject to tk Workers ComPcruetim movis:ass of that,labor Cale,you must SOILS FEE
forthwith comply wiNsucM1 ro,mon-,Nie lwmml,hall he clamed mmrkcd. WATER SERVICE
a �
7 Z CONliisacns LENDING AGENCY NEW RESIDENTIAL PCMB. $Q.FT. PAID
V Ikrwhich But
Nettkmiseed(Scc.097,Cing agenry for the perfarreneeof Dam Receipt
Iks r rise wort for which this permit is i.cw d(Ss.7fN],Cie C.)
0 U Lertdr/s Name TOTAL
V Iamlefa Addres TOTAL_
yI verify Na 1 have read this aWictumn and smm Net de adi im ormaion ix BUILDING FEE
N cmmelagrse mcomply wiNWcity and many adinerca and awe hwartWing to QTy, MECHANICAL PERMIT FEE
LJ Z building aawnsation,and haeb,muncriae pm vutivu of Nis eitymrnterupnn Rio SEISMIC MEASP
aMvcncmianul property for inspaainn purpose..
PERMIT ISSUANCE
(W<)agues to save,iNcnmify ab tap hwmkv N,City of Cupenirw agvmt ELECTRIC FEE
linhi itiecs.judgmrnu,costa argil expema which may in any way Beams eg,inu said City
in con.ci of thegruming or this NomiL ALfliR OR ADD lD MECH. PLUMBING IU7.
AP LICANT UNDPRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SpLV,CE REGUL ON.
/ AIR HANDLING UNI'I'(OVER III,gXI CIM) CONSTRUCTION TAX
f (o
Si tortofApplicant/ arena lata EXHAUST HOOD(WNUCD HOUSING MITIGATION FEF,
I IAZARDf)US MATERI 1 S DISCL<SURE?
Will the supplicant or future building occupant more,or Swill.beurdwa material HEATING UNIT 00 Iq1,"HTC)
n hOved by the Caper iso Municipal Code,Champ 9.12 ami are HWN asd Serety
Cade,Section 25532(+1? HEATING UNIT(OVER 100.000 BTU)
❑Yes No -
( VENTILATION FAN(SINGLE RESOD) Dete Receipt#
Will the apmicart m fmurt building meopent use achi,cacnt a davicas which
:mit hmenlous air conteminann ex defrnd by the Bay Area Air Quality Managancnt BOII.ER-COMP CHPOR I WAXXI BTU)
Us
OTAL mnl
❑Yet BOILER-COMP(OVER 100.000 BTU)
U)
•
1 Mvc reed the,is M malarial` unlc Clat car 695 of the Cali- AIR CONDITIONER
ISSUANCE DAT'
r, fame Hre1N n Safety Code.Sedans 25303,153JJ eM 25511.1 odcmnrd thw if tk NEW RESIDENTIAL MECH. SQ.FT.
buildingNosetaawhich have.teem,doto ismyce ola eritycatasty tkraxvpmt -
arrkrtyairetanewnicnmetkmetprig to iaeaarraaacenifawe errflmop y.
Owtcr or horthrivcd an, hate 'DOTAL: ISSUED BY
OFFICE,