29624 APPLICANTTO FILL IN INFORMATION WTI-HIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT N(Y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29624
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
x1543 FA�kt �lea� 4.�t gJ,a z S �
OWNER'S NAM& P ONCpt�nACfO 'S NAME LIC NO:
-
�"1cEJi.• rFSJsJl,poi`s4� 9`t{.-,3Lo WA 2c� uJS2oownsIJP . N/C CONTROL,
•4RCHITECf/ENGINEER: L NO: ADDRESS ❑
%� kz>. AJz.SAoJlsrooQ..
CUnf.AC. PHONE!: IJ11 ( BUILDING PERMIT INFO
Consuft.Vt Fees P by A 1 cant(IpW M) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby of rop dl.l I am licc,�d rider icons ms of ChWc 9(cmmnetxiag JOB DESCRIPTION
w0Z with Scclioi700B)of Dlvidoe J Mlhc Buurc.aW ProfeWVr,Col,and my liccne is RESIDENTIAL,
H O in full force°�vJ(gf PERMIT'ISSUANCE
�F-U� license CFsfrs — eO'� LIc.0 (A�i3Q SFDWL ❑KITCHEN REMODEL
NzW Uuc 9• —Canuann J APPLIANCES-RESIUENTLIL ADDITION ❑PLUMBINGREPIPE
I,•Oy ARCIIITECI•$DF.CI.ARATION k PANELS - OMULTI-UNIT STRUMRAL
Z O�j 2s1 undcruorxl Iny plans shell he mad ni public records MODIFICATION
OZ-0 UPT0 2W AMP5
F=I:In Ltnrunl Pmfeairoa ❑INTERIOR ❑CHIMNEY REPAIR'
2(11-1000 AMPS IMPROVEMENT
4y •'j OWNER-BUILDER DECLARATION OVER IIXXIAMPS
, -1ON
BATH REMODEUREPA1R DEM1f01
L O 6 1 hcrehy affirm Ihel 1 am exempt frontNc 0,on.lor's License Law for the �p yp
x�OaU fdlowbtg rtasas(Scction 70315,Basircu and Pmfa.imb Cork:MY city of many SIGNS ELECTRICAL DOTTER
DI LLO♦an which neeNira a perndt to consbuct,a1w,improve,hntulisb,m rcTvrt ry nmmme
F•_rn�l pnortoit..... c'dw rtyuir,x the epplieam forvuch pcorlilm filca eignm ywemcnl SPECIAL CIRCUIT/MISC.
f y than he i,liecnred puniwet to the pruvisiwu of the Cant u&t Ll.roc U.(Chapkr9
0O (caiiw,etring with Scuvn)Yp0)of DivisionJnf the Busircssard Ptnfasimu Codc)n TU IP.METER OR POLE INST. COMMA
d d ButIc is exempt tMefram end the basis for ft dkged cacmpitm.Any violation iR
'4�'N Scelinn TUJ LS by my upplicanl L.r a prmil vubyvra the appkom w v civil penally ul ❑NEW BLDG/ADDITION C]DEMOLITION
POWER DEVICES
n trop Brun five Nrulml dollen(53!101. ' ❑TENANT ❑FOODSERVICE
FZi• "' IMPRONTMENT
QOLuowork,lheprvpcnYrr i, employees withwagauoeirsol,7 tot, SWIMMING POOL ELECTRIC '-
yfZO will do the work,udnhc mucwrtis rxx imcNcd moDcmd for We(.Se<.'I(WI�".qusinc,s ❑OTHER
aand I'rofis,ion,Cade:The C...lmnor's License La.dm.ria apply to vt owrcr M I'll I Lti I'S-SWITCHES-FIXTURES.
+w y who Mtndr or inn,i ovca tictew.and wlw dm ueh work Nonsclf«thw611
his onion empoyect,pr'i that each impovenrlena ve en inteNN or W rod for NEW RESIDEN'HAL ELECTR SQ FT.
ealc If,however,the Wittingmimprovemrntk sold within one,earufcompluioq Ble SQ FT.FLOOR AREA vSQ,ET,
rcr-W ildcr will bavc de burden of paving tMr le did M W id or irol for pur-
pue of role.). Q
❑I,ss awrcr of de propmty,am exclusimy cnnaamdg with lic"n,cd comramiin to TOTAL ys�
ino.tlr pojcn(Sec.I1bd,B.,iress end Profnsionr,Cod,)TTo Corr.,,r,Li-
roL,wdrc,nnePyly monowrcr of pnp"ny who Wild_<err itttpmvn fl m.m,e,ta QTY. PLUM NG PERMIT FEE
wW cormxts fm such pojccrs with•cox n tre(s)licrosal Nrounu to the Cmurectoes
F7 Uw. PERMITISSUANCE,
❑ Lem exemp unMr Sec. ,HRr i'C lonM1ixmawn
ALTER %(EAI VALUATION
Dwm Doo / D eco
WORKERS COMPENSATION DECLARATION BACK FLOW PRO - UEVI
pE
--// Ilcrtby affimt uiakr penally of Perjury ane of the following ikdutuiimr
�IFuve and will maintain a Cerifxue of Consent ton aclLinsum for Worker'r Conipen- DRAINS-BOOR. F FA.CO y-� TYPE CONSTRUCTION
.cion,u provided fm by Sermon 3'700 of the Isbor Code,for the,cof c of the
Srm which thin permit k iumd. FIXTURES-PER TRAP
have amt 1111 maintain Worker',Contpe.1mir I.i,.¢r rtyuineJ by S ljc,t
3100oftheU Cctic.fm tic pefmmtce dtic wmk for which dik pcmit u is GAS-EA.SYSTEh1-I INC.40 CCC.GROUP. APN
My Wo sawn ric--Po,,,,
m eM Policy qyy
Camen. .fir. n iM • iblky No.', TDO�lB24e. GAS-EA.SY.SEM OVER a(IA)
CERTFICATE(11'FXE 1Pf10N FROM WORKERS'
COMPENSATION INSURANCE GRCASFIINDUSTRL WASTE INTERCEPTOR
flbia ter.rlcai nut be compkted iftle permit i.fm me W ndred doll—(5 tBD) BUILDING DIVISION FEES
or Icor) GREASETRAP PI.WCHECK ME
od employtoy tury thpea!xortthin
e apnMy omaainmnrcnesoo fmtheto becmfmrc wwhbljerhcrti dto
o PtheermWiotoisti n'Cr .mI,p,r.
SEWER-SANITARY-STORM G.301 FT
ENERGY FEB.
OZ ,anion Uws of Califomie.Doc, WA HIR I]HAT_ER WNEND/ELF,C1'R
/
O Applicant - GRADING FEE
t•%j NOTICE TO APPLICANT:If.after making talo Ccoifcuc of Eaciril you.hould WATER SYSEMiTRFATING
bccorn,mb}wv to lK Wnkcfs Compc"cation two,isions of otc UWr Codc,you nnw SODS FEE
W forthwith comply with wch pmvi,ions or thio coorl hall he deemed mvokd.
WAGER SERVICE ,
Q
CONSTRUCTION LENDING AGENCY
7Z NEW RESIDFMIALPfJ.1B. SQ.FT. PAID
U 0 IbercbY affirm shat tbae i.aawnrttnim lrnding agercYfm Oo pxfmsnatte n( Delc RecciPt♦
.w F tic wort for which th'il pen"iLise'd(sec.3(M.Civ.C.)
O U Urdcf. no !>•U J C 'DOTAL
[t1 Isrilcr's Addnus TOTAL
FIZ 1 certify thw I have«ad Thi,appficellon eM state that the above infirm boo is BUILDING FEE
V) cu ti.1 eRrtc to comply with rill city and county adiwrea and smla lows rtluins to QTY MECHANICAL PERMIT FEE
UZ building m"wuciio",and beneby outWrizc mpowrodivci of this city to ewer upon to, SEISMIC PER ,
�' above-neaionMpvpmty forinspnicn loco,a PERMIT ISSUANCE Ag
(Wc),ju epee m save,Irld c,i,y erd keep M1w in.the City of Cupcnimi agdny ELECTRIC D?N. -7
tocrities,judgmm�c.,n.ti.,.f thin eswhlch may inany wvy setae ugeinuliuid Ciry ALTERORADDTOMECH.
to rnnsegecnc of dlc granting of Chir permit. PLUMBING FEE
APPLICANT UNDERSTAND. AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TD 10,!1(11)CFM)
SOURCE REGULATIONS ,MECHANICAL PEE
�� C aY •�l �b AIR HANDLING UNIT IB,BBB CFM) CONSTRUCTION TAX
StlWmnc of AppionVCmtren« a•l DS eteL IXHAUST HOOD(WNUCH HOUSING MITIGATION FEE HA9ARDOUS MATERIALS DISCLOSURE
Will thc.,ld .lorfuwre Wildiegaccupantstortorhemllc Mxardaus ouncoil HGTING UNIT(TO IW.000 BTU)
u deftncl by the Cupertino hlunkipal Cade,Cluper 9.12•atnd the Hdth and Sefmy ,
Ili Code,Section 8532(0? / HEATING UNIT(OVER I(i BTU)
VENTILATION FAN(SINGLE RESIT) PAID
Will Ik.pplican or notion,Wilding i cowl use cyuipmew k dcsicea wbich NTY 0,f LiL rC.tlirci h.'le 1u
emit ltmmdmr air conumiilanta a+defnd by tle Bey Ams Air Qaalay Minn e,c., BOILER-COMP(311POR 100,00(1BTU)
Disldclt / 'TOTAL:
BOILER-COMP(OVER 100,0E[l BTU)
j 1 neve nein the hole .Inial,rt uircnceu unkr Chi of Cdi. AIR CONDITIONER
y My ISSUANCE DATE
forme Health k Sefery Code Seclttms 25303,8333 am185Jd.1 udnsocudtitod Thu if tle NEW RFSIDIIlITAL MECH. SQ.FT.
a ikc o"ILl n c rendY Imvn, Ynea.Cc irre reify tie aavPen
N do rapd wbe ntor ort iaslurce McCmiOcu of
OwntmmauWirirN agrnt
D. TOTAL: ISSUED BY:
OFFICE