30733 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL FERMITNO. 30733
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECUANICAL
BUILDING PROJECT IDP.NFIfICATION
BUILDINNGGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
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OW :R'S ME: I E n e C NT 4 'gN E C LIC NO:� 7 NIC CONTROL
C -�' 61 .t
ISI I�\kCHITEC i NGINEEk: LIC No: PD RESSSY ❑
S , l �4
CONTACT: PHONE: BUILDING PERMIT INFO
�9 I ` f-L���y ❑ consWlent Fxs Paid by Applicant(Wliel) Loc ELECT PLUMB mecx
o-rf' ❑ ❑ ❑
LICENSED CO ACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alrlm,mm I ma hcen.,al muRr pnnuioos of Llwpa 9lcnmmendne JOB DESCRIPTION
�gZ wiNSmtion7(XX))ofavL9ian3ofllellatincV"Itofevdau Cu udmylicevu is RESIDENTIAL
O r PERMIT ISSUANCE
�_ iaf face vN eff
ly F " v 1Jcg - ❑SFDM ❑KRCHFINRRE-PIPL
rnQ )am Gmuacl« APPIJANCES-RESIDI?Nf1A1. ❑ADDITION ❑PLUMBING RE-i'll'C
rF- RCH=S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z 1undcomrld m"Ituns.hall be ease.].public records MODIFICATION
OZ O UPTO200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
Liccoscd Pmfersimnal 20I-1000AMPS IMPROVEMENT -
OWNER-BUILOBk UBCLARATION OVER 1000AMPS ❑ TH REMODE AIR ❑DEMO ITIOR
Q 1 hereby elTrm that 1 am escarp form Ibe CoanntKa Liccnac Isw far Je ,1.
kOyU fdnming..(Scnit703i3.Busircu mW Rofcssiom Code:Any city m county SIGNS ELECTRICAL THER LfIJ� a �i.V Cy)//'j
3 Lwhich requites a permit m..ct,.her,improve,demolish,«repair any srucmm
O
g' priuna its Lnuarr,,ulv,reyuirer the nppicwl fmwch pemnion elevsi,mcd,rmment SPECIAL CIRCUILMISC, t �/
Then be is limedpw rasa to the pmviv«u M tn,Confordi s Liccnu Law lClewry J {- WIAL tkL✓S
COO (eammerlcing will Savion 7(100)a lTrision 3 oftbe Busimx and Pmfccrimls Code)or TEM P.METER OR POLE INST. COMMERCIAL
e ty IM1a he Is uttryu Nertfmm enJ the hair f«do vllcgM unrtpion_Any viulvtim of ❑NEW IILMADDITION -❑DEMOLITION-
tr. Satiun 903 L5 by any eppllcdnl G,ropem,it wM1j«tr the eppliwn menvil rynully of POWER DEVICES
' Zy nnlmorelhnnlivehunJredJalan(S5a11� ❑TUFAN'AO EAIFM )I ❑FOODSERVICE
�Oa O I.0 owurof the propeny,mmy cmplvym with cages as Noir sok rnngelcuiern, SWIMMING POOL ELECTRIC
will M the work,end ilr nrunme is nn imclW.l«Micrtd fa nate(Sec.7014.Businw ❑DTFiER
Gand Profcssinm CUM:To,CUntrmow'.Liam,Law d«s not apply m an owrcr ofcJUH,PTS-SW ITCIIIS-PIXTURIS
.. his. y why M1uilJa«,mprvvcs much improve..
who d«.a such wmk himself of ihmugh
his own ounc crcea,pmvfiri, then stah improvements arc oat amended m oRcrtd f« NEW RESIDENTIAL FLECfR SQ FT. p'�y���
uk.If.houerwidr,
havi P,burdn ofprormuwldwiid nmeyeuo improve fon.the SQ.FT. tl` i'a! SBQ.FT.
wna-hu w).will have Ih[burden of proving met he did not buil)«improve for pear-
Fl of arta.).
❑ Las ow�ruf Ne(Sec.7W4,
am e. ars,ad!c«amctint,with lkTo,Cmit xam', to TOTAL (J T
ec.ow.Lo 0elarojactpplyo card Bmcrof,andriy wh bra Code:)The c,thccmrs Li- JAN ? �C11
nselawa«x na apply to an owner of PrupmY who hilds or ilnpovcs lneR'011,and QTY. PLUMBING PERMIT FEC Ty L
whoam,Uw.vR,,mien pmic,t,wither contrastmfs)Iicencd Nourastlo the Combowmr'a CITY Vr w-LKfINV
Uceae faro. PERMIT ISSUANCE
❑lam cxcmp leader Ser. ,BkPCf«Ihia reasao
Owner Umc ALTFR-DRAIN&VENT-WATER(HA) .VALUATION
WORKER'S COMPENSATION DECLIRATION BACK FLOW PROTECL DEVICE /�/l,
1 hereby afErm umkr penally of pajwy one of the lollwing dalvari«u: LL/
•01haverad will maminina CerOfcate MCaucnno self-imumf«Workers Compen- DRAINS-F1.00R,ROOF.AREA,COND. STORIES 'TYPE C(1NSTRUCI'ION
tutirm,as pmvidctl for by S«lion 371X1 of the labor CWe,hx the r fnmmme of the
work for which this permit is uaucc. FIXTURES-PER TRAP
❑1 hove and will maintain Worker's Compensation humans,as requhcd by Smion
37W ofthelab«Crock,Ta the perfomurc,ofilr work f«which thispmnil is reamed, GAS-EA.SYSTEM-I INC.i OUTIJTS (KC.GROUP APN
M c"'. i Crgl,�nv_IinnI AA i nierPolcy NoYyn]u-mMyuaJi GAS-EA.SYSTEM-OVER a(EA) -
L {Fl 1111 PTION FROMWMITJtSal -13 �
COMPENSATION INSURANCE GRE.A!IMN'DUSTRL WASTE INTERCEPTOR
(This section«ed nm the,co nnewc!if the cmilt is for one hundred dollars(SIdid BUILDING DIVISION FEES
or k<r) GRI'ASE TRAP PLANCHECK FEE
1 certify that in de perhmorce ofthe wort for which this pavtit is ivwN,l"a"I
not employ any Perron u any bac wee wy¢.Tq the Wmkers'Can _ SEWER-SANITARY-STORM E.A.200 PT.
O Z .anon la,n,,fG lir.nie le 1 '-11 �� LNERGY FF£
��1� el is F WATER 11iAUHR WNG'1Xe1-17 R
z O Applievnl lJ>-i.� ' GRADING FEE
h NOTICE.TO APPLICANT:If,after making Nis Cemificete M Eaempdom y should WATER SY,STEINITREAIING
I—' ^ become subject to this,Workers Comprnsali it pmvivuu of Jc labor Code.you arms SOILS FEE
fanhwith comply with such pnniciora or Ibis permitmill be deemed revoked WATER SERVICE
Q'
CONSTRUCTION I£NDINOAGENCY NEW RESIDENTIAL P11.1 B. SQ.FC PAID
V0 work
which dead there iso dSeclionknligrncy fmthe perfmmuaz of Dme Raeipg
� ^ the w«k fm which this Inmit is ivucd(Ser.309],Cr,v.C.)
O ,,,,.rn Nemc TOTAL:
W .,Linda',Address TOTAL:
6. I scruffy tw I babe wast the,st,licromm and mart that the.hove infommtii, is OILDIN'G FEE
rn nmren.lagrtcmrnapy wiN dl dry ende„amy aJinallsa eM ume laws mlating e, QTY MECHANICAL PERMIT FEE
V buildingmnstrvctian,and hereby amlaidre repmvntufives ofthis city to enter upon the SEISMIC FEB
above-mcntiv«J grit for inapcctimn pm,Aa,. PERMIT ISSUANCE
(Ws)agree m save,iMctalify W keep ministers;Jac City M Cm,crtita against ELECTRIC FEE
isbilitics.jud,mrrt,coms mrd eapean which nay in any way acerae agamstvW Cita ALTER OR ADD TOMECH.
in on"t.a.e of the grunting of Thu permil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE ,GIJLATI AIR HANDLING UNIT"10.000 CFMI MECHANICALFF£
- -
//VIV//A AIR IIANULING UNIT(OVER 10,U)I CFAI) CONSTRUCTION TAX
S a lure of Appl'.a Cnm.aor Datc BXHAUST GOOD OVMUC i
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will Je applic/It on,(move baddingbecupmd sort or handle haard,ms matimil HEATING UNIT(TO I W.DD)BTU)
as Mhrled by be,Cuper-ama Municipal Curt,Chvplcf 9.12,and the Health std Safety
Code Section 25532(a)'f HEATING UNIT(OVER 1110,000 BTU) aeq
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAI/ �— 9V /7
Data Re,ciN0
Will the air cortin or future building rc i1rc,B y A a,Air Qu m devices which
emit herurdaeas sir comamlwnu u.Jenner]by the]fay Area,Air Quality Munagemenl BOILBR-COMI'(3HP UR IdU.WU BTU7 y
aOTA
�\ sWctf
❑Y,c []No BOILER-COMP(OVER 100."BTG)
1 hese,rraJ th, I
hvrnrdm.s retrnals AIR CONDITIONER
taTuirenenu under LTwplcrti.95nfP Cali- - IS ANCE DATE
forma Health&Safety Code,Sccdms 25505,25533 an125534.1 unknmrd then if pec
buildingdocs not donot cartnman
ly haveal .Ihw it is myu
tpmm mnsibilityntifydro,opeNEW RESIDENTIAL MECH. SQ.FT.
of de nyuarrems wbich mus he rnct pkrr to i.vwenc ofv Certificate of(kcur).
Owrcr or maborbted vg cm Date TOTAL LSSUEDBY:
OFFICE