29717 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 97
BUILDING PROJECT IDENTDTCYUON 2L 117
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT)
05-7-7 Z^I L{.�
OWNER. E: ONE: CO ACT R'SNAMEE N
NIC CONIIIDLN
\RLTifIECr/BIJG NB R: LIC A DRE55: F
CON PHONE: BUILDING PERMIT INFO
OIJG8 3
ElCOB I u[F � 4y App OII[�}Ih II) BLDG ELECT PLUMB MECH
IJCP.NSM CONTRACfOR:S DECLA ON El El ❑
ffvm tom I....Ikon U ander por's,on, Chep¢r 9 Romnencin QTY ELECTRIC PERMIT FEE
I herrn
r^ c JOB DESCRIPTION
OWcZ wild Sadon]U'IU)of Division Butirca..n,d Pmfca Code, m"seen RESIDENTIAL-
I� full f«eeM crtar>i PCRAfIT ISSUANCE
�FU� U'er,e �2G--Lic.N ❑SFDWI. ❑1{JfCI{EN RP.MODIiI.
NQi Dan _1
APPLIANCES []ADDITION �f]t�\LUMBEJG RE PIPE
g-Ovi CfITIECPS DECIA PANELS ❑MULTI-UNIT El SIRUCIURAI.
Z Ov�g 1 uMcalwd my plant.hall he used ee puhih rt nrd. MODIFICATION
OZ=fp UP10300AMPS
Lie..d Pmfcsiarul ❑INTERIOR ❑CHIMNEY REPAIR(•N.E-wJ 1111-1010 AMPS
aye OWNER-BUILDER DECLARATION INTERIOR GT
aX c w a I hereby affirm IWt I am exempt fmm the Con,ador'a License Lew f«the OVER I0XIAMPS [I BATH RF_MOUEUREPAIR ❑DEMOLITION
ow
W 3 U folling..(Sermon 7031.5,Bminas and N fieso ms G4e:Any city«counySIGNS F,LECI'1IICAL ❑OTHER
LLl which"rira a permit m nora
me,,idle'Improve,Jm
enlirh.of"nor me .ours
LLO
Una hoiuiss„ance,dso rtquim llevivionenl f«uehpm.il wiecose grcduancmrn, SPECIALCIRCUIT/MI.SC.
;!Ia0
Una licemed Wrwan,node povi,kimofthe CrmlmclNi 6Pme I.r,Cr Per9
y�O lcomncrcing wile 5<rJnn]0X0 urDiviaiun3MtW Bu.ircssanJ Prafeuluns Gode)m TEMP.METER OR POLE)NST. COMMERCIAL:
t1 d e pL Iha he is exemµdocrefiven seat the bais fee ebe alkgcJ exemptiam.Any violation N []NEW BLDG/ADDITION ❑DEMOLITION
^,y Settiom 7031.5 by any applicant fora Pearn,sublems,b,eppncanl toe civil pc.I,of POWERDEVICIS ❑TENANT ❑FOOD SERVICE
E Z Y not more Than rive hundred dellen 1S5011.
Oa ❑I,mownmofdepnrpeny,ormyempbys widrwe mNeirsokmmpem i,i SWIMMING PDOLfifj7Q0C IMPROVEMFM
c will do the work.aM ted srumum is net inteMeJ«uRered finomle(.See.]IH4.Resines. ❑OTHER
M 52 and Pmfewiona Code:]Be Coon.ofa License U.dor nut Fply In w owner of OUTLETS-SW FS-
iL
propmY who huJda«impmvcs Ihvcmt,erd who Jou rush w«k hirmclf a,lvwgh
his awn empl,y provided,hat...h ina,normene ere not imer,kc)or offered f« NEW RESIDENTIAL E Q FT
sale.If.however,the buildingnrimp.,emerl is sold within ane ycuafcompleson,the SQ.FT.FLOOR AREA $6Q.FT.
awrceb,awill Woe drc b«okn seri proving tW,he dW no,build a impt.ve fm Pur- n
pose of ude)owner
pi
❑ kuowner je" Sec. y,am'Beadu "Pommeling wilt.)1,e Cconuv&. i- A1.
c«uwn do pojee,(S«.]PIS.Best.rad Pmfessioru Code:)The Cunuac,aYs Li-
erns,law dons no,apply to an owacT of proPer,y who hui I&or ln,ptove,mmmn,and QTY. PLUMBING PERMIT FEE � z7�
w W eonwctr Iso Toch prujaP with a[mvenor(s)IiansN pwauant to do CmuacuYf c
Lceme Car, PERMIT ISSUANCE �y �V
0 I am exempt torte,Sec. ,B k PC f«Nia resets (QL(J
Owrcr Due ALTER-DRAIN A VENT-WATER(EA) •a//rV VALUATION
WORKER;SCOMPPIJSA]TONDECI,ARATION BACK ROW PROTECT.DEVICE
1 hereby aRren unkr pered,of Penury orc M the forawing declar ri.mr,
•Q 1 Wve and will maintain Cenificem of Comerit to sel&in,ur,fa-Workcr'a Conren- DRAINS-FLOOR.ROOE AREA,COND, STORIES TYPE CONS]AUCIION
lin Baa provided f«by Semi«t J]00 o(tM L.Pr arta,for IM p.rfnm,arre of the
f«which thin permi,isivucd. FIXTURES-PER TRAP
w I Wve aM will maimain Worker's Canpen�,ion ImuevRe,sew required by Semon
J 0)ofthe LUMr Cede for fine pvrwnamc of the work tie soh kh Nis permit knotted, GAS-E\.SYSTW-I INC.d ODIUM OCC.GROUP APN+•
My W«k9 pcm Inwm eerier erd FHhy
Caerim..(, ' ' Pat y No. rt. GAS'-EA.SYSTI9N.OVER 4(EA) -
CERT f)F EXEMPTION FROM W RKIi
COMPENSATION INSURANCE GRFASEANDUSTRL WASTE INTERCEPTOR
Uhis�reed non be n endued if Bre puri,i.f«oTe hundred&Alm($100) BUILDING DIVISION FEES
or leu) GRFASE'rRAP PLANCHECK FEE
I-y the i.de tory manner
anras to o omewhi[htto the Wrkn'Co ,,r- SEWER-SANITARY-STORM EA.300Irf.
n«employ any person in ntry manrrer.v,sa to hmrrc subjm to the W«trn'Cnmlxm- ENERGY HE
O z .w,io.laws or Calborn,Dae WATER HEATER WNENTELECTR
Z 2 Appliunt O GRADING FEE
tzi NOTICE TO APPLICANT.If,after m,l in6 this Cenificme of Exemption,you d ,uld WATER SYSTESIaREATING
5 hes m,rubpr m the Worker'.Comp,n.w,ion,Mkiam of the labor Cod,you mut SOILS HE
D.1
forthwith comply wi,n such Pmvisi.sa an the permit shall be oke,red revMed, WATER SERVICE -
0
CONSTRUCTION isa UN LENDINGAGENCY NEW RESIDENTIAL PLNB. 50.FT. PAID
U O Il,m,by.fr t�tm,ir,Pmam[tion kNing,mt[r bar the,perr«n,ana of Dot,- Ra'eTq N .
� �-+ the work f«which this part,is iawN ISa.309],Civ.C.) .,
OU Lendeh Name
UOTAL
Lcnhr'r Adhcsv
1 eenify the,1 have rest]this eppl i,wian end uem ted,the above inform.6,i. BUILDING HE
to ceras.l agree msvmplywith all airy enul county«Jwrcu a«I nate U—nelming to QTY, MECHANICAL PERMIT FEE
U btnildingcmtwuIt rad lertby authar'vc re enoti,esof,hisehym entaupond,e SEISMIC HE
shove-mc - dprupmly for iry tinn'aa'.s. PERMIT ISSUANCE(Wc .gree t.save,indemnify send l:ecp hmoless the Ciry o f Cupcnim WI. PERMIT ME
liab0idcs,j dg.,,.e a aM capcves wltich may In anywayxttue,lum,t id Ci,y ALTERORADDTOMECH.
in rnnTry ne of the ming of this nLL PLUMBING IlE
APPLIC UNDE STANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,OW CTM)
SOUR E GUI AT )NS. MECHANICAL FEE
— AIR HANDLING UNIT(GVHR IU IXM)CPM) CON.STRUCTIONTAX-
Sigro, oa . Iran EXHAUSTHOODIW/DUCfJ
HAZAR; S AIA D?RIAI S DISCLOSURE HOUSING MTIIGATION HE
will the applicant or hunt,building acupent time«handle M1arardom ons ial HEATING UNIT(T(k I W."BTU)
as lefred by the Cupertino Mumapal CNe,Chvptm 9.13,and the Hrahh and Sefcty
Code,Sation 21534(.)] HIATTO UNIT(OVER 101,000 BTU)
❑Ye, ❑No VENTILATION FAN(SINGLE RPSID) PAID
Doc RaciN#
Will the applkmn«mrs a nuilding oycup.ntyAreq iir mit okvkcnemem BOILER-COMP CHP OR IM."BTU)
,mit,nonobese air caoumiruNx as dcrircd by Bre Bey Arca Air QuvBry Mmagcnem TOTAL
Us,ncl] BOILER-COMP(OVER 1110,0(X1 BTI)
❑Y" ❑No
Ih T&S
hc adau man AIRCONDITONER
requiren,cros uMcr pup,m 6 95 of the Celi� ISSUANCE DATE
ftmu 11 Code.Sant 3 I,1,25533 and 21514.1 urdvswd,hu if the NIiW RESIDEN IAL MECH. SQ.buiWi J yWvea„n ,the itumy ray.mihdirymnaifY de cavpen.fd,e q trt hi[ muu be ono i.'re. f CeniF,I I Drip ipancy. _
Ow Ww c aTOTAL ISSUED BY:
OFFICE