30276 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E.LEC7PRICAL PERMIT NO. 30276
BUILDING DIVISION APPLICATIOW/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNE ' `qCg;� Cj CONTRACT(1R'S NA LIC NO:
l/ NM CONTROL♦
'sRCHIMCL'IiNGINE-R: LIC NO: ADD ;;.S: - ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cooealtant Fee,Paid by Applicant(Initial) BfTL�DDG.. ELECT PLUMB MEECCHH
K R ❑ Q
L.mart IDn ficrIRA tmdct S DECLARATION QTY ELECTRIC PERMIT FEE
I heeeby eiDrm thu I ern Ikemed udm pmviaion of CTupter 9(cmnmeminn JOB DESCRIPTION
t 0O with section 7000)M Disisioo Jof De,HurineW it Pn renLms Cale,mid my license a PERMIT ISSUANCE R 9IF DENTIAS;
FF PoII fora otlJ cRst.
<UU License CasesLoc♦ ❑SFDW7. (]KITCHEN RFJHODFJ.
�j Duc Coomnw, APPLIANCES-RESIDENTIAL ❑ADDPPON ❑PLUMBING RE-PIPE
F=w ARCHHT,CPS UCCLARAUON PANELS ❑MULTI-UNIT El STRUCTURAL
ZOnz IunJmsnn
l my plana shot be used n public rmend. MODIFTCATION
oz— UPTO 300 AMPS
P 4 t•W UeemeJ professional (j INTERIOR ❑CHUTNEY REPAIR
30)-ILYXIAMPS IMPROVEMENT
Y OWNER-BUILDER m Ce Coon ON OVER I"AMI'S - ABATH REMODEUREPAIR Cl DEMOLIHON
C .J
ly 6 1 Mcby a(Emn mw I om enema from the Camera Ced Listen Low for the a CJ falbh ore siren.mmol tt 90710.Bnirvs sedt cle torn Calc:Aoy city attention, SIGNS ELECTRICAL F1 OTHER
"r LL 0 F• which rttryvu n 1'crnlo b avn%the, aIle(,impale.h permit
a,a sired awclurt
F� thimminisseence,ds.ni mme the,applinmfa sucCuol—mil Liococ Law(Ch.mcnm SPECIAL CIRCUIT/MISC.
00 y (helmets nwit punaonl lathe ofasomn3 NehicBus mf.ntponeLewlChogm9
(a""n'eciC1"n with Secdcm9UW)of Divuim3NNC Buri(recs vrW Rofcssim.Code)« TEM P.METERORPOLEINST. COMMERCIAL
a a Ow he,is eemq tlxrtfmm and tk hunts for the alleged cscmp,i Any GoWloo of ❑NEW BLDG/ADDITION ❑DEh10LITION
Q� Section 70313 by any epplican(far aTmmit wbects the awhican(to a civil prrvtahy of POWER DEVICES ❑TENANIC1 FOOD SERVICE
r ria more men Ere humbed dollars($50())I- IMPROVEMENT
Q O 1,as..or On popmy,«my employees with wenn u theu.sole canpcnsatim, SWIMMING POOL ELECTRIC y�F ❑��� will do be work,and me svuarure is no(intick d aoResed fm are, 7114,Business
u1 and Pmfessioru Cads:The Conme,es License taw Jan nm apt ro an rwne of OUITYTS-SWITCHES;-FLXTLRES
�- pmpcny who Insoles or improves Nertpm,and win div woh work himself or Ibmugh
his aempAd uc
ployes, ovlmal sh impronu em d offend for nor intended or fa NEW RESIDENTIAL ELECIIt SQ FT. '
use,If, the buildingaimgvvertmCis all within os yes ofcvtlWlcem.the SQ.FE FLOOR AR $tSQ.FT.
owner-Wilder will hove me burden M poling sen he did no(build a imptove I f«pre- k.4'
d ).
owner of the property,am encle,sely com icming with Ilmnscc crmradnm to TOTAL, JUL 2 9
c .1 9DW,BusinCade:)
ess erd Pro r. The Cmuvcmr's Li- 011
19gg
rowada a acts. qyt ma impose thereon,rod QTY, PLUMBING PERMIT FEE Wry
whncsansfowchp naw c mmm') c pinuem 1.Ne Crtm
mctor's /I U).
License❑ lam Lown Ss. ,B&PIC fa(his PERMIT ISSUANCE `Vrlf((fn,U
on IF— ALTER-DRAIN A VENT-WATER(G) VALUATION
ORKER'S SAUG 11CLARATION BACK FLOW OTECT.DEVICE
I hereby atTtm ands,pewdty of perjury one of Oe following declanation:
I]Ihesx erd will meintniea CcniOratc MConse�v n.elf-irutuc fm W«kda Cortgrn- DRAIN. R.ROOR AREA,COND.
wtim,n providd fa by Section 37)0 of the Lehr Code,rm the permm
fauof ILK STORIES TYPE CONSIRUCHON
work for which lits pirmi(is issued. FIXTURES-P AP
1 base and will meanain worker's Con)petnmim Insurance,n requird by Section
3900afthe lobar Cole.fathe perfrmurce ofttr wok f«which this pemut is uaud. GAS-FA.SY 1- c it owxS OCC.GROUP_ APN
My Worker's Csmpertwion Inawnna terrier erd Policy number tart:
Csmi Polity No.: GAS-PA.SYSI®0 4 )
CHRTIFICAI'H OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE GREASE/INDU.WR W INTERCEPTOR UfLDING DIVISION FEES
(Thissuliwr«xd nwt be compktd ostia permit is raorchuMr idnllan(SI001
or leu.) I GREASE TRAP 01� PL
N)HEXK FEE
Ianify Them in Ne q+fanwnre oflhc wnrk fns white this l is iewd,I Mall
nm employ anypmminenY mtanrnQwv(a humane wthe Wbject(o Or mkm'Canpen- SEWER-SANITARY-S'IORM BA.3 ENERGY FEE
Z sarin laws of Califooda.Doc
Z O A licent WATER HEATER WNE!,?T Y fR
pr GRADING FEB
to NOTICE bj ct to
Work is Cott meklnn thio Geniusof of E-urbOr oo;you umost Wgl'HR SYSTEMTtGT1NG
become subject y the Worker's Com s or this
n povi,shid of the Imedr Coke,you most SOILS FEE
(uNwiN comply with such provisions«thiapmnit shall be deemed rtrded. WATER SERVICE
aQ
Oz CONSreUCIIONLENDING AGENCY NEW RISIUENfIALPLMB, SQ.FT. PAID
C..) 0 - Thor by which ma met there iseconsSm.3M.Cm,agency for thepMmrurcx of t ReceiptN
" ec work for which this permit in ivwxd(Sec.709].Civ.C.) '
U lamk/s Nuri
O TOTAL
0I I I.rnddcemyAddret TOTAL,:
a anify bu(I have mal this epplicnion tad ane IhOt the uhwe infnmutim ie BUILDING FEE
to mori I ayac to comply with ell city and camly ordiwxxe erd me¢laws relating to QTY, MECHANICAL PERMIT FEE
U 2 boiling,mmrwclion,sM bmbynwlmriae rtprtseluisxs ofthia tory to m(ttupon the SEISMIC FEE
above-memiond proTeny for inaymwan parpous.
(we)agm:to save,inJemmfy and keep hair the City of Cupm(iop agaire t PERMIT ISSUANCE ELECTRIC FEY
IluNinia,judgmrnls.mats calepmue which may in any way xccmeegaimt ssid City ALTER OR ADD TO MECH.
iv conaryuercx of the gmnOnn of Otis permit, PLUMBING FEY
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000 CEN)
ATI
SOURCE REGULONS. MECHANICAL Fido
AIR HANDLING UNIT(OVER 10.00)CFM) CONSTRUCOON TAX
Signenrtof Applieeu'Cmmuctr Due F](HAUST HOOD(W/DUCT) HOUSING MITIGATION FEEHAZARDOUS MATERIALS DISCLOSURE,
Will ilrc applicanluf funic Wild'mgrwrupant wrest handle haanrdon materiel HEATING UNIT(TU 104000 BTU)
u dc0nd by the Cupertino Municipal Cole,Chapter 9.12 end the Hehh sd Safety
Code.Smioo 25532GO? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
' VFNTIIATION FAN ISWGLE RFSID) PAID
null the ygliconl a futurt baildinn mcupCnt use cyuipmud n aeries which BOILER-COMP ORP OR 100.000 BN) Dane Receipt Y
sententiouss r cmwwruw sk dcomd by be,Bsy AreasAV Quaky Menagnrcn
• t s
Oissim^ 'TOTAL
❑Yes 0N BOILER-COMP(OVER 100lMH)BTU) :
I ruse and the bsaudrus m,ren r. AIR CONDITIONER
rt.d 533a s undsr ,1 urwa 6.95 of the Celts- ISSUANCE DATE
faildIkel(hn Safety Code,eaorma25505,hat i,is my and 25534.1udm(ud(haifthe NEW RESIDENTIAL MF-CIL � SQ.FT
building cions currently r.amna,x, orloismymspmlbilirym axify eat arupant
ofthe rtrluirtmemr which must Ina opsins to ivwmc olaCeniticate M'Oavpancy. V/P/Y 1
Ory osoaNmzdegcm Dwe TOTAL ISSUED BY:
OFFICE