29037 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0 7
BUILDING PROJECF IDENTIFICATION I
INGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
NFA'$NAME: PHONE N CIOR'S NA fE LIC NO: 7 N/; CONIROhM
a w ;U.-
•ARCHITECIENGINEI?R: LIC No DDRFSs: O
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/ PHONE BUILDING PERMIT INFO
V Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MFCH
(� L ❑ < ❑ ❑
LICENSED CONTRACTORS DECIARA'FIQTy CLECI'RIC PERMIT FEE
y anion slut I w IicrsN uMn Pro.isimis of Chaps 9(mrmrcxing JOB DESCRIPTION
OaZgq)nflyo,iao 3ofthe Business onl ProfnciuK Gxk,vM my imams,is PERMIT ISSUANCE RECIRRRTIAAAl
UVJ��jo Lle.M �^u�'5! k ❑SF_DWL ❑KITCHIN'REMODEL
��WJ�/i:-�_Contrecta T APPLIANCE'S-RESIDP,YIIAL ❑ADDITION OPLUMBING RB-PIPE
y ` 7RCHIi'ECTSDECLARATION ❑MULTI-UNIT OSTRUCURAL
Z O J z I unddwed my plans shell he used m public mcords PANELS MODIFICATION
OZ - UPTO 2t10AMPS
El INTERIOR - D CHIMNEY REPAIR'
[-.tW Lianscd Pmfe n...I ?01-IOW AMPS IMPROVEMENT
Sy OWNER-BUILDER DECLARATION OVER IIMI(1AMPS ❑BATH REA10DF1/RFPAIR DEMOLITION
❑C W 6 I hareblealarm that 1 an,cite la friths the Gmnamr'a Lkenm Law for the
1 kJ following mason.(Section 91331.5,Bashass and Pmfessimu Cade:Any city or county SIGNS ELECTRICAL D OTHER
4r I" wbich re tint it prnnit to cannuuct,alter,improve,demor.h,w repmu any svuaure
n•� Pram to in iuua 1.Np Mea applicant such
F� n,1.the pio.,a permit1.
aw(Cluelsent SPECIAL CIRCUIT/MTSC. r�
oVnn. ing,id Scobnttode pnrvuioes ofof Buv,inevs License LawlCTuper9
�xMC thanmrnungwit therefrom
]Ogp or Dbisiml3 ofth gifted smM ProfAnyvir Ction or TEMP.MI!fEN OR YOIR INST COMMERCIAL.
a�W Sec io u exempt merefmm eat or basis t the subjects
oho eae to Any violation of
IllllaallnalllEl NEW BLDG/ADDITION ❑DF1.tOLITION
Sation7011.3 hy any applicant fora posh nuM1jccu dsc appbcannn acivil perlwty of POWER DEVICES DiENANT ❑FOOD SERVICE
Fq Z}
not nuc man five hundred dollars(5500} IMPROVEMENT
2=GDwa
l,ucorofiny.a m
e"VIaoy cmm
plcys with wau
gs thn sale conspnsumm, SWIMMING POOL ELECTRIC
yF will do the xak.and detmctwe is.marvdcd oroRaed for sak(Sec.' 'Business ❑OTHER
aand Professions Come:The Comanclor's Lieeve Law does sat apply to an owac of OUD.ETS-SWITCFiFS-FlXTURFS
Foppery who builds a improves theressn,eM who doa,with work hinnelf or though
his own employes.Provided Qui hryrovarcnu are to amended!or offaM for NEW RESIDP.NUAL ELECTOR SQ ff.
ash,If,however.the buildings improvement lssold wilhico.yeaofcomplemm..the SQ.FII FLUOR AREA 5/SQ.FF.
awna-N Irser will have the,NNen of Proving Net be did oa build or improve for par
pwc of rola).
D 1,as owner of the,popmy,on exclusively solo oniog with Tic rased!aintrenm to TOT
nrtelmet the pmlat(Sec.7041,Basines,wd Professions Code:)The Contmcta's U-
me law dm to applytn an owmerofpmpeny who Nilds or inFri threw,and QTY_ PLUMBING PERMIT FEE
w pnca,Law.
fa such projects withncautztafa)IicemM punuwtmth contractors .
I.kmm is r PERMIT ISSUANCE NOVI •1
D iwevcmPr under 5a. B
� , k PC fa this tato¢ II �
1 ALTER-DRAIN&VENT-WATER(PA) VALU1ATI0
®aamr Data CfIY
WORKER'S COM PFNSAIION DECLARATION ACK FLOW PRO .DEVICE Vf (rLlr•tljlln
I hereby eRw under petullY of perjury tree of the following hcl V
D Ibnveandwlllmsinteina CcNfxvm ufCaucmu ILlmt S- ( ODE.AREA,CORD. STORIES TYPIi CONSTRUCTION
moon,u puvidN fur by Smivn J]W of Nr Me fa e «Rane t the
work for which this pemut is Luted. T R -P RAP
D 1 have aM will meimain Wates Gtmpcnmuon v,u mquimd h�le ntk '
J]W ofth Mbar Code,fa th pManune ofth f
me Nispemdt 1lis GAS-EA.SYSI-EA/IINC.i OU'ILEfS
My Workers Cmnpenmtion lnwmrce ecrrkr aM Pnii mherare:
11 OCC.GROUP APN
Curie: Policy Nn: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF MXEMPHON MOM WORKERS'
COMPENSATION INSURANCE GREASMNDU.STRL WASTE INT.RCEIv OR
(Thio section tteW not he completed if the permit is force handed!dallars(SIM) BUILDING DIVISION FEES
a less.) GREASE TRAP
PIANCHECK PEE.
'I mnify Bur in the any ormmnas of do work for sunk,,tete permit is q Cel l shell
ata employ en SIiW[R-SANITARY-STONM EA,2M 14. t �
p y ypemnin very mvnnerso uxw M1cemle wh}sun Ne Wakers'Cayp�o- ENERGY FEE
z' scion Lows of Calif Oue — ' 1 s U- b I�
� � pplicant �T N'A91:R fICA'I1iR WNENf/ELECDi GRADING ME
z `" NOTICE ICAPPL ANT:If,a er moving this Cenplfi a of f emrylon,you should WATER SYSTEM,TREAIING -
F' hrotne.thiol to doe Worker's amPrmatiw povisl le
later CME.you mut SOILS FEE
a0 forthwith comply with such pmrisien,or his pond shallhM<mM rtvokN. WATER SERVICE
7z CONSTRUCTION LENDING A017NCY NEW RESIDENTIAL PLMB. SQ.EL PAID
UC) Ihaebyaff thu Nae asset u mvp kMingaFnry forth peAtsmuaeof _ Due ReceiptN
G. .. the work for whichthix psomil i.issuM(.Sec.J(F7.Co.C.)
UIeMcrs Netto TOTAL
LcrAYS Dillon. TOTAL
r 0. 1 testify Bad I have¢ad this application and state that Ile above information is BUILDING FEE
�^ h correct.I egmetocumMy with all cityandcatmyorddoeacn andswe hwsteluingm QT-y. MECHANICAL PERMIT FEE
U sz Nilding rnslstrssdiw.and hrebyeuthwire rtpmentmivn orbits city loaner upon the SEISMIC FEE
alw e-trcaitsned property la itnpection puryoms.
(We)agree to save,ildemmfy aM keep humdcts be City of Culvert—Uaimod PERMIT ISSUANCE ELECTRIC FEE
IieNlitio.jMemmtc emu eM npwes which may in try way varve egsinn said City ALTER OR ADD to MECII.
in con.quence of the granting of this panni,. PLUMBING IEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'F(I o to,"CFM)
SOURCE E ULATTON5 MECHANICAL FEE
// f AIR HANDLING UNIT(OVER 10,000 CF
M) CONSTRUCTION TAX
SlgnattncofAWficeilocum Ua1c EXHAUST HOOD(W/DUCD HOUSING MITIGATION EFF,
HAV
A ARWUS MATERIAL DISCLOSURE
Nill the applicam or fmtw NilJing ocupunt surmwhoeallehvvtlw.mamrwl HEATING UNIT OPO 100,003 BTU)
an,defined by the Cupc tion Munkipl CMC,Chapter 9.13,mail dse Health and Safety
Coda Section 25532(up HEATING UNIT(OVER 100.000 BTU)
Dyes, DNa
VENTILATION PAN(SINGLE RPSID) PAID
Will sh applicant ne furore Wilding tecopanl use equipncnt or device,which Date Rdnipt N
earat mocadaas.corlrarrdenrus as defused by th Bay Area Air Quality Menagrnrnt BOILER-COMP(3HP OR 100,003)BTU)
Dislrinl TOTAL
[-I Y. BOILER-COMP(OVPR IWI)),000 BFDNo
I have and tae Incarnations rwerinla regtimtnw.tinder CTaper 6.95 of her Cali. AIR CONDITIONER ISSUANCE DATE
forme Heald,&Sudety Cook,Sections 25505.35533 aM 255]4.1 uadcntaM Nae if Jit NEW RESIDENTIAL MECH. SQ.FT.
NOdagdm wtearemlY Nveatenant,that itis1nyramtruihilitytonotifytedtccv I
d de mluimrcu.which rots h ma prime m iawmrce of v CdtinceR of t]ecapmey.
Ox w or mOxrired age. [)ate TOTAL: ISSUED BY:
OFFICE