29542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING.ELECTRICAL PERM IT NO. 29
542 4 2
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V/ L
BUILDING PROJECT IDENTIFICATION
'ILDINGADDRESS'. SANITARY NO, APPLICATION SUBMITTAL DAT
0_T ! -C�"Z G
NER'S NAME t PHONE
OGttJb OV TS �M
OJ /J�t�}.. 3 7LIC
N SCO/NJHOL»5
\ H i GINGER: UC NO�
e"k — Uy' i4 tWlflu ' I
❑ (/
CONTACL': PHONE If BUILDING PERMIT INFO
❑ Comvllant Fees Paid by Applicant(Initial) HI_Jx P.IE PLUMB MECH
LICENSED CONTRACTORS DECLARATION 9 P,maQTY ELECTRIC PERMIT FEE JOB DESCRIPTION ❑
hereby affirm thed I un licetesed under proviiiom of Chaprer aa sing
�0Z1 O witb Smtimt7 0 )of Divisb Sat cBu.iaaseml Profadmv Cas ,aWmylianncia pp,RMl'I'ISSUANCI? RESIDENTIAL-
full fmccurd if I' OSPOWL TCHEN REMODEL
aub u.ntVla _ � , tie.. S3 72 9� �+
I...Z COn�y APPLIANCES-RE.SIDFNIIALDfT10N ^JPI.UAfBING RE-PIPE
lFn= ARCHITECTS DECLARATION PANIBS MULTI-UNIT ❑STRUCTURAL
Z p 1 urdentvd my plans Jwll be used u public rnnrb MODIFICATION
OZ La UPTO]BOAMPS ❑INTERIOR [I CHIMNEY REPAIR
r-o t m Licensed Picurto mens 201-1000AMPS IMPROVEMENT
� .1 dontIxemptOWNER-BUILDER m the CATION OVER TUX)AMPS _ ❑BATH REMODEL/REPAIR O DEMOLITION
a 1 heresy alTmt Uw 1 em exempt from Itr Cntureclois I.icen.e I�w,far the
K LL la.
F fdlowity recwn.(Sectim co]0313,Busitold Pmfcasiolts CaAa
lc: ny city crusty SIGNS I LEMICAL DOTHER
I, which rtyuira a Inerrant to con mocl,alter,improve,demoln.b.m repair any structure,
prior to ias issuance,alto,requites the upplicmn for.wah pcmti0o rile asignN statement SPECIAL CIRCUIT/MISC.
and he is li¢r...n pursuant to doe Provision,of the Cmiancinfs License Lav PcIr r9
W OO (cattmngin{wtSenim]000)o(ITvisim Jlf to Buaircss and lhMeuimn Codc)a TENIP.METER OR POLE INST. COMMERCIAL
e, �d thin he in exempt therefrom and the hasin for the alleged exemption.Any viulvtim of 0 /A
NEW BLDGDDITION 0 DEMOLITION
Section 7031.5 by any opplicam fora Permit subjects the applicant to a civil pewlty of POWER DEVICES
I++^m OTENANT El FOOD SERVICE
E-Z M nm rtrae than Tice huralml dalton 15500).
❑Laslworoftlrehe..,,ar tvyot matured!
witwagaua1ei(Se,mm.Hannon. SWIMMING POOL ELECTRIC IMMOOTHER FI.IFNT
will dothcion.and to he Cma Is tta I Licenc,Law do for ante(.Re,.]pfq,Business ❑OTHER
oral Ry,who n Cak:The cti ttelmea L ern!ani law da,r wi apply to lf uwrcr of OUT -SWITCIIE9-FI%TURES
Irtn mans vM.yea,lda m improves Ihacnm.M v rmdmottdi wank namclro through
hi.own employe,IavVidni r r arch improvvmmu ere rot mantled ort offered for NI:W RISIU ECIR SQ FT.
snlebbuilder will the love thmguflm ofponicnt iHot sok!hewithin me rhino o improvetfourputhe SQ.FT.hLt X)R AREA LSQ.PT.
Maid der will hove the buNea of pwving Dint he JlJ not buil)a improve fm par
pac ofsalcJ. Kf1Jf
Las awns Of SIC notrit,70, am aces,any cmtracting with licThe Cnmuarlae to TOTAL: -)
CIIS
mII.Wtt dx:pmjem(Sec.]fNJ.Huninae oral Nofwinns Coal The Conlrwlo
me Isw docs tet apply to on owns of pnryteny who builds a imI*avea Ihvcae,anW QTV.. PLtXkING P,R, IT FEE /� >~^
.hocnmraetx fasuch p ojen,wit a vomm serf.)liamed pumtantmthe Contractors /"
laccnw lav' ISSUR ,
rERMITANCe 3
❑ luoexemq under Sec. ,B&PCfartixm. (�T.. ;
ot
ALTER-DRAT &V[NT-WATER(FA) VALUATION
Qw Mr Dal<
WORKER'S LI
R'S BACK FLOW P T .DEVICE
(hereby aR umbr pcnalry ofperjur,sic of One following Jrdeatiw: ,� L�C.C/
Ihave ard will mainun.CenlftcateofCaven to self.m.fa Workd,Conpen- DRAINS-R.00 .AREA,COND. STORIES TYPE CONSTRUCTIONcation,v pb idd far by Scum 37W rf the I:tur Code.for the penformaree of E,
work for wh'Ich rix Permit is manvi. FIXTURES-PER TRAP
0 1 have mul will maintain Warner,Compensation Inrwrcc,u rtquirnl by Sadun
100,
3700ofthe LaboaCode,.forte perfmrwcc oflM work for which thin pcondumated. GAS-EA.SYSIESLI INC.iOOCC.GROUt MIN
My Weidner x Compensation In.wmne carrier and Policy number ore:
Currier, Policy No.: GAS-EA.SYSTEM. (PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIANDUSTRI.W R
Mm ration stet nm he compinal ifmcpemn in firma hundred dollurs(SI(d) I L 'GD ISION FEES
m los.) of
GREASE TRAP PLANCHEC
I eerily than io the perfomvnee ofthe work for which tis Permit aiumd.islull SEWER- .
mtemployany,eiry QQIIInenym. tohea ub*lltolthe Warketa Compere SANITARY-STORM fA.2(gl ENERGY
,'� Id`xofAI UT WATER HEATER W/VENf/ELELTR GRAD FEE
OTILY TO AP%JCANT:If,ager tenting tic Cerifcate of F ert9'lion,you shouts WATER SYSTD,VTREATING
z =moue.to to Worker.Com,tamtiun pr Akio.,of the Lnhor Calc,you main 5011 Ji!
fonhwitcomplywit sueh pruviiitm.ortia pernilJWlbc dccntal revoked. WATER SERVICE,
y0
CONSTRUCTION LENDLNGAGENCY NCW'RESIDENDAI,P11.1B.• SQ.FT. ZFEE
PAID
L) I bambyofOrm lhutlMci.ann.Irvc.lnnleding agency fa lhC perfornwttre of Ib Raeiprtl
� .. dtc anal for which to pcnrtil is mut 1(Sac.709"1,Civ.C.)LeMeh Nemo TOTAL
WIcmkrsAddrta I cenity that 1 have reed this ii'ltcutim and sonetet tM obove information a BUILDING QTY. MECHANICAL PERMIT
U Z imildirgamunucrion.ard hereby au0wriee openserunal oftn,caymentcrupon the SEISMIC 4.E
above- entmed proper,for inapation pwrymx. 1'GRMIT ISSUANCE(We)agree to nave,italnnnify and keep hermit.the City of Cupertino ageing ELECIRI FEE {,�'
labili0a.jadgrtcnas.cocas anal open which may in any way.against said City
inemtuquence Mtint,marigoftispernra ALTER OR ADD TO MECH. PLUMB( GFEE to
APPLI(' M' NDERSTANDS DWI( .0 MPLYWITH ALL NON.POINT AIR HANDLING UNIT CFO I0.00DCFMI MECHA (CAL FEE
SOURC E( LATIONS.
\ ANe
AIRHANDLINGUNIT(OVER 10,000CFM) CONS TR ON TAX
S maturer can tet [)We EXHAUST HOOD(W/DUCD HOUSING MITI TION FEE
FIA]AR U. A AIS DISCLOSURE
Ihe"It'wtaf '(dine avmlxnt uaemMMle M1arardms merM.l HFATINGUNIT0101M.000BTU)
M by the CuWmno Municipal Cale,CE,ber 9.12,and to HenW and Safety
Crde.Sectim 255320)i HEADING UNIT(OVER 1(0,1X0 BTU)
El Yea C]N. VENTILATION PAN(SINGLE RESID) PAID
ER
•
Will -COMP(3HP OR 100.000 BTU)ll the applicam a fmtan ubuilding Hat,B oyit JUetc It Y,
sax uipnunl evicax which ' -emit IussNw ha(imby ous air awtamiruns l by the Bay Arra Air Wality Managcocnt BOILTAL:
Diu n0
1 Yen ❑No BOILER-COME(OVER I(p,(I(p BTU)
I love rad the heran ki mttcialsER ISSUANCE DATE
m0uirennents under Cluprer 695 of de Cali-
AIR CONDITION
farms Health&Safety Code.Seclkta 25505,2553]nod 3S3 .1 urdcrraral that if the
buildingddcs not ctmentl have o lnncra,tel it in to NIiW RESIDENTIAL MECH. SQ.FT.
y yrcyva.sCerifimna Ox iuulmnt "
i oflM regrirtbenas which orlon Moet pr;amluttartcc nlaCmirtcuc of(kcupWcy.
Owmer or ainhxizN egenl Dom - TOTAL: ISSUED BY,
OFFICE