30434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NU
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-SIECIIANICAL 30434
BUILDING PROJECT IUEM9FICATION
Irl U GApy]O SANITARY NO. APPLICATION SUBMITTAL DAU
OW , N((A�yM17//111° ,r IL C 'S1 @ p/ NIC CONIROLa
\RCHI CC IN R: CLIC NO. D S: .A - 1 G II 7,� {Lga1Al+ 1
CONTACT. PHONE, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Appli ant(InitW) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
I hertnr amen tMt 1 am IkemW umkr pmrisinna ar enapwr 9(atmRnting JOB DESCRIPTION
OCZ with Sation]OW)MDivi.ion 3a(th,Businusard Profusion. .k,and my Its.is
Wµ100 ,Sj pF.RntIT ISSUANCE RESIDENTIAL
F-y� infWlfmt'c ertd c@ L_ ❑SFDWL ❑KITCHIiN REh10DEL
jFU_ Licrnu 'I Lic.M
NQL Eaw�Canncam 4 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
f-Dm ARCHDECTS U[CLAI ON PANELS ❑MULTI-UNIT El STRUCTURAL
Z 0 n Za I understood my plan,shell he tiscl is puM1lic records WI IN w- MODIFICATION
O ZOO UPTO] ANIPN
r En F"W Liam i Pmfamimal ❑INTERIOR ❑CHIMNEY REPAIR
301-I0(XEAMPS IMPROVEMENT
Sax 's OWER
BUILDER asemfrom he Com ION OVER ItMAMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
66'' a 1 hertbY amrm thio"I un eacmpt trent the Contractor'. :Any c Law for the
3 a F following eemost.iS6Ykn]011,t,Btrsiacss ural 'a, epol'Code:Any city m caro, SIGNS ELECTRICAL SER Z
LLya which its iiam o lemoo to cmmrvre eller,impntve,demolish,or relay any am[lurt
F'LLOJ priuWid iswana.el.w rcyulau the applivant Gxauth pcmtiuu file a Law(Cawmcnl SPECIAL CIRCUIT/MISC.
h Ihnt he is litetnni a to the
puaamn lwvi.ion.o[tleConuano{sLianal�wfClaPc*9
�q0 (cormncacing wish Senion]BOp)of lTvi.im]ofWe Bu.ireasand Nofcxsiaa Cndc7 or TEMP METER OR POLE INST. COMMERCIAIL.
6 n¢ IMI M is esempr thereGom vd the hanin fur the alleged cwmpfsm.Any viilimm of ❑NEW BLMADDMON ❑DEMOLITION
tri Scc,map]0315 by any applicant far. .I wM1Jats the,mail.,wu civil penalty of POWER DEVICES DTFryAM' ❑FWD SERVICE
CzQh Lana more than five hundred calk.1$500).
I,unwrernf the prapcny.mmy cutpinyaa wish wagu aw thcir.x,k cumpanmrinn, SWIMMINGIOOLELECTRIC IMPROVEMENT
O willdolhewmk,mtdlhamroct eisnxituevdcdn offetedfa mk(Sc.]010.Busimm - ❑OTHER
and prorcmions Coln To,con aclols Liamc law duo awl apply to an owns of OUTLETS-SWITCHES-Fl%TURES
13 Property who h tilde fir impmvn de.r.,and wW doe,such sod,htmsclf or Ihmugh
Ink nwn ctnploycu,pno tdcd Nat such improvcneno art not itvendM or ufn J fa NEW RESIDENTIAL FI ECPR SQ W.
uk.If.Wwc.xr.tae builJingm ingmvcnKd is add within one year ofcompinim.the SQ.FT.FLOOR AREA VSQ.IIT.
tv Ibpilder will have the Wicen of pmvinl that he did na build or improveforpur-
ryae uLsolc.l.
co L a owrcr of ct prvpenY•am mne sivcly conhac4ng with:)The CLCNlaltta I. TOTAL
corse La the project(Sec.]011.wncr of r l whom.Codc:l The CaWclm, li N/eJ
AI
ulawdlcor% uh fly loan owns ofpmpcny who Widsorimn0 the Conan,.rW QTY. PLUMBING PERMIT FEEHwfo cmwca for atre'h prujnia with a nmtraclur(a)Ilccnrcd punu.nt w the Canlranor'•
Lwena law, PERMIT ISSUANCE14 REC'I
I am eampt under Sec. ,B&P C for thin renwn
Doc ALTER-DRAIN&VENT-WATER HEA) VALUATION
Owxr
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE VI�Vf VVi Lf1111VV
I hcrtby Off nn unlet prnally of pegm,otw of the lollow'mg&clamtirms:
❑ IbaveWwBlmintainaCenifcuwofCoasenlwalfiiaaurtfaW«ldsCompen- DRAINS-FLOOR,ROOK AREA.CONE. 5.1pR11'S TYPECONSTRUCTION
maim,ass povidtd for by Scnion 3]00 of the labor Cods,for he pnfamaree of da
wort for which this permit i.i..wel. Fl%TURES-PEK TRAP
Ithave and will maintain W.rtefs Ccmpenmtim In.wmrcc,m nyaved by Section
ofthe tabor Cb a for lie pMammince of Os work for which this pmol is ismad. GAS-FA.SYSTEM-I INCAOfTILGIS OCC.GROUP APN
My Wa MVr h
Iran ac—and Polkypr�����erty1
C...... policy Nm:ZMtO1 OAS-IA.SYSTGI OVER 4(EA)
CERIIFlCA F EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASIV[NDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thie mciion nod not Inc cmtplelM trite Wmmil is Grana Fundted&4lun O 100) GREASE TRAP
a less.) PIANCHECK FEE
I ardfy that in lheperfmaante midst work forwhich this PcnNl is named,l4all SEWER-SANITARY-SfURM I?n.300 FT
not employ any Perm in any manners w m to hccome ohJect to the Workca:Capper- ENERGY FEE
Z motion tax's of Celifomia Daae
O O Applicant WATER HEATER WIVEN'r/ ECIR GRADING FEE
NOTICE TO APPLICANT:If,after making This Certificate of Exemption,you Imm5 WATER SYSTEMiTREATING
become svhjat to the Workcr'x Cmtpenwaim provision of the IaWn,Code,you moa SOILS FEE
farthwith comply with such pmv sms m thh permit shall 4 deend resvtrJ. WATER SERVICE
is
az CONS]RUCIH)N LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V 0 Thereby amort cat there is a construction keeling agency for the perfmrrwce of Due Rtaiplg
D. p the work for which this permit is imud(Sec.3097.Ci,C.)
0U [. ,Name TOTAL',
CS11<WnS Address TOTAL:
0. I certify than 1 have real this apPlkuim and spot that Bic aMve ioforrrtuim is BUILDING FEE
H emaL Ia,ace to comply with all day and roomy Mmstacu and mate laws relating to QTY. MECHANICAL PERMIT FEE
CJZ miUrgconmmction,and hereby auO.cire relacwm ivu ofint city locmer upon the SEISMIC HE
dxwe-menWrom pnpeny far inspztion m,i PERNEff ISSUANCE
(We)agrs to save,immteify vel kap harr the Cly of Cupmtim ageiaq EI.ECTRICIEE
1whilitics,jndgments.utatont!expe,cr which may in any way acemeagainst said City ALTER OR ADD TO MECH.
inc cofdh grain,of this permit. PLUMBING FEE
A""I 'ANT IINDERST NUS AND WILL COMPLY WITH ALL NON-PoINT AIR HANDLIEG UNIT(TO 10.000 CPM)
5 I1R( PGIJL ON. MECHANICAL FEE
7 AIR HANDLING UNIT(OVER III.00BC 31) CONS7RUCTTONTAX
3,Fbaropen(Ap,ficarroscInplaaam Dew RXHAUSTHOODIWIDUCT) HOUSING MITIGATION FEE
H DOUS NIX[TRIALS DISCLOSURE
Will the afflictions a fumrt Wilding occuputl most m handle Mamdous mot HEATING UNIT CIO 100,000 BTU)
n defined by the Culcnim Municipal Cats,Chapter 9.12 and the Hcallh and Safely
,ImCdc,Scctrvn25533(77 I[EATING UNI'[(OVER HX),fXp PTU)
❑Yes [3 No VENIIIATTON VAN(SINGLE RESID) PAID
Date Remi M
Will plc air comlmfm,a Wilding by the ByAea Ai emit Manas,which BOILER-COMP(LIP OR IM."BTU) pr
mil haxard.cu air conlnminvnt.cn dcfind by the Bay Area Ab Quality Management
m ] BOILER-COMP(OVER 10LO )BTU) TOTAL
❑Yu FIN.
I Mve read the Fwzokim,nmaiaN Chytwr AIR CONDITIONER ISSUANCE DATE
rtgtumterva uadei b.95d'deGli-
fania gdoth&Safny Crile,ealimrs],thou i i55t3 sed 25S3d.1 undcmand that if da NEW RESIDENTIAL MF.CII. SQ.PT -
W[ding oma ran eormdy haat o term;2that it is my arund 25 14.1 m Holly the rcc if ft
af Ibe requirtmems which rrwt W ren prior an io mmce of a Catifcuc MOccopmcy
OxnerosauhonrtJ.gent Bat, ttl'AL: 7. 7,0 ,,,,,EDBY:
OFFICE
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