30126 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30126 O2/16/A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3K/
BUILDING PROJECT IDENT6TCATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(. "i q,6
OWfVS NAME: /PHONE CONTRACTOR'S NAME: LIC NQ
2S' -vr- � NIC CONTROL#
r CH/ ;CI]I:NGINFtk: D D�� ` IC NO: Dc)Lix e I J El
ONINIACE - PHONE, 'V BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial A4 BDG FI FCT PLUMB MECH
❑ ❑ ❑
LIC
m,than
ha I CONTRACIUR'S DECLARATION of QTY ELECTRIC PERMIT FEE
1nerdy )oF dw1 3 faac Buin,.ilroviaim.a or cbapler9 an,beerlcing JOB DESCRIPTION
X00 with Sn:tlm]IM01 of D;visim3oflM Bwbess ad NNasims Code.eMm Ecemeis PERMITISSUANCIi
�Op �� Y RESIDENTIAL,:
w� in full farce.nJ Kfat. ❑SFIWL ❑KBCHENREMODEL
�F.z W Ono, Claa LC.#
NQL Dem Conlmcla APPLIANCES-RESIDENTIN. ❑ADDITION L1 PLUMBING RE-PIPF.
ARCHIT CTS DECLA ATI-� PANELS
F.7m ❑MULTI-LIMIT El STRUCTURAL
Z p�1 Z 1 wrkramnd my plea dwll he orad u�pantie rtcurds MODIFICATION
rNW Ltccnv4 Profcavowl UPT020 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
C Y .,aI a u -BUILDER DECLARATION 201-100 AMPS IMPROVEMENT
y�w 6 I hertM1y tifBrm thw m exempt from the Cmuwaola Licen¢law for the OVER 10MAMPS ❑BATH REM I/REPAIR EI DNOL��DTraO.�N��
x 3 6 U following r�scim Section 21315,Buoi and Pmfmioa Cock:Any oily or county SIGNS ELECTRICAL. [IOTHER IUtI
F O�j whlcM1 milm cr a Rmlit til comnuc4 alter.impmve.Jttnlrlish,or never any s rucWrt ••••••
Prim tonn iawarce.alro mreileaNe"himmant fo,,.h p,:mOo Elee.i'm"emrnl SPECIALCIRCUIT/MISC.
�y Ihathcislicen.redpur tit)thepmvidomofl Conlracta sLiaaelaw(C-a 9 #
'WQ0 (mntrmcing with Stttim TOW)of Divisile3of then Busineu end Rnfcssian CMc7ur TEMP,M ITER OR POLE INST. Val W%w
d q o n that he is exeroPi Ihciefmn and ihM1 tui%0r Jx 91hyW exemgioo.Any vioWion of W BLDG/ADDITION ❑DEMOLRION
LLXl 4• Section]031.5 by tiny applicant fu a pemlh mhj BMitiflicanunn civil lrennhyuf TOWER DEVICES
FZY nal mune then Eve Immind dallun(ISM), TENANT ❑FOOD SERVICE
GI,aownrnof then lroleny.tr my e^mloYea witM1 wtsgcra their vile compenwinn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do lM work,and Ne soucNre is na inedd m offend or sale(Sire.]OLf,Business ❑OTHER
Wend Profeuimax Cledoes:The Cnnl.or's Licemst,law donot apply m an owns of OUTLETS-SWITCHES-FIXTURES
FwR'nY who Wilde ar imprava bin and wFn,loea a 1,,h word,Mari tr broad,
his two employees,movidd,l, olh;mpmvellenlr we ns;men11n1 w oRerwl fm NEW RESIDENTIALFt rCTR
ole lf,however,the WiMingmimlmnxmrntusaldwiNioae yar of mmplctim.thc SQ IT.FLOOR AREA "Q.IT
wnenbuilder will have the hunren ofpnlving IMt le did not W;Id or improve for pur-
pwc
❑1,aownerofthe Sre.70,tintaaclaai vcly edf.iEng wild:)fieranoviThe Cemir ,Ir,w IOTA
ccowun Ne Pt Ms(Sec.]II4,BlsrO' aMrty who buildr
Codc:)Tnc ear hereon,
V-
whoclawdrcsnot ritueh yet.n uwocr Mpmpcny who WJdrmianpmva lhmmm and QTY. PLUMBING PERMIT
Licei.uecu fm wen pmjecu with a cmuvnm(O licemd paean m the Convenor's A•�
Limuc law.
fPERMIT ISSUANCE
lan eacmlg aodcr Sec. ,BRPCfa this rtaam
OwerrDate 1
ALTERNT'
-DRAIN&VE -WATER(CA) t ^TIO#
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
�
I hembyunder paely of perjury me of the following ded,mumnn:
❑ I have ad will mainlnina CcnifcemofCmunaloadf-invert for WorkKa Comlm DRAINS-FLOOR.ROOF.AREA,COND, I.11 r ur uUrcrrllltJ
cation,as providal for by S comm 37110 alhe IaMx Code,Fr IW perlimwncc of the STORIES TYPE CONSTRUCTION
work f,r which Thu pentyl U issued FIXTURES-PER TRAP
❑ 1 have tiM will mtiinuin Water's Colnpensntlm Imumnce,es rtyalrW by Seelion
370(lof Ne LabmCode.for the perfamaec<ufde wort fmwhichlbupentdt is ivual. GAS-EA.SYSTEM-I INC.4 OUTLES OCC,GROUP APN
My W'irkID� lion lnsumncccorricratd PolicN,vy
¢ w
Policy FROM
WRK 2/f/72-- CAS-FA.SYSI'EM-0VER4(EA)
CERTIIOC O OE COMPENSATION
I N PRAM W(IRKBRS'
COM1,irom,AT10NINSURANCC GREASFJINUUSTRL WASTE INTERCEPTOR
(In6 aalka ted nn1 k crmtpktd if the permit is for me hutalrtd Joilon(SIM) BUILDING DIVISION FEES
or ha,) GREASE TRAP
I anifY lMtin tie rfnrrnancc of then wort fa which Chir PLANCIIECK FEE
pe rha,W.ruo'Con n- SEW'FA-SANITARY-STORM EA.200 F1'.
not employ say pNam in anY nmmcr m®tu Marc whjal w IM W'utkerw Cmtpen- ENERGY FEE
Z wtim live.-of Cabfom;a Dem HEATER WATER HER W/VFM/ET,ECTR
O APplirw GRADING II:E
N NOTICE TO APPLICANT':If,efts taking this CeNfaam of Exemption,you should WATER SYSfEM/IRHATING
a ; be ecamvubjenmde,Waker'sComrenlmim por't'ion.of the laMr Crk.Ym must SOILS IEE
W � farinwith comply with such pmvis;oa car thls penmil'lull W Jeeaval rtvolied, WATER SERVICE
0. Q
L) 2 CONSTRUCf10N LI'NDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
UIhertbYelOrm NNt in mwonametionleMmg agnlcy firthe lerfalancc of Nm Rettig#
then words whim W a Perot ins (Sec.3891,Cir.C)
O U
Lender's Nnme TOTAL:
Laa4 ;Addnesa TOTAL:
y 1 unify tbar 1 have and this appliemioo tied sime thin We tihove infomwien is BUILDING FEE
N rnnmLlagrte to cmtPly with Wlnry.d county ominweo.d nam lows mleting la QTy, MECHANICAL PERMIT FEE
Uri Wildingcauwelim.stdhcrtny euthurivertPrt'sentwivesof Nucilymenlerupon the SEISMIC FEE
above-nrcntiatd ptopeny for imnoe on pn{ases, PERMIT ISSUANCE,
(We).artam ave,indemnify enify and N Ise keep mamCity of Copan.ageial ELECTRIC FEE
liabilities,jwlgntenH.costs end evpense which may in any way accrue against said City ALTER OR ADD 3O MECH.
incroseyuenoe aide granting of lhu pc 'L PLUMBING FEE
Nf UN ER.STANDS A' ILL OMPLY WITH ALI NON-POINT AIR HANDLING UNIT(TO H,MM)CEM)
SOU CE TION MECHANICAL FEE
AIR HANDLING UNIT(OVER 18.00 CFM) CONSTRUCTION TAX
/ n App a I/ imetur am EXHAUST f1000(W/DUCD
BOGUS MATERIALS DISCLOSHOUSING MITIGATION FEE
AlAUU E
WiBtneupplietintunfamrtbailchm,te<u,nO1amor&mHr M1easNuuamaona[ HEATING UNIT(TO 10,011 BTU)
a defircd by I Ct im Municipal Code.Che er 9.12 and the HedN aM Sefny
Calc,Sstioo 25532(a)7 H A7HNO UNIT(OVER 10,000 BTU)
❑Tex C1No VENTILATION FANS I NGLE RLISID) PAID
Will the tipplian m fulNe Wilding«cvptint use egaiprncnt on dcviae which Date Re<rip N
emal hevandous air contaminwtn m defeat by the Bay Arta Air Qualily Mawpm¢N BOILER-COMP(3HP OR 110,000 BTU)
DiwlcR BOILER-COMP(OVER 100,00 BTU) TOTAL.;
❑Yn C3 No
I love real the harert4as mutdaly lager AIR CONDITIONER ISSUANCE DATE,
rtquitnrcaa order C 6.95 of the Cdi-
famia Halth&Sefny Calc.&mina 25515,25533 tin!25534.I utdcswstle Halt if,k NEW REMDFNTIAL MECH. SQ,PT.
Wilding Joca riot sartorially Ius:a NWnL that u u my res ib;Iity to notify he oceupara
allhc rtquitenenu which mmr Is,mot prim to;.orearcc ofe Ccmhjcme oft nosey,
OwneraemhlnvcJ agent Date TOTAL ISSUED BY:
_m��i
OFFICE