28545 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. O /� r�
BUILDING PROJECT IDENTIFICATION o 4 5
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
'Z G(')�
OWNER'SNAME: PHONE_ LONOULACTORANAME LIC NO:
��_ WC CONTROL ARCHITECP/ENGINEEIL n LIC NO: ADDRESS:21 V301 ❑
30
CONTACT`: PHONE /�/� BUILDING PERMIT INFO
yQ$--` - 2-200 ❑ C...] pt Fce Md by Appllcent(WtW) BLDG ELECT PLUMB MECII
LICENSED CONTRACTOR:S DECLARATION QTY ELECTRIC PERMITQ=z FEE ❑ ❑
I ne shy efUml'ar I.1 IkemW Lowen pru.i.ion.of CMPtn Y(eomn.Ming JOB DESCRIPTION
{Ia1 00 with Sation'/(IW)of Division oftheBuirea end Rvfesiom Godc,W mylcerue ie RESIDENTIAL
idEfull fora sons! t. �' PERMIT ISSUANCE
� O ❑SFDWL [I KITCHEN REMODEL
g�g..Uj Vu CI LIc.X
lnQa Dare CrOOactor APPLIANCES-RESIDENTIAL ❑ADDTIION ❑FiUMBING RE-PIPE
F.Dm ARCHITBCI'S DECLARATION [I MULTI-UNIT ❑bTRULTURAL
1 mdersandm I thin be and as Public records PANELS
ZOr�Zj my CHIMNEY
RUA
OZ Q UP TO 1110 nMP5 ❑INTERIOR ❑CHIMNEY REPAIR
l-i~WWW licensed Pmfvimlal 101-101p AMPS IMPROVEMENT
�u�'-{ OWNEno exempt
.DE RDE CIARATION OVER 1000AMPS ❑BATH REMODEIIRP.PAIR El DEMOLITION
a' a 1 ne .(Sum that 1 16 excmPt f an the Cssinav ov LiA nsc city
o f«the
3 6 U following r rtaam.(sarma 1 7—ours❑uninras and Pmfcuinne Curie:Any<i1y«ammy SIGNS ELECTRICAL ❑OTHER
yra which rarytrta a permit Ice cunYryCl.rites.improve.Jemah,,,«repair any.musnute
F��.] prior to its rt,weassee,also rcgoiru that applwnit for sixM1 permitto file a signd uuetrleed SPECIAL CIRCUITIMISC.
rWrW��� Net he is li¢nwl punovma,b,,,muisionsofthe GmmslMa J,c ,,,e law lCn,a.,H
Cep (commencing with Satir --tdfDivixion 3ofthe Busioeu old Profusions Cards)to TEMP.METER OR POLE INST. COMMERCIAL
r,t ie h exempt thereform rand der,hard.f«Ne eleged exemPtion.Any vwkti.or
rn= ❑ DCJADDITIOH ❑DEMOLITION
Senion]OJI.3 by sny.,Ii...I for npenot subjma the applicant to u civil psnaby of ❑TENANENANT ❑FOODSERVICE
POWER DEVICES ort en rive hundred dind.(53110f
sore Nri
C�0 O I.ar»mer of de IMPROVEMENT
F thegeny.«myot 1aa,mwiN wvgnuthei0w. 744,Bavation, SWUL\11NG POOL ELECTRIC
will dnhcwork.atdthahe momism Licensorofferor rev mkMy o so Du.of ❑OTHER
W-' foo erry w ions Cede:imp Cuovana'a License Law'dao.a apply to 1f ovnn M OlTL1E1S-SWUCHES-FLXDIRES
a 3— p,ape„y was nniw a ire�aa Nnr.,n,atd who aan nam wok nimalr«rmagn
hen own employaa,pmvidod IMT such imprn,toxois are no,intended«.Gored fur NEW RESIDEN HAL ELUCTR SQ F1'.
sale.IL however•the building or impmvernem,n sold wird.A.Y. fcornpinim,de SQ .FLOOR AREA SISQ.PT.
ownerbuiklrr will have the burden of proving that he did nor build or improve for pen-
' ryacofwk.l.
1,u owner ache pmlemay.sum exclusively contracting wir liconrd emeractae to TOTAL:
amsuivo One lin jest(Sec.'RN4.Busirnsr sed Pmfes:m.Code:)Tee Contnnur's--
avolawdoewlepplylranownernfpmprnywho�uilds«inspmven theme,end QTY. PLUMBING PERMIT FEE
whoemtr.cief«numprojects withacanrt r(s)lieenral putwent nthe Cmtrctoh 1
I um uempt ander Sire. ,H&P C for this rmwn PERMITISSUANCE. - sy
1
Owrrcr MaeALTER-DRAIN&VENT-WATER IPA) ON
[
WORKER'S COMPENSATION DECIARATION BACK FLOW PROTECT.DEVICE
I hcrt ill rdupnultyofperConrnto( lf-inikmingdecleertCrs:
❑Ihsve Povvi ll[for b ineCion,37etc of the Ludlto Cottle,rotatorset-11 'C of
DRAINS-FLIX)R,RWh.ARP\,COND, STORE / PE NSTRUCION
s orL for
u poovWN f«by Setim J'!1U of the lab«Coale,f«de perforrmrcs of ale
workavwhich that paintkn aro,e PIXTURIS-PER TRAP
I have end will maintain Wnekda Cu e.fi tl«rl,fonee,ev«spiral by gwtinn
3 M Wun<I�ba Cale.f«the perfvnvrce o(de work for which Nis perQmit is faucet. GAS-EA.SYSTEM-1 INC.4(BTIIM UP APN
Care r-�e nCfAA Pr i NIoy �� •� GAS-F.A.Sys'rEM-OVER4(11A)
CERTIFICATE.OF EXHMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE-INTERCEPTOR
(This.nclion aced not be e0nspleted ifOc Isomil is forone hundred dollars(1100) BUILDING DIVLSI FITS
or kss.) GREASE TRAP PIA HECK FEB
I ccnBy thet in the parfrmaeeo ofthe work for which Nis Permit it ustexL l shell SIiWER-SANITARY-STiTRM FA.21X1 FT.
Ml employ any Procan in any manner w a.to become subjeC
ct to the Wrrac, mpern- ENERGY
O Z sation Laws a California.Dolt, WATER HEATER WNPNTIELECIR
O Applicw GRADING
`/y NOTICE TO APPLICANT:If,alto,making thin Ceitifcste of 17xcntptism,you should WATER SYSTEWTREATING
F^ " Namme wbjen to the Worker's Compen codon Levis of Ile labor,Cede,You r.u4 SOILS FTE
Wfas th comply with such Pmvinions or this permit shell be decmpl revoked. WATER SERVICE. _
d 0
U 0 CONSTRUCTION LENDING leW AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O kfor hy whichaffiron this, ellhrre iseconslne.3N7,ding agency for Ne icrfurmerec of Ur¢ RacipiX
� ► the wrrk[«which NL permit is iaaad(Sa.]U9T,Civ.C.) t, R n
U Isndetame
s Ny K TOTAL:
O U 1<edcr.pddreu TOTAL &
W 1 comfy Thu I have rend Nis epplientirn and'.dw that,above inf«nwirm Is BULLDING FEE
h roneck i.gra m comply with all cieY W county oNimeae erd Conte laws Nning er QTY MECHANICAL PERMIT FEE
U 7 building conswction,and hereby euehorirr aTr,watativer ofthiscity lac enterurym the SEISMIC FtiE
sip na 7-19's
abaw,mandamsnl property for imPection purportn' O
v.•er—
( )agree,to save,indem.ify end keeP harmlexs the City of Cuperire spoor PERMIT ISSUANCE E12CIRIC
Iirbflaic..judgmcros.cowl,adcxry:nc which may many way memo against mid City v• ( I• I
nmscgaae of the granting of this pemlit ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTpLR HANDLING UNIT(TO 10,IXp CFM)
SOURCE'REGULATIONS. MECHANICAL FEE OU
AIR HANDLING UNIT(OVER M"CPM) CONSTRUCTION TAX
Signawm of Applk VGmtmcum L"' EXHAUS3'HOOD(WNUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLO UNE p,
W1l th,aEllicam or future buidingarnPatu so,orheldk hnreadmas mnerial HEATING UNIT TO 100.000 BN) 16
u def d by the Cupenim Municipal Cede.Clapu 0.12,pal the Health rand S.fery
Co[e.Seat.25532(s)'( HEATING UNIT(OVER IM."BM
E]ye "eNo
VPMIIATPAID
[ON FAN RISID) ate 871
Will Ban anna None me buildi.g o«upanl tut,uPeipmcm or kovne,which
minor Mardous air contaminants on defiant by the Bay Ama Air Qaality Maragcnem BOILER-COMP(JHP OR IW,M BTU)
District? BOILER-COMP(OVER 100,"BTU) TOTAL,:
pre g4.'o e d
1 have read ole baro/dwu nalcrvals AIR CONDITIONER
req 25533 na sandier C Ismatn95oftK Cali ISSUANCE DATE
horn.Helen&Sahry Code,Seniors 2.3505.255J1 ud 25534.1 u notify
dm if ole NEW RESIDENTIAL ASECH. SQ,17.
1cilNng doe cent cumenelY hnvcaleoune,lMlit is my ocyncnibilirymowtify ole neap t
M ole tcquimrcmv which maV bac ren prior b isuarce d'a Caeifeae Of IJ,rmpa.ry.
Owner nr amhurred agent Date TOTAL '100 ISSUEDR 1
OFFICE