31350 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. FERMITNO. /N ^ O
BUILDING DIVLRION APPLICATIONIPERMIT PLUMBING-MECHANICAL J{ 5
BUILDING PROJECT IDP,NTIRCATJON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7�0!5 i f%T 2 Sal 4-
OWNI!RS NAMLX. / I'fIONI!: CONT CTOR'S NAME: CNO,
1J\ •V/� N/C CONTROLHR)JRY
A IT
RCHECT(ENGINEER: LIC NO: AD qq ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Considtant Fees Paid by Applicant(Initial) BLDG F ECL' PLUMB MECH
❑ ❑
LICENSED that
I CONTRACTORS DECLARADON QTY ELECTRIC PERMIT FEE
I hereby eBfimt Inm 1 an Ikrmed nndrr pa"idrm",rr, enapmr 91samnrtnring OB DESCRIPTION
C0Z an f11f n70(I(IIT Division Jnr doe Budrccs unit Profeai.Code,aw my li.,, PERMIT'�00w p: w' RESIDENTIAL
full fact and cR ^Yn
-VU License tic,♦ v /� ❑ADWL ❑KRCHFI: RE-PIPE�ZQ pLL` Dae ntremor APPLIANCES-NFSIUENTIAL C1 ADDITION ❑PLUFIBING NE-PIPE
CTS UECIARATI01 ❑MULTLUNIT ❑STRUCTURAL,
ZO�„Z„ lard - myply . cued as ilcmro PANELS MODIFICATION
CZ G, UPTO 200 AMPS
P`4t Lr Pofc.v ❑INTERIOR ❑CHIMNEY REPAIR
201-10(k)AMPS IMPROVEMENT
Sy YW,'aj OWN ans BUIexeLDERm DECLARATION OVER I000AMPS ❑BATH RE DEVREPAIR ❑DEMOLITION
y < I hereby
arfrm on 1 1Sebemp(tutu the Cnnan,Cc Lkcnse Lew ra Ate
x 31Y U fallowing Hunan.(Section 7031S.Uusinca ar,J Rafasitm Cak:Any city or manly SIGNS ELECTRICAL
LLl LL LL which ryuira a Penni)to mnurucl,aMer.impale,demNixh,m repair any nructurc
C pfirc No res isauunm also requires lhcapplicunt furauch uo filcasi al alammrnl
rn penny Sn $PECIALCIRCUIT/MISC.
)�a,Y Jun he is lircmcJ pmuantwNc pmvisioea o<Ne Cnnmsmrs littnse law lChapter9
0.'�� Icomlmming win S«tion 71XM1)dUlvuirm3nflhc Uusimu vrd l'mfcari,xu Cotic)ur TEMP.METFA OR ROLE INST. COMMERCIA
6 a e WI he is exempt tWcfmn v,J Nn buil fm the JkgM eaerrrptvn.Any vidntian of
Section 7031dn ❑TENANT ADDITION ❑DEMOLITION
^m rise
npplicwnrs( pnnil euM1jecu the epplicunl lo pewlty of LOWER DEVICES
FZS' °O1 p11e rMn Erc huNnd Ooilwa 15500). ❑TENANT ❑FIbDSF.RVICE
p Q �1,nx owner of lb[pniperry,rr my cmpinya:�w'iN wage"mlheir win cnmpen"mitn. SWIMMWG Pp)L ELECTRIC IMPROOTHER P.MFNT
C4L will m Newak,Cade: buCon a tor.Lil,5gl aoRvd f«aek(Sec.]OSI,Baircu ❑OTHER
L m eM Pmfwaian Crile:The Conuheame Iicemc law rbc nor apply m m owneru( OUD.LTS-SWITCHES-Fl%KRIS O.
property emir wilds or impmva tensa,war who arta such t air himself err dwugh
his own employees.Pmvin, that such impmn.[it non not imrndcd a Dffraal*11.,an NEW KPSIDCNTIAL F.LECTR SQ Ff.
oak.ILMweverill ha Inebalnof M11ru inaalh did huild orcompletfoNthe SQ.FT.FLOOR AREA SSQ.FT.
we of sa)der will have the duden of proving IMt he did m huild m impmvc for par-
- 01 of sele.l.
I,u owner or de Sm.7( ,am umss arty mm,,sa,s wish lir .a. narucura m TOTAL:
mswn Jac prujm(Ser.7tlW,Hmirmv mal Pmfniau Cade:)The CnntnctNa Li-
cemeLion,Yn no apply m an owner ofpmpeny wile huitia orifrparcs lherma,amt QTY PLUMBING PERMIT FEE
wI r contnic s f«such pmjecu an a mmrueto(a)licenced pununni Ice Ne Conlnemr's
Eiavc law. PERHTTSSUANCE P A I D
❑ Ivmcxanpt u,dnr&c. ,B&P C Ta thin re.
ALTER-DRAIN&VENT-WATER(EA)
U VA DATION
dnmCr
WORK17R'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE IAV i� ��
IMehy aflmt umkr perelty of perjury Tac of the following Jrxlaatiom: NO 9%
I lure aN eat mainuina Certifi mtfConsent.self-vtwne fmWarkda Connpen- DRAINS-FLUOR.ROOF,AS EA,GOND,
tiara,an provided for by Senior 37110 of rhe Labor Code,for Abe p affomuncc ofthe TYPE NS9'RUGTION
wok fa which do,permit is incest. FIXTURES-PERTRAP i Ur Uur Y11IN
1 ha.c mal will maintain Worker"Campenvtial Insurance.as rtquired by Scnim
37M ofdre labor Code,for de perfammla ofthe ward,for which Nupmnit u lupuN/.� GAS-FA.SYSTEM-1 INC.4 OCC.GROUP APN
Car Wt7p PalicyNo: ��//-I GAS-EA.SYMLM-OVER4
RTIFlCAIE OF EXEMITON FROM WORKERS' "
COMPENSATION INSURANCEGREASMNDUSTRL WASTE BCEPI'OR
(This anion ncM mt M conmered If the p,oii in for me hunNal dnn SI.
llaW) BUILDING DIVISION FEES
a 1—.) GREASETRAP
PIANCHECK FEF.
1 ccnify thatinthe tiny roar ore of Nc wmk for which Nice permit is i rslred,l ahnll
nm employ any perwnin atynlwne vn ast/ti meaun'clbNe Warken'C SEWER-SANITA -SIYIRM EA.2t]n FT.
Z vsbo law MCalifamie.Due J� / " x anpcm ENERGY FEE
zANIami N WA'ItiR ILEA WNLM'/F,I,I:CIR GRADING FEE
In NOTICE TO APPLICANT:Jr,doer ricking chis Certificate of Eaefrption,you should WATER S fTtEATING
a ; bmonm aubjc I m In,Wndrrtx Grmfensetitn pruvist«In of IbC faMrr Gdc,you mu,, SOILS FEE
Q Q fmdrN manly wiN such pnsinfuns err Nice,per
mit slWe tate
nen,In, revoked. µ'ATE .ERVICH
CONSTRUCTION LENDING AGENCY
7Z N RFSIDLNTIAL PLM B. $Q.FT PAID
V Q Iherenynffirrndp Nem iiseamutm.3N7.a Coo
agency for the prr0mmaree a( Uom RadptM
� �-+ Ihcw'ork fm which Nis permit in,issued!)Sec.709].Civ.CJ
F-' Lrndcra Nanc
Q V TOTAL:
w Lader'"Addrtaa TOTAL
1 ratify Na 1 have read this application end nom that the dbs,a infamwNloo i, BUILDING FEE
rn cartel l ague m c«nilly wiN all city end many adBurca ads„^mw mWtiog m QTy_ MECHANICAL PERMIT FEE
C.> "Z buildiegcongraction.aM bertbyeuNorirc reprt"rnudvaor Nis city menmr urym the SEISMIC FEE
nnove-nocri pro,noy for laprnion Purposes. PERMIT ISSUANCE
(We)aye,m ave,iodcmnify and keep humin.t!x City tf Capenino og"inu ELECTRIC FEE
liebiliumladgmenn,crels adexpenses which fray inany way accrue agairst said City ALTERORADDTOMECH.
in coram arae a the,main'M Nis prmlh. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO HL"CPSU
SOURCE REGULATIONS, MECHANICAL FIE! 01
Z ZYO
AIR HANDLING UNIT(OVER 1),001)CFM) CONSTRUCTION TAX
Signature nf`A,hmaikC,,i1.i, Uwe EXHAUST HOOD I IDUC17 HOUSING MITIGATION FEE
F RDOIIS MATERIALS DISCLOSURE q �
Will Nenpldicnmar fumrt buildingampammnrcor homde hureNow imlcrinl HEATING UNIT-TO 100,100 BTU)
a drftrrol by the Cupmiw Municipal Cade.Chapter 9.12,and the HmIN and Safery
CaR,Smdon 25532(a)7 HEATING UNIT(OVER I00,W)BTU)
❑Ya ❑No VENTILATION FAN(SINGLE RESID) I'AII
Win Nc t m famrt Wilding ort Due Rettig
air cone uo,BayAegwptrcmmdevimcureal BOILER-COMP(3HPOR IBB,f0b BTU)
mit hvudaua air cnmaminmla m rkEr¢d by Ne Boy Area Air Quality Manegcmcm
0, unit? TOTAL:
❑Yu EIN'o BOIfIR-COMPfOVER 100,000 BTU) J
l have rad de lwaNrws rtmtaiala m,co.oiurder Cwptm 6.95ofthc Cah- AIR CONDITIONER / ISSU NCE DATE
forma Heal h&Safety Cork.Sertimu 25505,255]7 and 2P5 L 1 wdenwrd Ih3I if the NEW RESIDENTLLL MECH. SQ.PT.
wH,1a9doe's nes euneody have v."That it is my resporuiH1uy tu notify IM m.,enl
of the requhements which awsl 4 raw prior to i"suera of a Cer iflcac of Omwparcy.
Owrera vudxnuJ egmr Oem TOTAL ISSUED BY:
OFFICE