28556 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 28556
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
r2 rerOWN SNAMEO � PHO510_2_^ �-170� CONTRA' 'S NAM LIC NO:
L NIC CONTROL
ARGyI
Rem:
/IBJ,/f N I.ICNO;_ ADDRESS: ❑
CONTACT. PHON@ BUILDING PERMIT INFO
GrI`p r 510 _� -M M ❑ COnwltant Fees Paid by Applicant(Initial) u.E PI.uMq
G INC
LICENSED CONTRACTORS
m 'S DECLARATION ' I VGr QTY ELECTRIC PERMIT FEE f�(`
1 hereby affirm I am Ncervd under pov+aiou of Chnpttt 9(commencing JOB DESCRIPTION
aZ with Sceuon]0(10)of Divi+ion3af the Busiteu std Profnsiau Cure,onsf my ficeruc is R CIDFNTIAI_
O O PERMIT ISSUANCE ��
5 liaue infulluW eRmt.
❑SFV WI. � ❑KTI'CHEN REMODEL
<CUF�V Cl Clea lic.x
F�tDe. Contramor APPLIANCES-RESIDENTW. ❑AUDITION [I PLUMBING RE-PIPE
a
ARCHTIECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
~t2Z �mdenulGl'I�pyyyl�tCLcdn Public vd+ PANELS MODIFICATION
cz--c Lm�( twml�(� UPT02WAMPS []INTERIOR - [I CHIMNEY REPAIR
q Y
2
ER BUILDER DECLARATION f11-IlM1f1AMP5 IMPROVEMENT
ySyx 0 6 1 heaby.firm her 1 un cacmp from the Cmz
umra'a Urcr.Law for the OVER I"AMPS ❑BATH REMODEVREPAIR C DEMOLff10N
W 3 L IU. following ream.(Stttion 7031,5,Busman;and Pmfe.uiau Code:Any city m count, SIGNS ELECTRICAL [I OTHER
F O ya which re,mm,.permit to comtrum,.ter,improve,demolish,or icor any.1.
J prior to IN oriit1w myuuo tW aPpliam for such Permit o Rk a signi stemncm SPECIALCIRCUITfME,C.
ytnuk HliceruW pursuant tothe pmviniuta 'ContractNa Litems law(Ch.or9
CO (nxnvettine wim Sation'!UU)ofDiv' Juf Buvineu and Profnsinow Code)m TEMP.METER OR FOIE INST. CGM_MFRClAL
6q C far he u cacmp thateof eM is t«0sc al gcJ eaemptian.Any vmhm.n of ❑N BLDG/ADDITION ,O DEMOLITION
x�LL Scaim 7031.5 by.ny gglican .permit wbjau ,, icmt m D civil penalty of POWER DEVICES
W rn NANT ❑FMD SERVICE
F Z Y to.sore t,•"Ove (5300).
6 Luowrcrof
Y.or my empllyen wim w. uthcirwlecom,emation. WIMMING POOL EUCfRIC M, IMVFMI'1JT
$a O will Bothe a the uructme la sot lmm�JNmoll'er fer.sale(SU.70a4,Bmores ❑OTHER
LL] mJ Pmf is u Corte:The Cmtrectas liana Law not.poly to w..r of S-SWITCHES-FIXTURES
Irtopert .1,o Wild,or Imprlvn thereon,ar.who doe. work himself or t hrougn
his ow employe.,Pv iJed that such im%avcoee fir
i mmo ed or offers for NEW RESIDENTIAL ELF.CfR SQ FT. "
aa1e.IL ow ver.the WilJingarimpnwemanti Wwithin ycu Mcomplaen,tha SQ.FT.FLOOR AREA SAO.FT
'I der wiO Have the dude of pr vin h he did no Wildaimpmve fm our-
pmelf o).
❑ 1,as r of the y,ort ly cmtrctin im liueruN cnntmctors to
coume the pm' IS J Ihofp- Cede:)The Contractaln Li-
anreL. inn ni of Praped, Wilda ta
or ro,ro'c,dwreon.and QTY PLUMBING PERMIT FEE
who for eIt aconuact licenil,mommmmcennlmcmr'+
urc . PERMIT ISSUANCE
❑lame ,B&Pcfmmi,.aeon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
�D rc Due
W R ;R'S PENSATIONDECLARADON BACK FLOW PROTECT.DEVICE ��G'-•}�`
1 by.Eli mkr .ryn(prjury ane of the(011awinN Jed.ruiarn: (/C/
]Ihave wJlmainui nifxutu ofCmantmwlf�insurt Rx W'ukNn Cmycn- DRAINS-FLMR,RMF.ARPA.COND. 'TORI TY%i CONSIAUCTION
.xi del fea b 'm 3200 of the Mr Cede,fa the parfarntuncc of dse
wart(«writ Wa 'i mats.. XTURFS-PERTRAP �
❑ 1 have s. I ensu Worl et, • Insurance,v requrd by Ssrtion PI P9 o A'
3'IOOafthelshor ode,far Be pe.om ,kfawhi,hthufermiti.smuW. GAS-EA.SYSTEM-I INC.d OUTLETS
OCC.GROUP APN
My Wr.. Cvmp-asetin l a and alicy nun SEP
Currier.. 110 No.: rL S GAS_ErINDUITRLW ERJ IEA) - 7 t
CE -ftE OMPPP���LS 0 O OM t S GRFASFJWDU.STRL WASTE INTERCEPTOR BUILDING DEVISE FEES
rnti.sam:mz not W ifIN
s I oforcombmtdtmdalers(sloo) GpY , ..
«less) 1 GREASE.TRAP PLANCHECKFEEVUrCf 1 Z�
(certify thvt in rRxrwna ofthe wmkfu wli�clt this lenmit iermM,lah.l SEWER-SANITARY-STORM EA."I
rot employ any perm.N any m.nncr m as to N rmt,_'jeer m the W ur*ew Compen- ENERGY FEE in
O z a Irawa of C.Jarnic Uuc WATER HEATER W/VFNf/IiLEC1R GRADING FET!
Z A,hazara
y NOTICECE.TO APPLICANT If,after mai Wi+Coon,o of Lacmpti oryinshould WATER SYSTEM/TREATING
become whjcct to me Worter'+CanpawW ion pmvisiln,of the Limo,Cale.You must SOLI C FEF,
fmbwim comply with atwitpmvisiom mthia prmut Wll trJeemud rtvokal. WATER SERVICE
Q
a7. z CONbre'.c ONLENUINGAGENCY NEW RILSIDNMIAI.PIMB. SQ.FT PAID
U Thereby DlBmithm there isecsl(Seniml,Ci, agency fm Ne perfmvwalf Due Reaiptg
lL F., Lerthew ,Na whichtosspermit ixiuued Esse.l()99,Civ.CJ TOTAL
� U Iandc2,Name
y 1 reuly that llave reed Nl+application W,oro that the aMrvc information is BUILDING FEE
to CORER.)egme tlcomply-ith,"city ud county,mfituncuund state lews mining to QTY. MECHANICAL PERMIT FEE
Wilding conurvmim,md hereby auNMaa rePrucnmtivn ofWis citymemer upon the SEISMIC FEE
ebmx-memtiaasl psc i for inspection poopoi PERMIT ISSUANCE
(We)egra to.uve,inremtufy and k,,P hom,boc the City of Cupertino against PERMIT FEF,
lutil'nicejudgmrnts,cosu end expense,which may In any way accrue ag.wu uW City ALTER OR ADD TD MECH.
in mruequemc of the granting of this Ptorm. PLUMBING FEL
APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10,000 CFM)
SOU ' GULA SECHANIIAIIEE l'
AIR HANDLING UNIT(OVER 10,A0CE),) CONSTRUCTIONTAX
i,n+mreo on. I Uue EXHAUST HOOD(WMUCO'
MATERIALS DISCLOSURE HOUSING MITIGATION FEE
H
Will the-wit.or future hamling occupwt mmem mJle hmaMws mater. HEATING UNIT(TO 100.000 BTU)
u de(nii by the CuPmtiw Munici*Cade,CTaptm 9.12,W nc Health mill Safety
Code,S.6.25532(v)'l / HEATING UNIT(OVER Ift"BTIH
❑Yn J�`p'�` VEMILATION PAN(SINGLE RFSID) PAID
Tete Receipt N
Will the air cinntarfumrt Wilding arupamyAttaammeter ality .which BOILER-COMP OR 100.000 BTU)
:mit h.,••dou+.n cnntamironis as Jc(nM by the Bey Ana Air Quality Marmgcmcm -
Euxrl TOTAL
❑Yn � BOILER-COMP(OVER IM."BTU)
I hi mad tK lurmdou,material. AIR CONDITIONER - ISSUANCE DATE
r5.2553enu urxlm CtwPterti.95 Linn Cali.
forms Flnlm&S.ay Code,Seaiau'3505.255JJ ud 23534.1 uohrswd slut if the NEW RESIDF'.YTIAL MECH. SQ.FT
Wilds wt Neve that it ismynvpamibltiry to wtifY me mvpant
of swhi misvrmxe afaC 'feat of
'uJ agcm
Date ISSUED BY:
OFFICE