30261 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLECPRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30261 0 /L6
1
BUILDING PROJECT IDFMIFICATION �J V 1
AICILDINGADDRESS: OR—
NO. APPLICATION SUBMITTAL DATE
�qWWRSAl PHONE- O CONTRACT'OR'S NAME LIC NO:
WC - CONTROL
ARCH ICT GINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG .EC7, LU Mli
LICENSED CONTRACTOR'S DECLARATIONEJQ ELECTRIC PERMIT FEE �u[C'
I hereby mirm that T un licemN ander Pnariaav of Chapter 9lcommocndng JOB DESCRIPTION
t 'Z with Sermon J01M0 of Oirienn Jnfthc BTaircu tad Rvfeuivns Cotle.mdm licemeu
00 y PERMIT ISSUANCE RESIDENTIAL
in rwI roroe am eEat.
YW f- ❑SFDWL ❑KRCHEtJ REMODEL.
Q V V e Clw Llc.M
DomeDatCaurxtm APPLIANCES-RISIOFXTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION
ZpyZ Imuleormi myplms shoal hush u public acords MODIFICATION❑MULTI-UNIT ❑STRUCNMODIFICATIONOZ G UP T0200 AMPS []INTERIOR ❑CHIMNEY REPAIR
F
co Licemcd Pnaeseisnal 201-IOW AMPS IMPROVEMENT
y E OWNER BUILDER DECLARATION
I heahy affirm that I atn emmpt from the Cnmractor'e Limnx law for then OVER 1000 AMPS FI BATH REMODEVREPAIR (_1 DEMOLITION
X LL F fallowing reuutn.(Sedation 70313,Business and Professions Calc:Any city or countySIGNS ELLCIRICAI. [I OTHER
y which norm d.pomdt m ssm
axtn,alter,imp,.A,,demdish,or alai r any ururtuct
���� Iriorm its issuance,also rtdmtBo applicant Grinch permitto rile a signed statement SPECIALCIRCUIDMISC.
� QO that he is licenssd pwsuwe tothcpmvisionsofthe Contractor,License Law o0haraen9
(cnmmeneingwilhS li,n7tUllaf Dlvlsion3utdn BusineSnsdl'ndmsums Ct e)or Throw MISHiN OR P01,13INST. COMMERCIAL'
d a C that he is exempt therefrom and the loris Gar the alleged exon lsn.Any v'wletion of ❑NEW BLDG/ADDITION ❑DEMOLITION
^"k• Section 903L5 by any appliranl for a pcmill whjecoi the a,flacant m a civil penalty of POWER DEVICES
m ❑TENANT El MOD SERVICE
FF.. nm min:Than rive hu rocs Jollern y camp) IMPROVEMENT
CSD ❑I,to oxmsnf the pnlpeny.er my employaa witM1 wages eatMirsole comp oat SWIMMING I'()UL ELECTRIC
2222�_ will do the wm,,ard me,mucmre is inn ineaaaednro¢.red fins,sale US,,9064,Boo. ❑OTHER
a3 and!Profcuions Cuddled TIIc Cmdruloh license law do—rm apply tr en owner of OUTI.ITS-SW ITC111S-FIXTURES
property who buildv or impntvea thereat,and whr due.Bach work IJms.lf or Waugh
his own empluyen,provided those such impm,,eare s cc int racial or oHeated fa NEW RCSIDEsl ELEC*IR SO ET.
ate.iL however,tM1c hllding�r imDnvcment is,Nd wiNin one yea of completion.the .Fri.FLOOR ARTA 3 Q.IH'.
caner-builder will hric the huben M pnving That he did na build a imPmve for par- {� 8
pore ofoley 1 d
❑I,or osaner of the pruprny,em esclusively crntfacting with licensed aromas,,to - TOTAL_
raccur t Ne'*e:(Sce.]f W,Harems oil I'mfeedonr Codd The Conbmacmts Li-
c.Lit.dins,.epplym an owner officiation,who Milds or improver dhamt.and QTY PLUMBING PERMIT FEE JUL 23 1996
van,arose.fm etch Prujau with.cumra tti licensed pursuant to the Cmdanic tnlr
Lsmue taw' PERMIT ISSUANCE
T uncxcmq un ,9&P Cbar thice reason CITY lir uUt'tritHVU
ALTER-DRAW&VENT-WATER(EA) VALUATION
�wrer f.�L1—Duc
I 1 A SR'S COA PFNSAfI N D'NkRATON BACK FLOW PROT[CT.DEVICE
1 hcaby affirm under penalty of perjury m,of this,fol"ing
I haveud will msiu.ina CcnlfcccofCimatat to self-imiuc forWorker's Compen- DRAINS-FLOOR ROOF.AREA,COND. STORIES PE CONSTRUCTION
nazism,u Previdd for by Saeian 3900 of ac Labor Code psfamana
Coale.for the of We
work for whish Thi.permit is is_atal. FIXTURES-PER TRAP
❑1 have erd w0I maintain Wakcr's Carnprnuam Laurence,u aquuM by Stardom
JJUOoftic lalnr Code.for die pe,formsnee oras wort(«which this permit is coated. GAS-EA.SYSTEM-I INC.J OUTLETS OCC-GROUP APN
My Works'.Compsuation bauuaree carrier W Policy numbci ate:
Curicc Policy sh, GAS-EA.SYSTEM-OVER 4(EG
CERIIFTCATE OF FxAHi f1ON FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Tbis.uxti..need ma bemml4cted ifOc permit is Grrune modr.ddollue($100) GREASETRAP or loess.) PLANCHECK FEE
I certify Net in t he Nifomarue ofeba work tis which this Permit in issued,[shell SEWER-SANITARY-STORM IA.21X1 IR.
coremploy any Pennon in any nnnncr.m as m bea.nc subja'e to the Wooten'Compere ENERGY FEE
O z eatam Iaws of Cahoots.Duce WATER HEATER WNENTo.timu
Applicant GRADING FEE
� la,I NOTICE TO APPIACANT:If,.[ler oolongthis Ccniricdcof Exemption,you slndid WATER S YSHJN/IRPAT NG
a , haram,subject m she Worker\Cmn,asm inn Prockions of the Iuhur Code,you mato SOILS FEE
[IJ fine hwah comply with such lots i sin o,mit Permit dall he&eased revoked. WATER SERVICE
Q
0..
COt Himi sCIIONodamlNGAGENCY NEW RESIDENTIAL PLME. SQ.Fri. PAID
:z) - I MTcb both bitMtthcre saad(Scc..m leading vgcrry for the penfanrluue of Date Racily♦
I'- a work fm which deer prnnie is inroad 15th.JUJI,Civ.C.)
I--' Leader',Name TOTAL:
} Lender'.dradreu TOTAL
,r y 1 scnifY that l have rein this applirnaw and some that eM above information is BUILDING FEE
rn clmm.l egac to comply with diary ad cmmy ordiwucr and sum laws aluingm QTY. MECHANICAL PERMIT FEE
V Z builifim,ocesuuction,and heahysuthoire rtpresematives N Nkscityto smisrupov the SEISMIC FEE
above-mrntiarud propcny for inspatim puHroxs.
PERi
MRISSUANCE(Va.).pce to savc.iMnify tad kcp Ninth the City of Capcanon ee
liebilies. mcons mJ expewi which my in ny amy tactic,egant said City
uneofNptingofaapmt. 1E
ALTERORADDTOMECFTN
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT(fO I0.000 CFM) MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCIIONTAX
SipWure NAryrlicamsCslmrxdm Date EXHAUST HOOD(WMUCDHOUSING h1TTIGATION FEE
HAZARDOUS MATERIALS DISCLOSURP.
0011 ac.ppHevu sr future building mvpant once m has barardws material HEATING UNIT(TO 100.000 BTU)
m dcriml by the Culcnim Municipal Curie,Chugs 9.12,ud the Halal tad Safsy
Cuda.Scsiaa Z5J2fa)J HEATING UNIT(OVER 100,000 RN)
_ 0Yc E]No VENTILATION FAN(.SINGL.Ii RESiD) PAID
Due Racile«
Will cshe applicant or ratan building by ths,B use ryui irrcm ar Jcvic.n which BOILER-COMP QHP OR 107."BTU)
emit hunrdwu air cunulniwmt.os dcfml by the flay Arrn Air Quality Mvrwgeannt
TOTAL.
Okuda?
[-1 Yet, 7 N BOILER-COMP(OVER 10(),00000 BTU)
1 have road Th haran ous mmerialeAIR CONDITIONER ISSUANCE DATE
mymamrnte under Cluger fi 93 of ad:Gdl-
fumi.Hwhh&Safey Code,Smiuro 235115,25533 and L5531.I ander,oad thud if the NEW RESIDENDIA1,MECH, SQ.I T
handl ng,Tarrmao,which
rma:In leo:a of olsafyccof a ihim eatnldifythe Iccupane
of she rtyuimnunes which muN be owl Pmuna iuumuc of u Ceni�ale of Occupurcy.
Owner or audminud agent Date ISSUED BY:
OFFICE