29078 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLECTIUCAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMI'P PLUMBING-MECHANICAL 29078
BUILDING PROJECT IDENTIFICATION
HUILDINGADDRESS: /I - SANITARY NO, APPLICATION SUBMITTAL DATI
OWTERS NAME PHO4NI/ /V/ •/I./-CO T)"V.SE: r4r
NIC CONTROL'
kRCH1TECTIENGINEER: LIC NO. IDD /r...C./(...�/� L.�R� �; .^.- ❑ ^
CONTACP. PHONE BUILDING PERMIT INFO
/y/ � 7 ��/ ❑
Consultant Feev Paid by Applicant Unitlal), BLD IB,Epf PLUMB �I
(/tom LICENSED CONTRACTOR'S DIi RATON w QT-Y ELECTRIC PERMIT FEE y,J
I It urfirm that I un lian.i,d udlct pnovlaiau or Cli ler 9(mnmmnciny JOB DESCRIPTION
{��Z with Secdon7")oI Di,uim J of the Bu.und WPmlrniau Curie,anal my lie.is RESIDENTIAL:
F in full Rxcc vrd cf PERMIT ISSUANCE
QF.VZ5 Lkcae Uri.N ❑SFDwL Cl KITCHEN REMODEL
NQW Dae Conwnar APPLIANCES-RESIDENTIAL ❑ADDITION - [I PLUMBING RE-PIPE
F o, CIS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
I unci amdl my plus shill be to d ns rtM
public arda ODIFICATION
OZ � UPTO20(l ❑INTERIOR [I CHIMNEY REPAIR
QFQ��DI Liccnsal Ptafeasiarol 201-HKMIAMPS ]IMPROVEMENTy.YEJ - OWNER-BUILDER DECLARATION
y C,W Q I hereby arm Jul l am ml Rum the Coouxtonh licemc Isw for the OVER I.AMPS - BATH REMODF,UREPAIR ❑DEMOLITION
�(3 S V following rtawn.(.Semon 703 1.3,Buaiws ud Protmimrt Code:Any ary or moil' SIGNS ELECTRICAL CIOTHER�
41 LL O which mryirts a p it m rnnurvct Win,imryove,Mkt aalirh,or ri ur any ntualm, _-�I
priorm N issumtt.aln maim;the apphcmt for aueh permitto lilea.dgnaln amnnm SPECIAL CIRCUITIMISC. 251 -50
�y thin h<h lkmrel'union,to We povisiemoflhc Contuctah Li.lsw(Ch",9 _
W OyCpO (ctrmmm�uin8 with Sc,im](1W7ofD vieiun3nftM1C Bunirmxrand htofccsimit Cadc)or TEMP.METER OR POUR INST, COMMERCTA
a i e K Jw he u eaemq I fi.and ft basis fol Ne alkgcd excmpdma Aey siuluian M ❑NEW BLDG/ADDITION ❑DFMOLITION
t+• Sttlion]03 LS by any applimtforupmtrilsuhjmu the appl..,ma civil'rallyof POWER DEVICES
^va ❑TENANT ❑FOOD SERVICE
Z Q ret 1,u Jun of huMrtJ Jollen 15500.
�� ❑I, IN, of tk p,sto,a or myemnten&d ,nffmaae tail r( kamprnmuun, SWIMMING POOL ELECTRIC IMPROOTHER WIFNI'
will do Newark,anitk stfucaaisndinmodcdar oEcrtdf«sale lScc.70ran B.of ❑OTHER
and Rofetim;Cade:The Cmtrv,dt Liatue Law docs nd apply to m nww of OIIILTTS-SWTfCHES-FlXTIJRES
d 3'. N&o ny win oyi .o iv p da ttertnn,ud wtw u such work hinwelf a ibrough .
tis own empinYea,pmvided Jut such imlwvemmu m owalo int n,cfa i offcmd fa NEW RISIDpXItAL EIECIR SQ FT.
sola If.Mtxcvmtl M,,l, ing anll. rarirl ieruW within amino afatmpla loo,Ne SQ.FT.FLOOR AREA SSQ.FT.
"'cof lk.).will Nve the burden of prvviog Jus he did nm build o itttpmve for
I,u owtmr of the pmpenry•,am cxdu.uvely a'onuating wiN IkcrtreJ conuctm in - TOTAL
mruw,the project(Sec.70Md,Hudtmu anal profensims Co&:)The Connacht;U. Q SEP 23
aloe Law Jon ndupply muowter of pmpmy who build;or imposxa th .errI TY. NUMBING PERMIT FEE 19QC
whoemvafir such pmjecu with•cmvevo(O IitttueJ pmumuothe Cvnvanm's vv X01
[3 l m Law.
Tem eaemp uMa Sec. ,BRPCf«chis rtatun h `II r �' k'�a met IJItU
ALTER-ORA VENT-WATER(EA)
0,. VALUATION
Due .
WORKER'S COMPENSATION DECLARATION BACK FLOW PR DEVICE �D
I lameby at under penaa'lty rjury atic arc of follow in8 dcclminims:
•(]Iheve andwillnminmin nCrniOcue of Consrnuo alGin.wm Gr Wthetw Cmnpum TRANS- R P. D. i
tartan.u pill fa by S Tim 37M of the Isbar Code.(a the perfomu cc M ft 65 TYPE CONSTRUCTION
fa which Ibis permit in in.uad. FIXTURES-P
love aM will moinuin w'ahrr's Cdttpmwrtan lratuvee;¢�ayulraf by Se<Jao
]00 of Ile lahx.Codc,fo thepMorroentt of the wmk fa which Shia lentdt in issteJ. GAS-FA.SYSTEM-1 4ay; S
My Work o pc u ernmerarWPolicy ��,,..,,n.F..mss OCC GROUP pPN
Crrtkr.� yr
Policy Nta: /Y.T1 GAS-EA.SYSTEM-0VFHtJ
CERTIFICATE FHXEMPTIONFROMWORKHRS'
r COMPENSATION INSURANCE. GREASFIINDUSTRLWASTEIMFACEPIOR
(Thtion nmm le l nmmplmpai=cd lithe int in for ihundtnGREASETRAP
l dollma($1001 - BUILDING DIVISION FEES
q u na
) PLANCHECK ISE
I cmify thm in the perTamwtcwfthc work fowhlcbthiu pc.oh is ianad,l shallSEWER-SANITARY-STORM EA.200 FT.
ant empiny'uny person in any muner w a u to b;ori subject In tk Workm'Conlin- ENERGY FEE
O Z wion Low.of Cdifomia Dam
WATER IIEATER WNG'f/ELECIR
z O Applicant r GRADING FEE
y NOTICE TO APPLICANT:IL after ntuking this Ccnifi utc of Eamn r n,you x1l WATER SYSIEMPORBATING
a �" became euhjat to the Worb,,Cdnpenu,ian pro,,i.al We ISM Ct .you mwt SOILS R3E
� ,.., fmhwith avmply with rush poroi,ions or this pants,dull be dernrd rtv9tcd. WATER SERVICE
� z CONSTRUCT ION LENDING AGENCY NEWRESIDEMHALPLMB. SQ.FL PAID
L) O Ilrrtby alRrmthat Jmrc is ecannrtmtian lendingal for perlurmaee 0! - Data Raelpt'
LL r the work fo will thinm
pttit u iuued(See.3047,Co,C.)
Q f•" Lmr!&a N. TOTAL
L e,Adds; ' - TOTAL
y I cenify thin 1 brie read thin applic m not nate thin the shove infatm,ion is BUILDING FEE
pl corrtcn lagmemmmply with Wl city uJ mumy uNinaaa std w,c Iowa mluingw QTY MECHANICAL PERMIT FEE
V Z' buldittgaxumation,mal hereby aninal rcTaaentawi .(this city to enter upon the SF,ISMICFEE
above-mcntion<d pmpeny for tspetim purpama.
(We)agrte I.nave,itdcmnify and keep barril Hall City of C.,m.rLWm, PERMIT ISSUANCE ELECTRIC FEE
IWilitiw.jWgmems;cmts and expens6 which only in any way nrcme against mid City ALTER OR ADD TO MECH.
in awequctse M thegwnirl of thin Ill. PLUMBING EFF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT QU 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FTE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAY
Sigwurt of AppliunvlCmtrvro Dam EXHAUST HOOD(WMUCI
3 HAZARDOUS MATERIAIS DISCLOSURE HOUSING MITIGATION FEE
WOthe a,plicmtmfwurt buiktingacupant stoe or baMk ltaanJaus material HEATING UNIT(TO 100,000 BTU)
u deEnM by the Cupeninu Municipal C,d,CMpmr 9.12,anJ tM Ikolth anal Safety
Code,SMion 2553N.)? HEATING UNIT(OVER 100,"BTU)
❑Yes /No VENTILATION FAN(SINGLE RESID) PAID
Will the ap,f.a fist.Mtild.,acupmt ore aryiptrmni or device which Date Receipt Y
t hawJau Wr connotation.,a;JeCn by the Bay Arta Air Quality Marti; t BOILER-COMP(NHP OR 100,000 BI U)
TOTAL
�Distrkrt
❑Y BOILER-COME(OV[R IIp,010 BTU)
ro,
I have real Bte twudws a, L,raaimmaar uokr Chapter 6.95 of Oe Cali- `�
AIR CONDITIONER �)
W ISSUANCE DATE
Taw Hl B Sifay Code.SaMs 25N)3.2531]and 255]1.I unktsurd thin If tic
bd,.raa tl celctwnt.Jwtit NEW RT•SIDENTUh MECOI. SQ.FT.
uIIcan
8 Y av yroptx�aiMlity to miifY ilm dxvpmt
of Ile rtqui>e�s t cttct piur to ivuaece MaCenifyWc� ,
TOTAL ISSUED BY
OFFICE a