30803 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICALPERMRNO. 30803
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL, 3 O H O^K J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - ,SANITARY NO. APPLICATIONSUBMITTALDAD
1! 7 t4ft 72-
OWN E R S A L D� 1 r PI I(IN[:� C MRACIDR'SN 1,113 , Orns LIC NOItil :
1YIY11Py NIC CONTROL
UTLiCIENGINHI7R: LIC NO: ADD ESS: /`/
'L 00 lit AIT�O 9S TV .
CONTACT: PHONE: BUILDING PERMIT INFO
❑ ConaRltant Fees Paid by Applicant(Initial) gLDO F11iC1' PLUMB MECH
LICENSED TRACTOR'S DECLARATION QT ELECTRIC PERMIT FEE
I�]•N� \Ic'fSi` \p�`
M m Z 1 lemhy.ram IIw L E d ander provisions of doper 9(eammencing JOB DESCRIPTION
ith$canon 7000)d Division 3, Nusirlesserd Pmfeasiom code.eM rtry lkcmeis
( FCC on full fmce and cRal. .1! PERMITISSUANCF,
%U�j Liarcse ClrulJc.M iFS FOWL ❑KITCHEN RE MODEL
ZL Due(� L � p� Cam,xur AP%.IANCTS-RFSIDENTAL ADDITION - L1 PLUMBING RE-PIPE
ARCHITECT'S DECLARATI N PANELS ❑MULTI-UNIT-' ❑STRUCTURAL.
ZOyZ ladcrsmarnd my plans,hill he uxdmpuMic sada MODIFICATION
OZ�❑❑ UPTO200AMPS '
r- NI Liamed Ymfcviorul ❑INTERIOR ❑CHIMNEY REPAIR
2(11-100DAMPS IMPROVEMENT
OU OWNER BUILexempt R DECLARATION e OVER 1000AMPS ❑BATH R�Aff1DE1/RSPAIR'O DEMOLTION
5 a 1 hereby affirm OW 1 It exempt fmm,hi,Contractor's Lknue Law for the }Y �s 1LJ!
3a followieg no.(,Sesior,I(Ei3.Buaircz.and Pmofesmacts Code:Anycit, county SIGNS ELECTRICAL [j OTHER
a which regaires a penman a con.ruct,filler.improve,dribi.h,or refVir any,immure (}—
C prier to its i.svwae,also requirca me appllkau fa such permit to Bkadomed.mmomf SPECIAL CIRCUIT/MISC. m(•II DCnan
pipgns' Ws he is liernW Up
purbouo die ovisi,ms of the Caecrarn ljoem,e law(CM1eper 9 wl:
I+I�00 (commencing with Scbmm700)of Division 3 of he Budnbs and Professions Code)or TEMP.METER OR POLE LI
frST.
a a y them he is exempt thereomd the been for the all,exi exemption Any videti,n of pJ
CteD70N ❑DEMOLITION
xx•�4• Seaia 7"71.5 by any applicant Lr a emot subjects the opplicwl I.a civil pc emy or POWER DEVICES vu. C'(I
Way ❑TENANT N(/OFooD SERVICE
F u
Z Y °°,nc than f vi,hwdreJollas d ($5(10). ,
IMPROVEMENT
6pI,mowner athe"breny,fir my employes with wage.e+,hcir sole comPnsetiun, SWIMMING POOL,ELECTRIC EI=.a will do am
thewoA.admearuceNnotimmd
� alofofleralfor sale(See 70,14.Busircss ❑DTHEft
W1:
3�_ end ftofsavwm Cute:The Ccotrctara License Law does m apply a an owner of OVfLEIS-SWRCHFS-FlXTURES
�• pm etfy who huildv,r impmvu Ihcxnn,and who floc,such work hinnnclf a thwagh
his own earRoYcca,PovidN that such imposemcva are not iaesded or offered for NEW RESIDENTIAL ELF.CTR SQ PT.
vide.If,however,the,building oritnpmovemenm is wild w ithin acYcarnfrornpletion.lhc SQ.FT FLUOR AREA $SQ.PT
cr.huildrr will have the harden of loving tam Ie,did not build or improve for pw-
pox of sale.). IL
E] I,as mvnsr of,he property,an exclusively enntra,ing with hcem+vl comm tori of TOTAL:
amucm thepaned my .of Noone adrty who bui Crde:)Thc Cootracwis li- 1
who
wiwerdpropeny wemnuts ldsorimprovesCurcon.um QTY. PLUNGING PERMIT FEE
who ion,LAW for each PojNs wish•conlrvemrta)Ikenxd puna,unuoIt!Canxmore
Ocrnx law. PERMIT ISSUANCE
❑lcon cxcmpr umkr Sm. n
,B&GC for rraran
Owner [)me ALTER-DRfIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I
I heathy Mian under under prnalry of perPay ae d de folB,wiog declamations: l- O I�
J Ihnveemd will mvinainvCcmticvc nl Gmxnunsdf-inwmu for WuAdc Gmnpcm DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
ided for by Section 7100 of Ire labkthe
or Co, ,for permurce fo *of the
wmka provforwhkhmi ,,trootisisa,ed. FIXTURPS-PERTRAP
❑I have old will Inanraln Workcra ComPmmia Inwmrca as xyuirN M1y section
JYWoode labor Code.forthe pemercamccofmAcwmk fmmmerM1 dtis pemdt ix isarcJ. GAS-EA.SYSfiAt-I INC.40fITLLTS OCC. APN
MY Worker's Cmnlprnwmia lamw,la carrier and Policy numMr ac:
Cartier Policy No.: GAS-1,:1.SYSTEMOVER 4(FA)
CERTIFICATL OI,EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASI%INDUSTRL WASTE IM17RCEKOR ULIDING DIVISION flFS
orI..(Tua accmian recd nor be compinedif the Rnrdtufmme,huMmeJ dollen(SI00) GREASI?TRAP PLA
1 unify that rife,Prfmmaee of the work for which his pmnut is it ucd,1 shill
not employ any person in any main rc son my tIn Els Wnmlo"'Callen- SEWER-SANRARY-STORM E.A.200 FT � F., i
pus-
ZZ sada law w(Culif Dafc _\ �� WATER HEATER WNfMIELECTR GR LNG
O Mpie.nt jN
h NOTICE T� li
APPI,I AM:ILii t ni&Ari me of Exca ioa,yw,u should WATER SYSDEM?REATING
ea
Nvr cubjec,fo Be Worker's Cun Lion positions of mate Lubar Codi,,you must SOILS FEE
WfoMwith canply with aueh provisions or lhispamir sM1all be,kemed revoked. WATER SERVICE
a.
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MIL SQ,FT. PAID
U0 Ihcxhy affirm lam dart in uca..runion lcMing ugwcy�onnepMumnmcc of Uva Receipt
V. .r the work for which this Permit is issued(Sec D099.Cr,C.)
O U Leader's Nems DOTAL-
Istdcrs Addri TOTAL:
E" 1 1 emit,mlmt I love rad this epplieau,m and some NH IN,above Iofwr,n.>tion is BUILDING FEE
h mrmect.I agme w comply with ell city vN cuunmy ordinances and state ww<mlmmg In QTY. MECHANICAL PERMIT FEC
U z building CamslrwXtia.eM thereby authorizexprexnwivs ofthuciryacne,r upon the SEISMIC FEE
ahnvc mentioned p,tem y per inspection purpoaca. '
(We)figrtewsavelaknmity ad keep tlamle.0 me Cimy of Cupmin,ageing PERMIT ISSUANCE CLECpRIC HE
liabilitica.jwlgrrcas,costs and ex,emes which may in any way acme egalmf said City
in nnxquence of the grenti ng of this profit. ALTER OR ADD TO MECH. PLUMBING Fti
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITT,10,000 CFM)
S1 CBR IATICKS, MECHANICAL FEE .
AIR HANDLING UNR(OVER10.00aft CONTRUCIONTAX
Aprili ructar Date EXHAUSTHOOD(WIDUCI) HOUSING MITIGATION FFR
H RDOUS MATERIALS DISCLOSURE _
W,Ihle tm fume building rucupantsao or hamdle hmvdom numeral HFATING UNIT(10 00.000 BTU)
ux defined by the CuPniaa Municipal Cmk.Clepler 9.12,and the Health and Sefay
Code.Semon 2 532(.0 HEATING UNIT(OVER 100.010 BTU)
❑Yes ❑No PAID
' VENTILATION FAN(SINGLE RFSIU)
W II IM a Deme KeceiP N
pplicvN or fame building occupant sax equipment m devices which BOILER-COMP(3HP OR Bp 000 Is ID.
t hemNoua air contaminants m,kfml by the Bay Afee Air Qati ty MwtiVour t TOTAL:
? BOILER-
COMP IOVI?R 100.00a)BTU)
C.� ❑Yes 7N
I hate read the haralloru nomerala requbemrnts umda Curtner 695 of de,Coli AIR CONDITIONER ISSUANCE:DATE
Rema lkelth&Safety Cade,Smias 25.505.25537 oral 25511.1 a,dasmrd mho if the NI?W RESIDENTIAL MECH. SQ.FT.
buildiogdocs mcwcer have•mc*ml4 ma imumy regraesiUlirywmdfY IhC,eY'I,PImM
of Be,r,mor ,a which,,,..hems prbr w i.mmce ora Geni(eaaor(kc. nut
Owrcrm eelMrird ogrnt Dore .TOTAL: ISSUED BY:
OFFICE