30792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTIIICAL _PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30792
BUILDING PROJELT IDENTIFICATION
BUILDINGGAIMILERs: /T SANITARY NO. APPLICATION SUBMITTAL DATE
/ 9 65 / — Ito—g7
OW ' R'SS NATE PfIONE CONTRACTOR'S NAMP.: LIC NO
//VV +rGr� oZS3-GB2-I L6Sev-rrILT (1,77N❑�
CONTROL
\RCHIECIENGINEER: LIC NO: UnSS:OJXV� OTVICTN '[W,B
CONTACT, PHONEu
BUILDING PERMIT INFO
❑ Conwltarrt
I.Paid by,Applicant(INflal) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATIONQTY ELECTRIC PERMIT FEE
1 hereby ailuro dws 1 an,licensed ods,pm,md v or ch w,v(ss mmencing JOB DESCRIPTION
DWZ wffi, ricn 7")aDivision3efthe Business and lTnfwi«u Code.and. licewa is
Y REGI-„ [DENTIAIc
�,O in PERMIT ISSVANCE
full fwc,aM en
IF-ZU, Lic, Cl-L f ff Cic.X, �77 Y46� ❑SFUWL ❑KITCHEN REMODEL
NQL Uate 44^ZS '9r Cmnnnm /4RLE EOtIC_ APPLUNCGS-RESIDF,LTIAL ❑ADDITION ❑PLUh1BING RE-PIPE
Fah ARCHITECTS DECIARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Zp«2Z I utderswtdmy plums dcol he dud as public ream(, I MODIMCATION
OZ—E UPTO?W AMPS ❑INTERIOR ❑CHIb1NEY REPAIR
t�i I4crnsW Professional SBI-IB(In AMTS IMPROVEMENT
ma I am exempBUILDt fr DECLARATION tits, RAT10N OVER UWAMPS O BATH REMODELIREPAIR ❑DEMOLITION
y��uuII 6 I hereby affirm Nn I am comp from the Comrvcmr's Lkeme law for he
x C)2 U f Ah,sine ressom(Section 70315,Busim-as and Pmfes ions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
u!LL LL which rtyuitn n permit,u cuwmac.abc,hicu ve,demolish,«rmar any nruclure
��Cprior m,u to.. rectum the applicant fm much Permitto File a riyrcd,wement SPECIAL CIRCUIT/MISC.
that he is licensed yumuanr to tlr Provoions offie Commcturs Licee<Law lChWer 9 _
(er.ing wlNSmtlon 701O of Di oon3ofthc Bmircaatind Professions Code)or TEMP.METER OR POLE INS'L
that he is exemp therefrom and do lusis for disollegcd exc.,fi4 .Any vioWi.of NEW ADDITION 0 DEMOLITION
4• Section M3 13 by my applicam for a mm,it subject the applicant to a civil Penalty of POWER DEVICES
'h ANT ❑FOOD SERVICE.
F Z} 0 mmc due five hunted dollars(eopl.
ODl.os he worts.and
the the mc ,«myemployeu with wages forme their mk mm.Barsim, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Newrrk.otdtheur,cmm1mvto inteMNe 1-aw does
(See."1 an Bu ,of DOTHER
I'd 3 mJ ecol who a Gde Thu over h tars Limns, do Joel to apply to an owner d OIJII.ETS-SWITCHES-FIXTURES
pgeny who bold.nr,tnpmvn Bruch i oM who
oi Jtsw such wart himself ci theough
hies own owe eyces,pmvlld Nu such impnwenenare out intended o NTertJ far NEW RESIDENTIAL EIPCTR SQ FT.
Ile.IL however.Je building«improvcmcm 1s ml beidwithin mrtycmofcros,,,efm,one, SQ.FT.�O(T).LPSRP.1 LSQ.FT.
1rc.f add.will love Je burden o(povine hdid nwt huild«improve for Pur. p �JJ
aI �). p Ma
(]1,u owner u(the Pr4enY•em exclusively mnvutine wIN IisenuM contramm�to TOTAL:
answn the pujnt(See.7DW,HEsirc.s and Irafesmiwa Cade:)The Codrry«a V- C ITC(��
ansa law don nm apply.an owner of Pngcny wbn Wilda or improves thereon,and QTy. PLUMBING PERM IT FEE
who c,ntracu lm....h pmjms wiN a umtmcha(s)liccnmi purwmt rn Ne CmNmtera J
Li.Law. PERMIT ISSUANCE - I IIVKI
0 lam exempt dude,Sec. ,B&PCfnr this,.,. r Vr v\Jr ejT
Oester Dura ALTER-DRAIN&VENT-WATER(HA)
VALUATION
WOR KERS COMPENSATION DECLARATION BACK MOW PROTECT,DEVICE
I hereby effrm under Penalty of perjury one of the heibwing dclamtiom:
I have and will rom .aCanificate ofCmn,m 1.self-i,uure for Worters Cutnpcn- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CONSTRUCTION
a rien•as provided f«by Senim 37M of the Inbnr Cud,Tor the penfornunce of dtc
work for which Ba pmnni,is inux T MIXTURES-PER TRAP
0 1 have and will maintain Worse',Com,ricatiun Iret..tens,oneJ by Section
37D)cf Jte blur Code.for the pert'onmrca Mtha work forwhich NuPermir is issuM. GAS-FA.SYSTEM-1 Bi C.4 OVD,ETS OCC CROUP AI'N
My W«t�r{C�r,)Qcn�rion�ln.wm«ccerrirr ud Yolky nu i s gIZ '9L GAS-EA.SYSTEM UVFR4(EA) .
myCraWo ic` susev •olicy N,,
CE URCATE-OP eTI' ll 10N Ilt0M WORKERS'
COMPENSATION INSURANCE, GRFASPANDUS'Rt1.WASTE INTERCEPTOR
CDdm ration anti t,a bearmpletW if the Mcmat is forune hundred dollars($1(1(1) BUILDING DIVISION FEES
or less.) G P
PLANCHECK FEE
I eedify Nu in the peHmnwrce of tk west f«which Nu Pamir is issumL I shall
nM employ any prem in any namnawnrrobec�me wbjecr to the Wwkers'Co SEWER ANITARY-STORM G.200 FT
Z ration Lawsof California,Guide ^Wen ENERGY FEET
z 'R HEATER WNENT/F.I.ECTR
z Q Applicant GRADING FEE
uJ NOTICP,TT)APob,Wckm,,,r.aftm,.ti his Certifcme of Eaenor Cas ptuaho", WATER SYSTEM/TREATING
f-' becwbe subjtet y the W«term Compewtion pmvimia l oethe IaMr Code.you most soils FEE
W � fnMwiN rnmplY wiN such povisitsm«Nia Pamir shall hedeemal revoked. WATCH SERVICE
M Q
UZ CONSTRUCIIUN LENUINGAGENCY NF.W RESIDENTIALPLh1B. SQ.FII PAID
L) p Ihertby Warm Nut Nem imaninnructim lending egvey for the pert«nonce dF - Dote R«ciptM
u. w. Ne work f«which Ni.pemm is r.vited(,Sec.3097,Civ.C.) $Cp'fIL 711 A A&-&AWAt/ -
O b+ Lmd,ra Name TOTAL'.
WCirri AdAus TOTAL
R. I cmtify thu I have reel did,;,,A icmion and sate that the lho,infmnahnn is BUILDING FEE
A comet.I agree to comply with all city ami couny«diturces and us In law:rcluingtu QTY MECHAMCAL PERMIT I FEE
V Z bung cumttuction and hrn
ereby audorize r,peues
nvaf Nis city toeoterum me SEISMIC FEE
abtwe.mcmimd prapeny for in pcxdon purpoms.
(We)eBrte m save,indemnify and trop h—occs da:Cuy of C.,ni.a6aiw PERMIT ISSUANCE ELECTRIC FP,P.
liabilities,judgnrcnrm,sous and eapmws which may in any way accrue aguinu mid City
io avo¢quettce N rhe pantieg of Nis fermis. AI TCR OR ADD TO MECIi. PLUMBING FEE
APPLICANT UNDERSTANDS AND WIL OMPLY WITH ALL NONTDINT AIR HANDLING UNIT TO IB,WO CFM)
MECHnNICAL FEE
SOURCE RP.UI U'.5.
� AIR HANDLING UNIT(OVER I 0.00a)CFM) CONSTRUCITONTAX
Si a/ M pplicanaCirmicuor - D. EXHAUSTHOOD(WMUCT) HOUSWGMIIlGAT10N FFP
HAZARDOUS MATERIALS DISCLOSURE
Will the emlicen«future budding nearson arae,or hurdlehvmsbos material HEATING UNIT UID I W.000 BTU)
u
named!by the Cupertino M.nin,al Code,Chapm 9.12,ad the Health and Safety
Code,Sec too 25532(x)'! HEATING UNIT(OVER I00,M)BTU) .
0Yes [-I N.
VENTILATION FAN SINGLE RESID) PAID
Will the applicant orfuwm building dnvpanr u,ev uiptrcm or devices;which Due Rmeip M
vrdt hanNwa airconramiwms to defined by the Bay Arta Air Quality NI"erom BOILER-COMP(3HP OR 100,0sM BTU)
District^ TOTAL
❑Yes ON. s BOILER-COMP(OVER I0),00013TU)
1 twvc rend tie httzvdau matcrialm ryn'ucvenu wider Chapa 6.95 of N,Cvi- AIR CONDITIONER
ISSUANCE D/IAT�yE{/�/(1//
ftmie n,di&Safety Cute.Scctior i, hit.25533 std 25534.1 udvuard Nu if the NEW RESIDENTIAL MECH. SQ.FF
buiMmg,uh ve currently hast atenantthatit iemyc,of.CiBtywnati(Ythearcy.
of de rtquhvmnm,tech n,usthtrct p��rro iaswtrcc ata Cmifrwe of 0.rapatwy. ,
Owncorautwrisda,ert Uwe TOTAL ISSUED BY:
OFFICE