28689 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY `
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL n O'y� O Q
BUILDIN'1:PROJECTIDENT9
IFTCATIOB L v 6 v
ILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DA
�IVNFR'S NAME_ � COI. ACIDRSNUMB:
L42 VO?iS✓ .G "/ po/3 N/C CONTROLY
ARCIHT. TrEbiGNEER I LIC NO: RES$: - ❑ .
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Appliwnl(Initial) BLDG • .FIEGT Lu MECH
❑ ❑ ❑
LICENSED CONI'RACneu mviCLARAItON QTY ELECTRIC PERMIT FEE
11em1ry.fr wt l un lianud alder Prnviaiana a a.pttt 9(rovurcecing JOB DESCRI ION
Oocalz Jth Scvtbn]OIXll of Divi.ion9of the Hu.vitocwarW Posfc.vions Cak.Rad7a lirensc i.
00 wforce,nncI �/�3/ y PERMIT ISSUANCE R SUDWL LIAR
FU'1
License sl e _ IJc.X�h2K _ ❑SI•DWh u ❑KITCHEN REMODEL
N Q d Dem Caarenor APPLIANCI.S-RESMENTIAL ❑ADDITION - ❑PLUMBING R&PIPE
Dm ARCIITIECTS DPC1ARO1ON C1 MULTI-UNIT • ❑SfRUCNRAL
ZO',n? 11nD WDYv .*Public lgprdc - PANELS MODIFlCATION
OZ-O / iISa�/� UPTO?W AMPS ❑INTERIOR _ 11 CHIMNEY REPAIR
OWNER-BUILD RATION 301-1000AMPS IMPROVEMENT
ejy
1Cyx CC Q 1 hemhy off rm thv 1 em e.e liom 1 nuactor's Lkcme law for IM OVER 1000AMPS C1 BATH RF1.10DEVREPAIR [I DEA10Lff[ON
W O U following rmaon.(Soni.]031.5.13 sircx."Pmf s Ctde:Any city or count ❑OTHER _
til > y SIGNS PIECTRICAL
a LL which fegmRv x pClmll la tonal ,eller,improvL den ifh,w reptif any sWCtwe
�,LL� prim to ire ivuarec,dn.qui applicamforsuch tofileasigre,duoemcnt SPECIAL.CIRCUITMISC,
�p. mm he if licrnwl puwann ocpmvmbrftuflhe Cont btu cense Luw(Cloplei-9 COMMERCIAL
�00 (carwom M with Ss' 000)d Dlvisim 3oftlu Bushes Pmfessions Cade)« TEMP.METER OR POLE INST. -
G. a� the he is exemp t oro.mod Be kinin r Om leged excmq n.Aoy vid.tim nt ❑NEW BLDG/ADDITION ❑DEMOLITION
�q5 4• Salion]OJ13b any epPlimm fQr p jxu Nc .sear •civil fctullyof POWER DEVICES
t++-rn o ❑TENANT ❑FOODSERVICE
�, ttm ft.,te roan r e hnnerm m�nat.
tEQ D i,as oxner f the propeny.mmy t t ec»mpenutim, SWIMMING POOL ELECTRIC IMPROVEMENT
fc 0 wJl do lM1e wn eM e.Jrvcuo I '. Ic St,. BW,Basin— C1 OTHER
LS$ and Probe CMe o/s w w supply to oof OIIILEfS-SWITCHES-Fl](TURES
pruperty who ilds m u the who wch wort hub a wwner lf-th u.'h
his two erttpIn th ttngno are.imaged m oRetcd for NEW RESID HAL El SQ FT.
sole
If,M1owev the buil 'ng Ion conern
is
wilhin ora:year ofmmpn.letinthe - SQ.IT.II.OGR AREA g/SQ.PC
owner-builds. Ihave den of povin athedidnotbuildrcimprovefmpur-
you of nk.l.
F-1 I.as owner o Ir paperry,int aci vely ednuocung with lieenxd MIIhMIM2 m TOTAL
canwuet the[mj t(Ses.]DYf.Bus nand Pmfmsima Code:)The Conb IcWs Li- r f
aseL<wdocsnntt'lytnano refpngmy who builds ofitttptuves thcmvt,ami QTY. PLUMBING PERMIT' FEE
whornnuaeufor pmjuu thacontncta(OliceneN pmauant to the Comnnors
Lcmw mow' PERMIT ISSUANCE
❑Lam ecemp wder5s. ,B&PCfar this remon
eTvty Doc ALTER-BRAIN&VG'f-WATER(E)Q VALUATION
r WORKER'S COMPHSISATION DECLARATION HACK ROW PROTECT.DEVICE
1 hvcby'efrum urlaa penalty of pmjury ax of the following dslmniom:
❑ I have eM will maimain a Cenifocatc of Conunno self-insum for Wmkcr's Com,em DRAINS-RWR•ROOE.AREA,COND.
mion,v la aviddl fa by Secoon 37M of the Lebtr Cale,fm the pnfontunce of the STORIES TYPE CONSTRUCTION
wink for which this pemut is issuce. MX RES-PERTRAP
[ 1 have W will ttulnuln Workers Comlcnwim Insurn,u raryirm by Section
3] .fthe lrl.+Cods,for the p<rfomutecs.ftM work for which thle permit is iuoed. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP .UPN
My War Wu (barrel Paltry licy
k. ''Jy Policy No:
GAS-EA.SYSTEM-OVCR4 IFA)
CERTIFICATE OF EXL'MPITON MOM WORKERS'
COMPHNSATON INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR
(This section nee J no,he cornpicemi
d ifthe Pert is forare M1uudrnldnllara IS 1001 BUILDING DIVISION FEES
or lar..) EASE P PLANCHECK IEE
I ccnify that in theperfmo,,ncc ofthe war far which thio permit is issued l shall SF,WER ANITARYSTORM EA.300 IT.
rw employ any N.in any nwref s0 a to bsme wbjm to the W'mkcn'Campco- - ENERGY FEE
� zsett.laws of Calibnnia.lyre ATTR HEAT WNENT/ELECTR .1
- GRADING FEE
Z Applicott
NOTICE TO APPUCANT If,after making this Ceuificem of 2amn ion,you durvld AIER SYSTI?JrVTRP.ATING
bccofs subjst to Ile W'od to s Cumprnsetion penvisib u Of the LWQ Code,you toua SOILS FEE
forthwith comply with wch provisions or this pcmtit Jell be daemel mvuked. WATER SERVICE
a �
7 z C(lNS1RUCLIUN LENDING AGENCY NLIV RESIDP.N'1'IAI.PhMH. SQ.IT. ' PAID '
V IMrtbyaRrm Ope Hese iaacm(Ses,,mlcMiug ogcocy for tiepMumoaeee of 1). RsciPY
� P Oe work fm which this pcmtit u issteJ ISs.3097,Co,CJ
U Ietoeels NorTOTAL,
TOTA
WLeluler's Addre,I
IL I certify that l love teas this applirylnn and slam that w ebsov infornution is BUILDING FEE
(4, ayss'LLagmc to comply wild ill coy and connry mditmncn and wmlaws mlatingm QTY. MECHANICAL PERMIT PEP
-
UrZ builoing eonattetion,erWl veby authori¢mptccntativcr of this city to enter uptm he SEISMIC FTE
`� Rhone-fRnlien[d lttupemy for impecuon putgrua. PERMIT ISSUANCE:
1 We)agree et save,itdenmify and keep harmless tie City of Cuperiim eeaiuu ELECTRIC FEE
I.•ti itigjudgmenu,cosu efd eeprna which troy in wy afty aceritc,ttitm acid Ciry
ANTER OR ADD TO MECO. PLUMBING EEE
in muquens of the gnn0ng of this permit. •
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLN105
HANDLING IB,gIn CIM) MECHANICALFEE
• SOURCE U TIONS.��� AIR HANDLINGUNR(OVER IO.000CFM) CONSTRUCITONTAX
1000///'' FXHAU.SI'HOOD OVIDUCT) HOUSING MITIGATION FUE
/�
ILVARIRTUS MATERIALS DISCLOSURE ,
WITH the epplicanfuturehcupanlshore mhostile af6ua materiel HEATING UNIT(t000.000 BTU) y-
aNnod by Ile Cuperira Municipal Cote,Clurytt 9.13, b the Health py
erd Safety W
Corte.Sxtion 23533[a0] HEATING UNIT(OVIA 100.000 Bill) /
E]Yes L1 No PAID _.
VENTILATION CAN(SINGLE RFSIU) pate R&e y
Willsos to,euro«forme building by IM
Air QutordMunaahich BOILER-COMPUHPOR 100}100B'TU)
emit havadxu air amumimnu m detitee by tM1e Hny Area Air tJwlhy Munigctrcot (.)
r UC (.UYr rlTOTAL
DisWnT
❑Yu ❑Nn � - � BOILP.R-COMP(OVER 100,000 BTU)
I base reed the hmu m
ntdmutttids bcuitemenu undo Clm ton 6.95 of the Cdi- AIR CONDITIONER
q p ISSUANCE DA
fmrda Hcdlh&Safety Code Section,25505,25533 and 25531.1 uMttomd dor If the NEW RISIDFlfIIAL MEC I, SQ.PT.
hudding does rix ewrtntly bve.l.nt,that it is nsy taTm.iNliry m nwify tle uc,,b u
Of the rtquiremrnb which ram be net prior to lseuftcc Of a Catif Re,N Occupancy.
6wterorawM1miW agent Date TOTAL ISSUED BY:
OFFICE