30452 APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRMITNO. 3 n 0 ^ 52
BUILDING'DIVLSION APPLICATIONIPERMIT PLUMBING-MECHANICAL �F
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANRARYNO. APPLICATION SUBMITTAL DATA
ay6 / L
OW UR' NAME
�f�Ii(�Jf��'
M1 NAMIi, / /y 3v CO,
y 7 !' NIC CONTRN
OL
-�AR TTiGf?,NGINEER: 'LIC No: AD)KESS: 7 ❑ - .
/ 6 a'
CONGCT: PHONE: BUILDING PERMIT INFO
❑ Conwiusa t Fen Paid by Appllc t(Initial) BfL�DhG .ELECT PIAMB MECH
4L ❑ ❑'
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I_
I herebY.fr dew 1 son licensor under,paviaio s or ChaIan,9(rnmtneneini JOB'DFSCRIPTION
WOO with Seaimn70001 of Divisim 3afdec Busiew..udPvfnommi Ctde,atad mylicamc is
TDO RFSIDFNTIAI� ,
FMin full forc<atadc PERMIT ISSUANCE. I;DWL El KITCHEN REMODEL
��� ue e « �f5S3o�
g„<S �— f Cuero,•„ „ APPLIANCES-RESIDENTIAL UADDHHON 71 PLUMBING BE PIPE
ARCHITECTS DECLARATION ❑ I ❑
VF,�O•n MULTI-UNSTRUCIURAI,
PANEL S
Z O 3 • I uwemmid my plum shell M used ae public raimb; MODIFICATION"
OZka UP TO 200 AMPS - EJ INTERIOR ❑CHIMNEY REPAIR
W lianacd Itofcuional 201-11X0AKIN IMPROVEMENT
2 OWNER-BUILDER UIiCLARAIION ' OVER HCOAMPS - ❑BATH REAIODELrREPAIR DEMOLITION
�yy1 I hareby affirm thin 1 em exempt from Ne Co bactur'e Licence law for the gL OTHER CLU U m1knai lg torn.(Section 70315.Husircss andPmfeauom Cale:Any city or county SIGNS ELECTRICAL
ID 3 tL which ncyuirec a permit to eauwn,aper.improve.dcreofi ,or rafter any eencluw
ISI O Prior to iD wuercc.alw�umesthc applicant fursucM1 tto Dlc a si
Perm Tac(Chaptcm SPECIAL CIRCUI(MISC.
} Thu he in tic®edW�p to the7")a Diaiom of the Conlr,ine. Licensclaons Cod erg
00y (rommenang wNSenior700f1)of llivivinnJaf the Uusircss aM l'ruf¢�ehna Code)nr TEMP.METE OR POLE 'ST COMMERCIAL'
d^e LL Thu tr la cceotp Iherefwm and the basis for the alleged caempt on.Any violuion of
El NEW BLDG/ADDITION [I DEMOLITION
�q5 on Section70313 by any.�lkatwforapermil subjects Ne elglicanl toe civil penally of POWER DEVICES
t++^y ❑TENANT ❑FOOD SERVICE
CZQm tarre Nan f hundred tbllma(1510).
❑Iasowncrol l&p'Yertytwmy employam with xvpesmlM1drwle utmpcwtiou SWIMMING IrcR)L EL' RI IMPROVEMENT
SW wiO do Jeume,and thesuu Curtutia"L a ora.dua,not S ply.7Bt4,Bnecu El OTHER
W 3 arc. n,w1ho tr Cole:The Cmuhereo tarmac law(iea tw apply ro an owner of OV11.I;TS-SWITC -
his...wed bull,,nr a th thereon,and wmamea ouch work himself txecuugh a
his own cmployaes,London, than.Itch impruwmrnu ase rad imcnJed or aRcm1 fm NEW RFSIOENTIAL EI.ECTe Q
.alert-bora willcbudingarimprtnemaot is wild within arcild or icumplcIoo,Nc SQ,FT.FLOOR AREA LSQ.FT.
ftoe builder will Mve lie buNrn of proving Thu he di(nabuildnrimproveforpus
-
phsc or downer
0 L v ownerP d'dm poperty,an core.velyand contracting Code:)The Ccunaanors w IOTA
rnawn the as not (Sec.7(114,owner
oto and Hnmwho thru Code:)The ea tlmclds I.i
u low coca not tpply lowownerid pupcny who Mi(d.or lmpnwa therms.nal QTY. PLUMBING PERMIT FEE
who rnurecufa,uch pquu xideacaalrCliala)IicemNlwauantm Je CanranMa �
IJttn+e law' PERMIT ISSUANCE a✓t
I am exempt under Sec. ,B&P C fermis rtouxa
Ower Data ALTER-DRAIN&VF1tT-WATER(EA) VALUATION
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE r
1 hereby affirm under pemilty of Perjury ale of the following decla uirrin
�❑lhavcavdwiU=inuinaCe fif ofComenttowif-imioefm Workdx Co - DRAINS-FLOOR.ROOF AREA.COND.
umoM,a.fowu Pel for by Senior 3700 of the Ialxn Code,for the Perfonnarca of Ne STORIES LWI?CONSTRUCTION
watt for which Nix permit is i.uaed FIKTURES-PERTRAP
❑ I have std will maintain Worlds Congcmuim Itwuvrcc,as rtary'ueJ by Senium I,
37Wofilc labor Code.for the Performance ofthc wort for which this permit is Lunde. GAS-PA.SYSTEM-I INC.4OUTLETS
OCC.GROUP APN
My Wur4:cry Comlcnwlkm lnvumn,e earticruad Policy numbcrora: -
Camrier: PdNMO.: GAS-FA.SYSTEM-0OVER AUG 23
CERTIFICATEOFCOMPENSATION
N WORKERS
COMPENSATION INSURANCE OREASUINDUSTRI.WASTE INTI;RCF,1'IT)R
BUILDING DIVISION FEES
(This rctiim recd rad M1cmmplcred if lfe pimit is farame hundred dvllua(pl W) ' GREASETRAP
m lean) PLANCHECKFFE LurLt111111
1 cutifY that in the perRmhuce of dee w•rck for wM1ich Nu prnnit i.jawed 1 shall
SEWER-SANITARY-S'TGRM LA.2W FT.
ax cmdaY tnY Y Tanner plc p�ylbJect m✓p Worked CanPen- ENERGY FEE
atom lawn M -f'/ she r m WATER HEATER WNII.'AILEC 11
�7 Applicanti•(y GRADING F[P.
G f%1
,F"—
,
OTI"I A I ICANT:H a,at
making this CcniBculc of latepto ,ymu sh oeW WATER SYSTEM1VfREATING
became subject to the Watac's Cootpcnouim pvvisiam M tte Labor Coda,you moor SOILS HE
forthwith comply with such povidones or Nis Permit Nall te dcettted tevmkN. WATER SERVICE
d
7 z CONSTRUCTION I cNDINO AGENCY NEW RESIDENTIAL PIMB. SQ.PE PAID
I hereby affirm at there i,a construction trading abler y for Ne pefurtoace of Date Reccipt4
W Nconstructionconstruction the work for which to,Permit is issued(Sce.3107,Co.C.),
1^ ICMeYa Name TOTAL:
WLeor ,AL , TOTAL:
CLa I certify that 1 Iauva read this eppfc.im and vete that tic above Inforotation is BUILDING FEE a `
h cnntcn.lagaY marmply wllh Wl city and cwnry omlinorcu ud,wclaws rtletingw QTY. MECHANICAL PERMIT FEE
U Z buddinecautruniem,card hereby atilhoriu repocse es'cifNu city toentuupon dee SEISMIC HE
amve-ne"un cd property for iruPe b n putpasca.
(We)agree u)csvq in&mnify and keep huntico the City of Cuperinn epaimt PERMIT ISSUANCE ELECTRIC FEE
liabilidca.jadgmnuscm cxPena whicbmayin. yx yrcrueapain4uid City ALTER OR ADD TO MECH.
IM g
in evn,egaienee of ranting of Mia permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNT'(TO 1LLUIp)CFMl
SOURCE REGULATIONS. MECHANICAL FEE
ATR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicanuCcomseter Date EXHAUST HOOD(WMUCI)
HAZARDODS MATERIALS DISCLOSURE HOUSING MITIGATION ME
Will the applicant or future building occvpanl store orhatdk haroocuv material HEATING ONG CIO IM,HM BTU)
is,&fired by the Cuperioo Municipal Code.Chapter 9.12,artd Inc Health and Safely
Code.Section 25532(.):' HEATING UNIT(OVER 100,000 BTU) t
❑Y
VENfILAT10N1AN(SINGLE RPSID) I'ND ,
Mill me,"licant m future building occvpnt use equiprn &
nt or vice,wtu h Dote Receipt N
mit besma is air contemiwhts as defined by the Bay Area Air Quably Management BOILER-COMP CHPOR I00D00 BTU)
TOTAL
DaVnm'
cYn BOH13R-COMP(OVER 100,000BTII) -
1lwve read tHr havNau,Iwcrials«atiiremcnls order CMpterb95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fano.Health&Safety Coda,Seniao 25505,25533 attd 23534.1 ualmermil that Edea NEW RESIDENTIAL MECIL SQ.FT.
budding does amt aatrtrnly hoe"
•retool.Ibal it is M nee aibility to tuify the,occitpmt
of the rtquircntcota which mut he tier Prior to iauutcc of.Cenifmve of Ocupaay. -
O cr istolinnsclapenr Dale TOTAL ISSUED By
OFFICE