31429 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT N
BUILDING DIVISION O: 31429
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING PROJEC9IDENTIFICATION
BUILDING AREIS: SANITARY NO. APPLICATION SUBMITTAL DATE
al B
UW' FRES NAMG' b (C F PHONE. _ CON, @'S FIE: U&
SIC �I�TROLY
•M 011T13C'UESIGINEER: LIC NO: ADDR S: Ir �a-mD ���mziIj ❑
CONTACC PHONE: (-/l BUILDING PERMIT INFO
❑ Cmuvltaat Fm Paid by Applicant(Initial), - BI-DG ELECT PLUMB MECH
❑ ❑ re( ❑
LICENSED CONTRACIY)R'S DECLARATION QTY ELECTRIC PERMIT FEF.
1 hcodby 70afnmathr1 3licensd Iver Malorrf of gaoler9(ory Lceeing JOB DESCRIPTION
F�OO d'Z in aSarreea.p)uf Division Jaf Ort BusittumW Pmfeuiwu Code,erW mY littnu ie RESIDENTIAL
in full fmm awl cff �� //''__ ,`�(�Q PERMIT ISSUANCE yFN t' '
Fa.U�j liccmc Clan �LIiC.X �Dc^�I `�� ❑SF7)WL ❑KRCHEN REMODEL
Nab Dem Cauractar APPLIANCES-RESmENTIAL / ❑ADDITION ^p�"��',I'UMBING RE-PIPE
ZOOM ARCHITECT'S DF.CIARAI'[ON PANFUS ❑MULTI-UNIT LJSfRUCURAL
Z 1 Iwaetnnd my dens sial be used m formic necmdi MODIFICATION
OZ—a UP TO 200 AMPS I]INTERIOR 11 CHIMNEY REPAIR
1-�r[u1 Lieund Profevioal 201-1030AMPS IMPROVEMENT
C
OWNER-BUIWER DECLARATION OVER IHMAMPS ❑BATH REMODEIIRFPAIR ElDEMOLITION-
4 1 hcmh,off.tiro I all exempt from de,ConumalMe License law fw ttr
x a L U following reenter.(Section 7031.5,Bourton and Rofecxime Colic:Any city or county SIGNS ELECTSICAL � H�
41 LL which rrywma wmn
Rr N derc� uru ,eltn,impmu
ove,deolish, repair r Y runurt
FSO priunnru iewanw.al,ut rtquircx the olrplicam forwcM1 permiunfi0uaignrcd:mmneot SPEC1ALCIRCUIT/MISE.
f y shot he is licensed pururw ro the pmvivonsar the Cumnnrrrs l.ittnsc Lvw lChapta9
RI 00 (comm ting wish Seninn]000)af wo,ian Jofthc Bali.ad Pmfecaioea Code)m TEMP.MITfER OR POLE INST CZIMMERCIAL
a q o eE this he is cxcmM thucfnm IVId the bogie Grz the n lcged ucnytlion.Any vinletinn of - [INEW BLDG/ADDITION ❑DEMOLMON
W—on yi.tion]0313 by tiny epAir.Far.pearl iuNceu tic eppleenER DEVICES
l In.601 lletlalty of POW
not nitre than five harWmd dallen($500) TPN/uNT ❑FOOD SERVICE
0 l)1.Iu owror of the PnMmy,or Illy nnployece with wages as 0cirulc comP'nulion. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the wak,erW the wucture ie m intcndd m uRemi favk(Sa.70U,Buireu r�OTHER
Rw1mW Rorrowns Cole:the Carlini].icenrc lat w no,apply to an.of OLMLETS-SW 111 HES-FIXTURES Jf`
a 3— PrTcny who builds or imMnvd Ibercon,and who docs wch woh hicroeFor through
her own employed,provWd that such imMossme its vc nm imedcd or offered]for NEW RESIDENTIAL ELECTR SQ FE
sale,If.however, Iehi ildi,orbnprovemem isaoldwithin one ydr of cvmpletlun,We - SQ.F-E "Q.FT.
loi,ne,-bailitc,will have the Unden of Moving that he did no.buildo,inlprovc for Eur- X IJ
px otf uk.). TOTAL D r/
19$conwsct the Project Sec.701],Hulions and Rofmims CdeO The,Conlarow,IJ-
sone aw doe.rx VPly to an owoer Mpol win WIWI or mproves thereon.land QTyPLUMBING PERMIT FEE CITY
.
wM comrxw for.mcb MojwY with aaomraclans)Lied punuunt wthe ContnclMs
Lkcreac
Q IcannM ander Sec. ,B&P C for ddd resort PERMIT ISSUANCE �rCnJf(YU
leiOwrer Dae ALTER-DRAIN&VFM-WATER(FA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 haehY.T.under penalty of'do, on or the fnlluwing dcelariuione:
❑ IhaveendwBlmaiwinaCrniBcete ofCovemwsclf inwnefnrWMers Contpcn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
wire u pnlvidd for by Scctiw J]ql or the IaMr Calc,fur the perfomarce ar Ne _
work for which this parotin is issued. FIXTURES-PBR TRAP
❑ 1 have and will IxWnuio Worker's Compensation Imunr c,u r ird by Smiav -
'ON)of
ll Q for the perfomrome of the work for which His peror iv Issued. GAS-EA,SYSTEM ETS I I NC.a OUTLOCC.GROUP APN
My Wmkch Ifm 1 eoJ Policy nu
Gorier w I�Pat. No.: C Q� r GAS-G.SYSTEht-0 (E
VER4A)
CERTIFICATE OF EXEMPTION FROM WORKIiRS'
COMPENSATION INSURANCE ' GREASIVINDUS LEL WASTE INTERCEPTOR
(This%.0.rcd not be comphod ifthc Pmnit u lm are,hwdrd dollen(Strait BUILDING DIVISION FEES
a IeesJ GRPASB TRAP -
PI-ANCHECK FEE
1eatiry don indoe perfanans ofthewortfarwhichthis permitis ern'Ci Ishell
nd cmdoy any pnsun in my namer.vr aimbecame rob' wore Wakm'Cam SEWIiR-SANITARY-STORM FA.200 FT.
Z sedan taws of CNlifonlu,Date �- ENERGY PEE
Z WATER HEATER wNENT/ELECIR
Z O Applicant GRADING PEE
UJ NOTICT?TO APPLICANT:If,after muking thin CcniOute or tixemption.You 4rwW WATFA SYSTEMII'RFATING
W bccmrc w.io y the Wtvh foo,eW. sminn Poriitsbcd of the Inedr GWc,p.r moa SOILS FEE
� forthwith cmnplY with such pmvLrilxismthie pcnoit.shall he tkemd rtvokd. RS RVICH -
7ZCONSTRUCTION LENDING AGENCYNEW RESIDENTIAL PLMB. SQ.FT. PAID
UO IhcrtbYafEnn Wttherelsacnn.twcron RM'Ing egmcrrw lbe pu(nmlantt ar Ihm Raeif.
LL•F. thewM for wtich thin Permit ie ia,ucd(Sec.3097,Civ.C.)
Icwkls Name
O U TOTAL:
0L Lcndch Anifyt L'
4 I certify that I hove i- thin eppliamion and ealnnvetM1et the uMve in mlation ie BUILDING FEE
h brother lege[tommply whhe0cityad rc,.So uend Crone lewsreleting m QTy, MECHANICAL PERMIT FEE
u huilding cnti,xi Fn.nml forehynuNorverooa,. vu of this chymmmrupon tK SEISMIC ME
ebave-men)re MoPenY for inspectionpurPnd.
(We)ogre w nave,idertmify vnd keep barmkss the City of Cupmiro Xguw PERMIT ISSUANCE EI,ECITe1C FEE
Iiabililia,jndgmcm,oKn,oml capcnxs which mayln any way mcmeagaimt mid City ALTER OR ADD TO MECH.
consequenceI. nti
of the grang nl Thi n. PLUMBING FEE
APDL . , UNDERSTAN A WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT QO I0.fp0 CFFU
S CER ULATIONS - MECHANICAL FEE
12 AIR I IANDLWG UNIT(OVER IQUUO CITE) CONSTRUCTION TAX
Sign rtof App' Vl OntrazYnr
Date EXHAUSTHOODOMMUCp HOUSING MITIGAI]ON FEE
FIALARDOUS IATER1AIS DISCI.OSURE
Will Neapplicantw(atone buildintocculraru use natatorial hvardoumwerod HEATING UNIT CD)100,000 BTLD -
or defnd by the Cali Municipal Cale,CnaPer 9.12,and the Henllh an Safay
Code.Salon 25532(e)^ 'HEATING UNIT(OVER 100'"BTU) -
❑Yv. []No VENTILATION VAN(SINGLE RESID) PAID l
MJI de Dale ReceiM N
yr ciuntm,mune buckling ac he,Bzuseea Air Qurmtkvia.swhich BOILER-
nnit huardour air mnanrinwuuJcfind by de Bey Area AirQwliry Mangeinem COMP(3HPOR 100.(100 BTU)
in� TOTAL
Dlur
E]yes El No BOILER-COMP(OVER IW.p10 BTU)
T hove teed th hanrdvs metcriala AIR CONDITIONER ISSUANCE DATE
' myuinemrnu unda Chapta 6.95 of do Coln -
to.Ildlth&Stiny Cade,Sanaa 25505,25533 W 1.5531.I unlaumW tIW if the NEW RESIDENTIAL,MECH. SQ.F-E x
building doe,not conemly Irave o mrumr tion it it my�rylnsiMity w notify the uccuparu -
oftlercaryirtmcros%hicb nluu be mn Pier to iswerceoreCmircmc of(kcvrynry .Z,.�/�y//{y�� /1
Owncr rautheri'redugent Due �Tw ISSUED BY: V/t/" � �`/✓/
OFFICE