30904 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES`USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELFCI'NICAI. PERMIT NO. 30904
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF,CT MENTIFICATION
BUILD 7NOA PREW.� _ - SANITARYNO. APPLICA ONS MITTALDATE
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OWN' F �/`' C P W v /i CONI IA Pr' ME:A-I 1 / !O�1 NIC CONIR
ARCHITEC'VENGINEER: LIC NO: Vi YVJfJ^ ADDRRESISS J ❑
CONTACT: - PHONE: BUILDING PERMIT 1VF0
Jieg�t-4 t,4 1.1,4 4 ,•r-7?_/� IDCmsuhnnt Ems Paid by Appllcenl(Initial) BLDG EI. Lu e E.H
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Lm min ID CONTRACTOR dorder S DECLARATION ELECTRIC PERMIT FEE
I Hereby affirm Net 1 am IieenseJ ceder pntvixiw of C r,l 9(nmmenr a JO DE CRI ION
aZ Ih Scnian 7000)o1 3 of the Budnc,,v endl c c Cd liam ,,
00 wt PERMIT ISSUANCE JOA
full force eml e!f �/� �q/!SI
<FVZU Li.� �.2-0— �' ! ✓ ❑SfUN1 [3 KITCHEN REMODEL
N6u Dae -- /—Gaunt APM.LANCES-RESIDENTIAL ❑ADINTION []PLUMBING RE-PIPE
FOy AACHM--CPS DEC RA'I ❑MULTI-UNIT CSTRUCURAL
Z 1 undnluad my plmx Jwll he u,,nl mr a reeordarp PANEL S
Z O MODIFICATION
OZ-p UPTO2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
'FBF•; Domatevi PmfeuiorW 1(11-1000AMPS .IMPROVEMENT
Y
OWNER-BUILDER DECLARATION OVER IgM1AAtP5 BATH RE D IR CDENOLITION
y P1 < I hreem ul0rm Na 1 1 exempt Form the Comncmor Linme law for Inc
x 3 a U following levan.(Secthm 00]13,Buniws oad Pmfeuiau Code: *city ucamty SIGNS ELECTRICAL OTN R
wbkb riak.l ith"tornlsuuc4.11y,imfeeeademolish,rrrtpirmYRoemurt
pnorlaimeemed alararyvu tlragptinntfe Comrermilto Ek.ngrr4 ntatement
y SPECIALCIRCUIT/h11SC. -
y lemhe isem,vediNcemrinlhi:at DivinnenfortCmnnne,i,iLarne Ww ;Cocelr9
(conurcniog wiN SntiwT(MIIO ofDivisim3of the Buxlnas sed ltofes.inm Cak)ot TEMP METER OR POLE(NST. COMMERCIAL
a then he is eaem i tfrlcrmm and me Insist for the elkgd ucmptivn Any eiNiim of CNEW BLDGIADDITION ❑DEMOLMON
Swim 1031.5 by any applicam fore remit subjecu rite applicant toe civil perok,of POWER DEVICES
IIg..... ng morn Nen Five hundred dollen($5(0). ❑TENANT C1 FOOD SERVICE
CO OLnvawnQ Ofthe pogaty,the mYcmploYmwiN wageamttriruAeeompcmntim. SWIMMING POOL ELECrRIC IMPNOVEMFM
1122'' will do 0r work,and Ne xmrlurt ix not imenlM a noned for We(sec.lout.Buniws OTHER
W and PoNe vicars Cade:The Conlr ors License law doe,M.Igly to m oases of OUTLETS-SWITCHES'11 RFS
prafsny who huilds m am m,u pirmon,and who does such work himself or though
It,awn employ.,provided that each in,,ements one tot Intevled or ofkrtd for NEW RFSIDENTIAI,FL.EMR SQ IT.
rote,If,however,the Melding or implovcmcm H e ld within one Year orcompletion,Ne SQ,FT.FLOOR AREA ESQ.FT.
owrc-buddio will have toe bidden of Mein,thus he did not build«improve for per-
pax of nlcJ.
1,vn owner of the Mupeny,am exclu,,ively enmrveting wIia
ith namtm
d ncon to t t
wTOTAL:
construct the project(S«.]OaL Business raid Profasioen Cade:)The Commictes Li-
certain loo,doenot applytomwrrrafropiny who builds or itriprova lhurnn.ead QTY. PLUMBING PERMIT FEE
whnmmrens fm such pmjms wiN•mntractu(s)littnud pursuant to the Cmtramor s
Deer.law. PERMIT ISSUANCE
C 1 ant exempt under Sec. ,B&P C for fir".
Owner One .
ALTER-DRAIN k VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affimn trader Penalty of perjury one of the following dm=Ct nx
•F (have wad will mvnuinv Ccnif tcofCm,,cm to self-irtoue for Wmtcr'x Cmnprn- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPECONSTRUCTION
swim,v Mvided for by Section 37M of tlr labor Cradle,for he pe rommce or the - -
wmk for which this pmmit k i,,aed. FlKTURES-PERTRAP
C I have and will maintain Worker's Compen,ro.In.re.r,as reyoird h,Scot m .
37Mlof Ne lain Cute,f«the pefmriarcc ofthe wntk forwhich Nis permt iv wird. GAS-EA.SYSTFN-I INC.J OUTLETS
My Wo �C luxe ad Policy j/{�f�} OCC.GROUP APN
Cutin:pPdlry Nu.:M IWI • ' _ GAS-IA.SYSIT'N.OVBRJ(EA)
E OMP( , TION INN FRO 1 E S' GREASEIINDU.STRL WASTE INTE..--. N
COMPIiNSAT1ON INSURANCE BURRING DIVISION FEES
(Thi„sstim rralvot hcomputed ifthe pemdl i.four Mmdnd ddl.n(SI00) GREASETRAP
PLANCHECK FEE
(certify Net in the tiny nieunce of stote,tfar whiyeet to pbe V/o i.,,ud,IJul1 SEWER-SANITARY-STORM EA.2001.7
nm employ.nY Irma in any mmnlrr w v,,m become nubjpcn m the\VMera'Catnpen- ENERGY FV E
Z station laws of Caldomia Du<
Z MATER HEATER W/VENT/ELECTR
Z 2 A,ficiuNOTICE
GRADING FEE
NOTICETOO ,, tic Worlre vNcr nuking Ibis Ceni Ocae ofP at lode.yoohauW WATER SVSTEN✓IIIFATING
C't bean¢iemb y tf1 Warkttk iv.omtinnprovisime of the TaMm Ctde,pu must SOBS LVL
foMwiN comply with wch pmviniwmNin pnmit shallbodeemrd revoked WATER SERVICE -
a �
UO CONSTRUCT
ON LENDING AGENCY NEW RPSIIIFJ.TIALPLMB. SQ.Fr. PAID
Ihm hi,h dii,'tthem naed(Se 3fAC,nCing egexYfmtheperfmwnaxof Date RaeiptN
O �-+ We walkfor wniuh Nis permit it iarud f5re.9119].civ.CJ
I”' Lender',,None TOTAL
WIrldcf.Addren TOTAL
I cmify Na 1 hove mod Nis epplicaion and ale that Ne above information or BUILDING FFP
N conal.1 egmc i comply with all city end manly mclim mxa and umc lawx reloting to Q MECHANICAL PERMIT FEE
V Z building mrt,,tructim,and hereby auldhon[,,a Iepresaomavea of thus city to ever upm the SMIC LTR
`+ above-rsviomd progeny for inspection gnpasec. PERMIT ISSUANCE
(We)egrce m nave,io I mmirY end keep hvmkaa tlr City of Cuperthrm.gaimo CLECIHIC FFE
Iubi111ien,jWgmenn,
ucon,,and upernxv which may in my way ettnr again!raid City ALTER OR ADD TO MECH.
in mmBm
trcc of the,granting of this pmNt. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT CID 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,(1110 CFM) CONSTRUCIION'TAK
Signarmof AWliamuCammctor Due P.KHAU,STHOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will Ne ytplit'mn a furore building occupml non or bulk harudwso iel HEATING UNIT(TO 100,000 BTU) -
v deftN by the Cupcni to Municipal Gder Chapter 9A 2,and the Ilalm mut Safety
Cock,Sntl..25591(.)! HEATING UNIT(OVER 100,"BTU)
C]ye, ONo VENTILATION FAN(SINGLE REMD) PAID
Will the a,icem or future huilding oceupmt u.¢equip ienl or dovEx,,which Dam Receipt M
.it hmanbm in,contaminant,o,,defirrd by the Bay Aren Air Quality M.vegemem BOILER-COMP(3HPOR 100.000 BTU)
jf�
TOTAL:
u F1 No BOILER-COMP(OVER 100AMI0 BTU)
e mal tic havardottx"arinneln AIR CONDITIONER ISSUANCE D
teyuirtmcnts under CheMa fi.95 of the C.li-
de.Snow 25505,ii fty m 2553x.1 ul noilf d Nn If dr
havicetvun ill 33. iwb0hy roe id NEW RISID[NTIAL MECH. SQ.FT.
r vpuvN C 'oc
10
thmiudag m Don, TOTAL: ISSUED BY:
OFFICE 2— /