29877 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO I BUILDING.ELECTRICAL ^ PERMIT NO,
BUILDING DIVISION APPIACATION/PERNIIT PLUMBING.MECHANICAL (] O
RUILDINO PROJECT IDENTIFICATION J o
BUIIDING ADDNFSS: 77
SANITARY NO. APPLICATION SUBMITTAL DATE
OwNE CU. CTOM$NAM LIC NO.
N/C CONTROL
\RCHITECTIENGINHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: HUILDING PERMIT INFO
❑ Consulumt Feu Paid by Applicant(Inifial) ELECT PLUMB MECH
AK
❑ ❑ ❑
LICENSED COM'RACDSR:S UCCLARADON QTY ELECTRIC PERMIT FEF,
1 I y affirm that I am licensed ender Ptovisiome of CLapmr 9 f—mm—cing JOB DESCRIPTION
O=Z with Satwo](IW)of sion Jof the BusirraaaM Pmlessbu Code,aM mYlicemeis
m o O PERMIT ISSUANCE RESIDENTIAL
F in full fo'ecode0cet.
aFU�j licxmc Clm Lic. ❑SFDWL ❑KITCHEN REMODEL
NQL Date C«Inst« AWI.IANCFS-RESIUEMIAL [[ADDITION ❑PLUMBING RE-PIPE
I„ ARCHITECTS DECLARATION PSS ��a\//s;L,ULTI.UNff ❑STRUCNRAL
ZOt Z l understand my plan shall he used as Public records MODIFICATION
OZ UPTO200AMPS ❑IMiRIOR ❑CHIMNEY RF
1_-.4,�n Licensed Pmfuwiomd - IDI-i"AMPS
OWNER.BUHAER DECLARATION OVER I AMPS ❑B H REMODFLREPAIR ❑DEMOLITION
Q 1 hertby alum thv i ons cscmq from take ContrstNs Litton Law for,tk
kO a U following Tormn IScOion 70311.Busimess and Promasiuu Codo:Any city m cwnty SIGN %AV ❑OT FR
YI :O which Iryuily a petrel to awumcl,Wcr,�mprvve,dcmuliilt,w Icpoir any arvnurt / rTjj-WV Iry N-1
� L,n pri�rw iu iuuarce,also reyclm the applicux fm�shlvTnitwfikesigTred suturcm SPEC UIT/MISC,
that he in licmmd prouum m the o,vision.s ofmc Cootracl«'s Learn Eiw(CT ,=
�CO� (emnmesine with Seen.70001nf Division I of Rte Bminru and PrfeasionsCnde)« TEMP. VLE I. 'f
else,e K that he is c.actlpt thcrtfmnt and the beaL�f«Ne allceN cscmryion.Any violatiaa of ❑N RLUG/ADDITION ❑DEMOLf
�m Section 00313 byany app0dant fm apcmn,mbjects tM olglivaouo a civil peWty of POWER I ❑T&NANT FOODSERVICE
ml nasrc than,five bmdrtd dollons 155110). IMPROVEMENT
0 Q I,ae owema n(the proleny.mmy empbyeee wish wager as thou sole compenavdon. SWIMMI IC
a will dm the wo.k.erd the structure is nib emended or u2crodfmsale(Sa.71, Business ❑OTHER
and Professions Code:The Cmmof,b rs I.i«me Isw does rot apply to an owner of ouTLE s. -S CHCS-FIXTURES
0: pnspmty who M1uilds or irnpnwa thrmm,amt wind de,such woxt hirrelf m dwegh
his own empinyecs,provided that ouch imWocnents art o t intandocl m oRmed f« NEW RESIDCNPIAL rLLECTR S L —
sde.If,however.the,building«impsovcttemA sold within orc yc1 of umnplerinn,the SQ'FT.TI:OOR'ARFA $5Q FT.
u-1,mIder wBl have the burden of pwviM that he dd ma bund ts,t r vefari
Twine o kms.
of the popery.am exctuaivcly c«msring wild licensed oomre —1m AL: MAY / 199
«u ea the Project(Sec.]D41,Bminece cost Pmfc.ti«u Code:)The Cmmstar's U- 6.
c se wd natapplytaenownnufpropenywN)h ilds«imprnvut mm.aml QTY PLUMBINGPERMIT FEE ily
l
who cmnuacu for wch pToJms with eroouamMsl lkcrvad Psmanl to the Connector's � Vr,Lur
Lieenw Law. PERMIT ISSUANCE rt,I IAV
❑ temeae tmder5a. .B& 111irn-rim -
ALTER-DRAIN&VINT-WATER(EA) VALUATION
O er Uva
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 he elf under Penalty of perjury me of the following declani«n:
Ihevicend will nuumaineCenif acute ofGnrentwself-ituum f«Wmkers Compeer. DRAINS-FLUOR.ROOF,ARE\,COND. - STORIES TYPE CONSTNUCI'ION'
sation,as pnvided f«by Seofo rt J]m 0 of the Labor Coda,f« M
iloc performontt of t
work fort which Ban pemtit is uwN. FIXTURES-PER TRAP
1 have and will rommoin Worker's Compnmsulnn Inswnrce,as re hired by Section
3100 M the Lab«Code,f«the perfonrunce of the,work fawhich,hi.,pernit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS \(J/GROUP APN
My Wacker's Compensation Imucance cattier and Policy number are: OAS-PA.SYS IEhI-OVER 4
Cvricr. Policy No.: l
CERTIFICATE OF EXEM PTION MOM WORKERS'
-COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR - BUILDING DIVISION FEES
Olisstttionorvinm he com,f od ifthe permit is mcoie huntbed dollars(S I W1 GREASETRAP
PLANCHECK FEE
'TcenifY dw in de performarceafthe womb lmwhich thispmnitu'..•„d,IsNll SEWER-SANITARY-STORM EA.20(l FT.
rot employ any perm in any manner so as m bccanro suhjat to the Workers'Comlen- ENERGY FEE
OZ avian laws of Califsmm Due. WAMR HEATER WNENVELECTR
Z O Applicant GRADING PCE
` NOTICE TO APPUJCAN T:If,ago maker,thin Ccmfiaone of Iuermption,you should WATER SYS@NTREATING
bcaxrc subjar to the Wcokc'K Compencvmn Poovisions of the labor Code,You must - SOUS HE
fordmwith comply with such pmvisiow«this permit dull be okrmN revoked. WATER SERVICE
Q `
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PLMII. SQ.PT. PAID
V Iherchy affirms I"is o comstruction laading agency for the perf.e.f Done Recci,4
the weak fm which Nis pemlitN issued(Sec.31197,Cs.C)
V Iaala's Name _ I OTA].
Isnder'n Adros, - TOTAL:
0. I cmify that 1 have Beed this applioadon and snare that the abate infornwtion iv BUILDING FEE .r
TA e«uct.lagra to comply xith all city eTrd cwaty wdinenmen sed satelaws rtlringto QTY, MECHANICAL PERMIT FEE
U Z building conurction.and Wreby awhotirerepresenutives ofthis city toenur upon the, SEISMIC HE
above-mentimld laopery for inspection purlros.. PERMIT ISSUANCE
(We)agree to save,indemnify and keep barmleu the City of Cts rirm egicinr ELECTRIC IEE '
liabilities,jttlgmcnu,coetvwdcspcmes which may inany way accmcagantor said City ALTER ORADDTO MECH.
In conugeencc of the granting of this potmit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING,UNIT(TO 14010 CFM)
SOURCE REGULATIONS. MECHANICAL FFR
AIR HANDLING UNfT(OVER ELNNI CPAD CONSTRUCTIONTAX
SlFcaom of Applica Wontrcwr Uvc EXHAUST HOOD(W/DUCq HOUSING MITIGATION HE
MATERIAIS DISCLOSURE
Wll thcapplicuntormo a buddingocculmnt uwe«haedle bnaaadoes material HEATING UNIT(T011111.18X1 BTU)
ns dcfneJ by the Cupmimm Municipal Code.CFa for 9.11,and the Health and Safety
Code,Satins 25532(M] - HEATING UNITIOVCR 100.000 BTU)
❑Ycs ❑No
VFNTILA31(lN FAN(SINGLE RISIU) PAID
_,
WBI do,a,pficana or frme 41chng«cu,,an,use cquipmem«dcviev which Dme Receipt N
�-mlt hu arbes au...I,as defined by Use Bay/w AU Quality Mana{enscm BOILER-CO.MP(JHP OR I W."BTU)
District] TOTAL:
❑Yes ❑No BOILER-COMP(OVER I W,m BTU)
I have red the bvnNous matCFD11 V oc uimn>Lnu mater Chapmr 6.95 of the Cali- AIR CONDITIONER
ISSUANCE,DATE
tains Health&Sdcsy Code.Smi«n 1505,25573 and 25511.1 endcmaml that if the NEW RESIUCNTIAL MECH. SQ.FT.
sedorsathat h inmyrtapmuirtototk«cagwt
4 Uertwhich.e.IN,and Prixr w iexa«eora cooIBram ofo
aertw«Y.
0.nm or vuth«ixJ ager Done TOTAL:.. ISSUED BY:
OFFICE