28646 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0. ^ ^ ^ 4
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICALL l}J( {l.�l {ll�
BUILDING PROJECT IDENTIFICATION
BUIIDINCy[,DpRTSS: `fc,y- Aw, /I U ^ SANITARY NO. APPLICATIONQSUBMITTAL DAPI
O NER'S NAME; P10NCpAIOPVS N 4 NIC CONTROLYA�/ L
ARCHr1ECDENDINEER: LIC NO. ADDRISS: a ❑
n *'I I f l
CONfACIb PHONIC
BUILD WG PERMIT INFO
-❑ Consultant Fees Paid by Applicant(Inithj) BLDG ELECT PLUMB MECH
UC RltIeX
CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE
I thereby affirm flat 1 em Eatlwder unpmviaioeu of clmper 9(wnmete;ng JC'k DESCRIPTION
�OZ wiN Sstim]11D0)MDivioonloflk Bunimus; tofeuions C°Je,ed my lie,ameis R -SID NT—I AAS
I- O in full fora ❑
end cant. PERMIT ISSUANCE -
IcY�.� SIUWI. TLTi FN REMOUEI,
tnzW Date Llan Con. APPLIANCES-RESIDFNfIAL ❑ADDITION O PLUMBING RE,PIPE
fl-n=y ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCITIRAI.
'ZO! Z I ualderstnnd my Alam shol k used!as public rtcoeds MODIFICATION
OZJJp UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r�FW Licrnsd Ps°beuimW SHL-IIpUAMP$ IMPROVEMENT'
OWNER-BUILDER DECLARA'DON
IOVER IoW AMPS El REMODFURF"PAIR [IDEMOLITION
yqx 6 I krtby affirm that 1 un acmlx fmm tk Contmws Liccnsc Isw f«tk
W 3 a U following resmn,(,Salim 11115,Business arW Profaswm Calc:Any ciry orcounty SIGNS ELECTRICAL ❑OTHER
F OEa which roquim a pentyl to mown,site,,airline,denwliM,or b,,as,tiny nructure
vyJ pi,,n int is.,elm requites le applicant fee such permit to Ble a signed sevcmrnr SPECIALCIRCUITYMISC. O
vWW11y Jwkis licebiN purtuannothe pmvisinna of theCmmmnm'shkcnsc law(Chepmr9
1p0a (mrrumlcim with Sestian 7000)of DM3 of Ns Bodine and Profcsuana Cade)of TEAR MUTER OR POLE INST. COMMERCIA
a L_
e 4. IMI k is cxcmpt Nemfnnl cold tk beam for tk alleged!eacmplxn.A.,violuinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Secbass703 IS by any an
opliesntfor s peat subjects the applicant to a civil peWt
ty of POWER DEVICES []TENANT ❑FOODSERVICE
Z y not marc Then Five hudLed dollen []TENANT ISSUII.
0 ❑I.mreM N «
owr c pb,e, , nry cmploer wages'awith is their sole amai,mtai°n, SWIMMING POOL ELECTRIC IMPROVEMENT ,
will do de work,ud the vrvcture is ltd intended or offert,l f«Nile(Sec.7144.Business ❑OTHER
ad Pmfcaaiom
Costs:TCoouxtals Liana Law die.art apply to m awvcr of t OUTLL:TS-SWITCHIS-FlX'111R1_S
a 3^ Is upcny who Milds or improves r envm,and wb°dans wish wank himself«through
his own smPMecs•pruv;dd,hm such impuvenrnts ere our imcnded«offered for NEW RESIDENTIAL HLECfR SQ FT
We.ILhoweve,de hsldingmimprovement is sold wiN;n o«y®rofmatpktiose tie SQ.FT.FLOOR AREA SISQ.TV
owner-buildn will hove the buNsn of sroving tat he did not Wild err iui rvve fee pur-
af gid.
M the prtyenY.am exclusively nmtnciing with licemvi eomrveem,to TOTAL p O
oasawt de pmjecl(Sec.]Ota,Buircas d Profeaaiom Code:)The,Caxrctots u- p4
ee..e law dace nd apply to an owner ofp ny wills mild,an;mProvea lkrtan.ad QTY PLUMBING PERMIT FEE
wbeveLaw. «a«h.ad wi�ar «a)la d w tinted Ca t�w a SEP 191995
1",ante Isw PERMIT ISSUANCE
❑Tam escarp ludo 5«. ,H&PCfor this,,timed
Owecr Detc ALTER-DRANT
INh VE -WATER(FA) Vii-I Ur , VALUATION
VII.W
MPENSATION DECLARATION 15 Urr si 1.
pcnory nfperjury one oft�g deeluruiars: BACK FLOW PROTECT.DEVICE ` Oval
❑lbwCeniledeofCnn¢mm f«Workels Comiso- DRAINS-ELOOR,ROOE AREA.GOND,
Nitien, ction 171X1°f Ilse 1 far µrfomuna of tk STORIES TYPE CONSTRUCTION
work f isaud, f FIXTURES-PERTRAP
1!wiWn s Campcnsa I.s.es tquitd bySecti«t
J]WoftklaborCode,f« a work fur which Nis permit is ixsud. CAS-EA.SYSIFJr1-I INC.COV11fi 1Su O°e OEC.GROUP APN
My Worker's Con"nes,tinn er dPolicy nunadver : -
Cudcn— I GAS-EA.SYSTEM-OVER 4 TA)
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIJINDUSTRLWASTE INTERCEPTOR
[This section recd me k cwtpldd ift a permit a forensic,hueubd dollen(SIM) BUILDING DIVISION FPFS
or fres.) GREASE TRAP
PLANCFIECK FEE
A,anyNuintk on,. nee ,ofiou«,ob sub*10 P!,,Wc iawCmfort-
netnnplaymype,sus in any nwver wr,tit to kc,me auNtttwtk Wuhe,s'C SEWER-SANITARY-STIIRM I_5.2W PT.
Z auioo Laws aCJifourow Dass wtpcn- ENERGY FEE
I❑ WATER HEATER WNI:N'NLLCfR
z O Applies, GRADING FEE
N NOTICE TOAPPUCANT.IL making aking this Cmf m iof Caemwyoupti ,yshould WATER SYSfEMlTRP.ATING
F becomesubjbjecttoIW«key'sC« nsdpro
npenn vLslwsdti � kw re,,.. — SOILS FEE
f«NwIN rotiPIY with such lmaieionn«thin pcmun JUB kdmnd tnvnkd. WAfF.R SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RI5SIDHNTIAI"PLMB SQ PT. PAID
V 0 I hcrtby eRml then dine is•c«uwction L•nb'ng s{cxY fee tk perf«nurcetsf Due R
tk wor,for which Nis permit is ivvud(.See.3097,Civ.C.) -
O U Larder"Name 'IUTAL:
L) Lender.Acidness
G1 certify Non I have read this s I"fiun end sane tkn Nc above inftmmalw is BUILDING E
red ..n,ece l.gns wComply wile ell oily end mart,araun.neer ed slam I,w�rtlating to QTY, MECHANICAL PERMIT FEE
G Z builiingemeawctiaeeM hertby auNan,no repeessmaidoesofthiscitymerun-ri nJs: SEISMIC
above-memiuned Impeety foe inap[Cli«t wrposes.
(We)agree to Nile,indemnify ed kccp ntirmine the City of Cupcnitw ogoinw ` PERMIT ISSUANCE ELECTRICen
Ilubilitie+.judinem-v rnYcad ezpcvn which vlay in enY w'+Y+sc agnieun sod City
omsgence Mtk tin of ALTER OR ADD TO MF,CH,
migu permil. PLUMBING FEE
APPLIC^UNDERSTANDS WILL COMPLY L !-PC AIR HANDLING UNIT TO I R(J(I CFM)
SOUR[ RI C IATIONS, '
AIR HANDLING
Z;wz UNIT(OVER IH.IpO CFMMECHANICAL P
CFM) MECHANICAL
TAX'
glwe aAppliredlCorum« ' Dane EXHAUST HOOD(WMUCI) HOUSINGM CATION FEE
HAZARDOUS MATERIALS DISCLOSURE
w
WH by the Cucamafdme building«cupantuomnrsedlchvatdwsmetmvl HPATINO IINff fT01W,1ryt BTU)
u def nd io the 32o,)?ao Municipal Costs.Clinger 9.12,sol Nc 11rdN and Ssfcty
Cade,Seeenn 53532(e)] I IFJSING UNIT(OVER 100,000 B'IV)
❑Yes ❑No
VENTILATION FAN(SINGER RFSID) PAID
Due Rmip 9
Will Ne ayplicom in future a dJlding acsulvd use yu it Qu m 4sadmi which
Dish hewdua air c«mntimnu u.Jctind by de Buy Ams Au QaelilY Mewgcmcnt HOLLER-COMP(1fD'llR IIXI,gM)BTU)
District] BOILER-COMP(OVER IM WO BTU) T AL
❑Y. C]N.
I hove red the hvun4xu mueriaLs Imisons under AIRCONDRIONER ISSUAN -DATE
esqu' Cheer h 95 of the Cah-
faenu Ha1N on Safety Code,e.mans 25305,25513 and 25514.I I ndcrvatd the,if tk NEW RESIDENTIAL MECH. SQ.PI'.
bre.frh nrdao,nvus whuthy have aIOuee.Then1 ismyreafnC,rube de o¢upaa
ofdm rcgairtnems which mon tic roti prior to iswnna ole Csnifanc of Occupancy, �T'�������\'J S
Owned°remhainectient (late ISSUED BY.VQ �y��•G
OFFICE ��� /