28623 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28623
RUILDING PROMECTIDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIi
2 O hs GT ��i3 ..r�,Sr
�F E: PHONE: CONTRA 'S N .��/.N UC NQ
�����g NIC CONTROL
ARCHITECT/ENGINEER: LIC NO: A DRESS'. ❑
CONTACT. PHONE BU ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
As ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q-ry ELECTRIC PERMIT FEE
Iiorp700) thatlan ftheBlcyderm!Fc,,umof Clup'a9 my licensing JOB DESCRIPTION
0Z with Seniim]WO)af Division menmircv rid Pmfeoima Cale,and nay license RESIDENTIAL
Lb w' PERMITISSUANCE
in full Rncc ord cffnt. ❑SFDWh El KITCHEN REMODEL
�Uj U„rue CWv Lie:.x
�QI{l Dau Cmrractar APPLIANCES-RFSIDENTAL ❑ADDfIION El PLUMBING RE-PIPE
F�L ARCHITECTS DECLARATION ❑MUI.O-UNIT ❑STRUCTURAL
� I rulnaam my plant Dull be used m public records PANELS MODIFICATION
OZ—CI I1YT021g)AMYS
C1 INTERIOR [I CHIMNEY REPAIR
Q�k LicensedP Tassiooel 201-I(Mg)AMN IMPROVEMENT
�y OWNER-BUILDER DECLARAHON
OVER IIX)OAMPS ❑BATH R EfJREPA ❑DEMOLITION
< 1 hereby affirm tot I em exeraft f.Be Continences Licence law fm the
xd O 1 co
U following ren.(Section 7031,5,BrdreaW a Professions Code:Any city masL ❑
tty SIGNS ELECTRICAL
t+l a LL I" which rccmort a Pamer'r cenvwct,alter,impinve,denaliah,w rtryir any wvctute C
F':Ot3 prior or it,i.wenre.rds rrenmor,de appl Lvnl focsoch pconit to Ilk a siµredsta¢nnnt SPECIALCIRCUIT/1,11SC.
�} trek ie lion.iwrsumlmihc ltsnvi.vimsof theC BLUncn'a Ucrnv WwfCuskrU9
(an Iss, cingwit thereiatanand UsDivuian3 of W,Budrcvamian.An stational,
Code)m TEMP.METIER OR POLE INST. COMMERCIAL
Q. o K der h,703"b tanefrmn and the buia f«td,,alleges esemPtiaro Any ilioWim of ❑SEH'BLDG/ADDITION ❑DEh101,IT10N
Scmion]03 13 by my applicw fm a pmnil wbjecn de applic.nt to•civil pevaltY of POWER DEVICES
o" ❑TENAIsT El FOOD SERVICE
C= ret marc than fof t h rm dollen y empr
Q ❑ Lusnwmrk,the he oec.m,' c imemswithwuga usme,(reit amspmwiun, SWIMMING POOL ELECTRIC IMPROVEMENT
22 prof ltr work,amtheThe Ceputrvnoli LiceneoroRnWforvkpply to
Business ❑OTHER
F70�1.
W $ sad coy esus,b Cade The Cmtthereo I.icctuol law doe ore apply m an owrin of OVRE'1'S-SWITCHES-FIXTURES
a 3— no;..who builds a imfmva r soda i erd who dors rich rime Mmxor o lootthrofah
his owo eweloym,provided ri arch impmvemenwithin
are ret intended cr nRernd fm NEW RESIDENTIAL LR.ECTR SQ FT
sxlnlLhnwers.d haveli ahurcln of
ithat Ix i'hi o(ncild or
inre,oa 50.1'T FLUOR An 3/SQ.FT.
wrcr-huidu will have the burJn'of prvving that he did rxst build or inipeuve fm pm-
uk.).
wrcr of the See7property,am exclusively emfee long with licensed crmat i- TOT'U^
o pmjc(Sec.]DfO,Busirev W Profeuims Code.:)The Cm'tutm's U-
censeLaw Aesnot apply manown,-rofpropcnywho huildsmimpmvuthcrmn.ami QTY. PLUMBING PERMIT FEE PAID
who conlM;ts foe such projnos with a roc ri cttx(a)licemcd porsoam no the Cmtractor s
Dana,Law. PNCE
❑1...np order Sec. ,B&P C f«'his rrasm Oraw-
01.
A UTER-DR A IN&VIENT-WATA HA) VAUD
WORKER'SCOMPENSATFACL ATION BACK M.OW PROTECT DEVICE
IMrtby rfhrm under pemllyof perjuf fullawing Jc<Imatie❑I love ata wll rmorn:t CmiBcare ofCmn ae imine fa Wmkcr'a Cnaepen- DRAINS-FLOOR,ROOFAREA,C ND.sulom as pmviN fa by Satire J](gl of tk O ,fa the perRmsatta olthe STORIES TYPE CONSTRUC ION
wind,fa whh Nu pemrt uissuedFIXTURES-PERTRAP
❑1 have aM will mainwin Warkca 17 nI u u requirM by SectionxthepeHunmrccn , 'GR wM1ich lM1iv pencil it iu GAS-NA.SYSfEM-I .00 ,FT$ (xC,GROUP APN
MyWorker"CompnuwimIn urnmeaname' 1' nrrMirr we'.Cat pGAS A SY 1 Rq IEACERTIFICATE OF EXEMPTOM WOR ERS'COMPENSATION RANCE L BS� USTRL INTERCEPTORC laia.1.real nm he eotpinNif ttit in frroe a di'llun 151 W' PUIIAINGDIVISIONa It..7GREASE I'LANCHLCK Iqt whichthia tisnsrai,ishdlnot ca loY any Person in any maturer an as to e subject In the Woreai Covepcn- SEW -SAN'ITART-STORM EA.2W FT. ENERGY FEE
Oz uniore n iM California.Doc AER THEATER WNGT2LEC R
O Applicant GRADING HE
y
NOTICE'PJAPPLICANT.IL aficr makinjhim
is Ccni(celc of Escmplim,you ghoul WATER SYSTEM/TRP,ATING
become suhjcct to the WtNer's Cnnycowprovisions of de Inbar CuJc,yo m SOILS FEE
fonhamh amply withsuch prosmioru or 't shall be dremd rtvo WATER SERVICE
5z CONSTRUCTIONINGAGEIN NEWRESIDEN-DALP1.M11. SQ.ET. PAID
V O 11herebYaflm'0uttbereisacon,muctimgrncY fm lie perfnrmuce of Due Receipt
the work Lr which this pcnni'is Tuned f.Src,309],CivC., t
O U Latdeea Name - TOTAL:
L) Teadcea AdLces TOTAL:
y1¢Wiry that L have read Whit i'linclum and eue'llat tr above Int..or BUILDING HE
to correct,I agree to comply with all cry and courtly ordimm'es std nam In relaying to QTY, MECHANICAL PERMIT FEE
L) z buildingcmwmetim.ud hereby ambxirc uprt.¢nrutivs of Nis city no upon the SEISMIC FEE
alavc-oentimel pntpcny for inspection purpvmcc PERMIT ISSUANCEF1,ECIliIC FEE
(We)ogre to.save,irticonify and kapw
hmlen ole City of Cupertino against
liabilitin,judgmcrw.emu and cxpemn which tmyin any way rcrve vgaian end City ALTERORADDTOMECH.
cmaequ,nc<of die graining antis Pe.I, 4.1.P.E'
//////IIIIII,',',',�,�,� PLUMBING FEE
APPLICANT UNDE STANDS AND WILL Iy)N 'T AIR HANDLING UNIT FN 10.000 CFM) MEC'HANICALFEE
'UlN5 // AIR HANDLING UNIT(OVER 10,000 CFM7 CONSTRUCI'IONTA%
Sigm'w M treWf Dam EXHAUST HOOD(H'/DUCq HOUSING MITIGAT]ON FEC
OMAIFRIA
Will the applicenlnrfo'we buildingocapan'Worn handle lwmtdaa maend HEATING UNIT CTO IW,00)BTU),
as delinN by the Cupcnino Mmri,p,l C9dc Culpocr 9.12,and the Death nod Safety
Code,Samoa 25532(a)t HEATING UNIT(OVER 100.000 BTU)
I-]yea E]No
VENTILATION FAN(SINGLE RFSID) PAID
Will Be applicant or from,building occupant rte equipment or Jevitts whid' Date Receipt N
.it hmNm air
eoevnmmimmv cs refined by ml,Buy An.Air Quality Management
BOILER-COMPfJHP OR I W.fpU Bl'U)
DTOTAL
mrct]
❑Yes 71N. BOILER-COMP(OVER 1W."BT
I have retail the hamobus nwerials rtyubcrterva ender Chapter 6.95 Mdn Can- AIR CONDITIONER ISSUANCE DATE
tomo Heald'&Safely Code,Sections 25505,25533 and 25511.1 ualrnutW 0w of or NEW RESIDENTIAL MECH. SQ.FT.
bu ldlog clo-ret eumetlly have a umn,thrill is my mryamibirly In notify(W occupant
of dee napmenrnu which noun be ren prior w:amrrae of n Cenifn'e of Octupoi
Owner or aalhariaiaagen' Data TOTAL ISSUED BY:
OFFICE