29222 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ ^ w
BUILDINC DIVISION APPWCATIONIPERNIT PLUMBING-MECf1AN'ICAL L L'LJL
tlUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAU
OW R'S NAME: PHONE: CO CTON'SNAME / LIC NO,, Z/—F_ 961
WC COISTROL0
,�4R ITE /L'NGINFPft: LIC NO: ADDR S: EJv- 9 7 57, .tl.
CONTACT. PHONE. BUILDING PERMIT INFO
❑ Consuhmat Fees Paid by Appllrant(InHial) Bulc LECf PLUMB MECH
❑ ❑
LICENSED CONr.d under
CON QTY ELECTRIC PERMIT FEE
1 wrtny,mom mm 1 am ti.<n.wJ nnaer mr,.lx2m.of Owgw v(r.�nnom, ]OB ESCRIPTION
1aQti'Z with Section 9Dg0 of Division 3u fine Basovitai" fica,siuun Cate.atd my licensch RESIDENTIAL
h OO le full face mud effect. PERMIT ISSUANCE
Y W ❑SEEWL ❑KITCHEN REMODEL
Q U Dauc CDca 1Jc.X q
Duc Camruta APPLEAI:CES-RESIDENTIAL � El ADDITION WPLUMBING RF.-PIPE
F, y ARCHI'TE'CTS DECIANATION PANELS ❑MULT6UNIT 11 STRUCTURAL
,Z O'�� lunlcnrmd myplans"In he used as purlic rands MODIFICATION
OZ UP'r0200 AMPS 11 INTERIOR ❑CHIMNEY REPAIR
r,a�� Luccnsetl l4ufecswmW 201-IOTAAMPS IMPROVEMENT
yXW
OWNER BURDFR DECLARATION OVER I"AMPS CR BATH REMODEUREPAIR ❑DFM0LrrI0N
tY 6 I M1crtbY affirm Thu I em BUH_D from the RATIcN Licrnse lees fw the
x a L U followin8 ream.(Sr diem 7031 J.Bao.and Plvfessiaua Code:Any city a.,y SIGNS ELECDUCAL OOTMER
t[] W which rs,,m ct it Pcramit to c,mmium eller,iarpnvc, hmolish,«rtreir my itclun,
O pier to i0 i.ssa...,al-mlulrcrthert'Nicvm famch'mnluofik uigrcJ gmcmnnl SPECIAL CIRCUIT/MISC.
iN+ the he is licensN lXYFnMI to lM rluvisium 0Inc C,mllvcmr's License lyw(Owper9
00 (manenoing with Srction7")ofDivuim 3 oflhe Bminusud Pmfeuions Cak)ar TEMP.METER OR POLE INST. COMMERCIAL'
that K is esempl Ihertfrom and tate baso fa the alleged!eseelpian.Any violation of
4• Ssetimu]031.5 by any gplicw for e reemil subjects the applicant w e civil penalty of POWER DEVICES �NEWBLUG/ADDIIION ❑FOODSERVI
�y ANT ❑FOODSERVICE:
F,Z Y m uswre Inas fn¢M1u,ldKd dol Wes(5500).
CLes awns of the propMy,or my emrloyca wish wages a.thcir.snlc nsnprnsetiun, SWIMMING POOL ELECTRIC IMPROVEMENT
wdl du 0c wruk,unl the stmmune is nig inwndd urulfctW for w i,(Sci,,Tt,4,Rusinccs ❑OTHER
�_ and Pmfc.uitms CMc:Tle Cmduclora License law des not apply w un owaa of OUTLETS-SWITCHES-FD(TURFS
4' plopeny who builds or improves ft.and who does such work himself of dirmugh -
hu own employ.,,provided that such ingrwveraenae are nn intat a oRered for NEW RESIDENTIAL Ft I= SQ ET.
sale.ILMsvem,Ne buildin8a ingm,vemem 4.14 witleooeyeaMmrmtdoorne SQ.f ..FLOOR AREA 3rSQ.P-n
mr-builder win av,,the laden of proving that he did not build in impnve far par- ei E v
ona,of sakg,
I,as o,acr of the pmvvd,,aa,C,r]a,ivtIy t'rvon,tin,with II«nuJ c'oamica—In TOTAL:
cmwnct the PmjcO(Sa.7044,Business and Pmfcuhnts Cava I Tlw Clmbalas naorLi- QTY PLUMBING PERMIT FEE APR - 21996
vee law&e t apply to an owner of pvperty who builds or poandimves Ihenco ,u
whoccausa.faweb cojau witharintruma(s)licensed pursuam to the Contracmet
Iisrnsc law.
❑IameacmpuMer Ser. ,B&PCfurlhiancasm PERMITISCUANCE
���'�( Vr IXUi Ctrllh
Owner Dart,
ER
ALT -DRAIN&VP,NT-WATP.R(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I heathy affirm uMcr pearly of perjury one of be,following decluatiaa:
❑ Thecae and will maiaalnaCmifucue MC«ued la relf-imvrt for Wakcrs C«nprn- DRAINS-FLOOR,ROOK AREA.COND.
wivn,u province fa by Senior 3y0l)of the Ia vmr Cook,for due K..a of the STORIES TYPE CONSTRUCTION
sunk far which this pemdia iesual. FACTURES-PER TRAP /e
0 I have and will maintain W..ker'a Compnsalion Inmtmee,ar le9uimd by Smlum
3701(Iuftne Labor Code,for the pif«nwue of the wuric fm which this permit is i.esucd GAS-G.SYSTEM-1 INC.40VRETS
My Worker' Cslmpcnwim lnsyynna cvmicreal picY�m OCC.GROUP APN
Certirr.�cmi Fi-_�•l� PalkY Na. GAS-EA.SYSTEM,0VER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS -
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This s cllon need ort he aanpWcd if the pmnit is[err ore hu,dad ddlars(SITU) BUEDW G DIVISION FEES
a ksJ GREASE TRAP
PfANCIIECK FtJi
1 cenify that in the 1m mainucc of the wad fur which This permit k iu id.l shall
SEW
t employ any pemsatratransitin any transit so as to became subject ft K'orkm'Cmvpco- ER-SANITARY-STONM FA.200 FT.
reENERGY FFP
0Z sation laws of Califcsimi Dae WATER HEATER WIVENiEl-EM
Z Applicant GRADINGPEC
V] NOTICE.TO APPLICANT.If,after making this Certificate of Gen,plion,you slcud WAG( SYST?,V REATING
a [' beasne subject w the W«ta's Cun,pcauion provisions of the Lshn Calc,you must - SOILS ITE
1' [i falnwim c«,ply with such pmvirivmr or this Permit dudl to JccmM rtvoked. WATER SERVICE
a �
U Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PEAR. SQ,FT. PAID
I herwhich 11YIIntrti3aaex](Scel30 len ling ageayfmthe per(ornnnrntt of Due RsaeipX
�� the wwk f«which tis pomit is icsucd IStt.J097,Ci,C.)
O U leadeOl Nene TOTAL:
L) Lmrl,,,AdJrtnx TOTAL:
y 1 certify Inv 1 have rt&this application and sour tbut the ahuvc iof«muion Is BUILDING FEE -
t/i a,nal.l egg to canPly with all city am cvumy ordirurce and nuc laws at a- QTY. MECHA_NrICAL PERMIT FEE
V Z Whim,cawrvction.card herebyaulhu crtpreseaaivuo(this city to atter upon lie SEISMIC FFP.
above-nrcrution.d property'fpr impecEon puryoaa.
(We) to cave,i,demnif ad keel hmmk a to City of Cu PERMIT ISSUANCE
^C^e Y r ) penst dCity ELECDUC FEE
Iiacobuc acn, ,,f hecoonanalut mi which may in any war acmeageing said city
ALTER OR Allll TO MECII.
' conaryucnre of the granting nl'Ihir � PLUMBING FFR
APPLICANT UNU STANDS D LLC PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(W CFM) I Let
SOAR ONS. _ MECHANICAL FEE
ci AIRHANDUSIGUNIT(OVEH 10."CFA) CONSTRUCTION TAX
SiVischnsin ol'AlSplimainfiCurbstedli a Date tLHAUST HELD(WA)UCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant orfutwe building«[upMlamma handle M1vadws material HEAUNGUNIT(TOIW.0(X)BTU) '
as declined by the Cupertino Municipd Cook,Ctaper 9.12,and the Hrnitb and Safety
Cade.Satan 25532(.)^ HEiOENG UNIT(OVER IW."BTU) ,
❑Ye ❑No
VENTILATION PAN(SINGLE RESID) PAID ,
Will the of licanl or future building ucc,anta nt vime
Date RcipX
mihaznNtau air cmmianudefred hYthe Ila,Area AirCalilY Managementment BOILER-COME(3HP OR IOO.M)BTU)
Ohariar ITOTAL
❑Yep QNo BOILER-COME(OVER IW,000U)
BT .
I have teal his,herallous materels rt9aircurcnausMer AIR CONDITIONER ISSUANCE DATE
form.Health&Safety Cove,Seniw,s 2554)5,25533 ard'_S5}4,11 mdcntand that if the '
Iuildin8die,noes cunealy have a tenant,that it is my wNvmaiNlily to notify theawfsat NEW RESIDENTIAL MECH. SQ,FT.
M Pie ncydremcnl,which null be ael Malo i.uancc of o Cm 11..Ic of Ikcupeny.
Owner a autharized agent Date TOTAL: ISSUED BY:
1 OFFICE