29942 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. !�(� (� n4 L/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL G J J
BUILDING PROJECT IDENTIFICATION -
BUEDINGADDRESS: SANITARYNO. NSUBMITTALDATE
LO S- -
GW COMRA�I' R:S AMI:"�/••_ LIC NO:
Y a6 Y= I/-_ NIC CONTROL
VtCHfTECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fans Paid by Applirsnt(Initlal) B& ELECT PLUMB M[CH
,�, ❑ ❑
LICENSED nCONTRACTliunder S DECLARATION QTY ELECTRIC PERMIT FEE
I nneey worm Nn I.m OcenYd under paxHimx M cTupter 9(catutrcncing JOB DESCRIPTION
moA-Dw=O in isfull fooe eec!cff«D.ivixiaoJof the Buirinx end PrMf¢xians Cade.W mYliccmeis PERMIT ISSUANCE
RFCIDFNITIAI�
IF-.ZW Licence Clss. Cron ❑SFDWL C]KITCHEN RE-DIEL
' N<1 Dne Cmwna APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PSE
I- ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCUPAL
Z O I Z I uMvsww my palls chill be used u publk heads MODIFICATION
OZ - UI•T02(10AMP5 ❑IN`MRIOR ❑CHIMNEY REPAIR
F.H..F 41 Licensed Promeounul 20I-1000AMPS IMPROVEMENT
gy R[P OWNER BUILDER DECLARATION
IY Q 1 hereby eRno then 1 am cxcmpl I.the Convector's Licctme Lew for the OVER IUODAMPS C)BATH REMODEL REPAIR ❑DEMOLITION
X 36 V following Ieuon.(Section 70313.Busiluvs end Pmfeuinru CMe:Any city or campy, SIGNS ELECTRICAL 00 HE
Yl LL which requires.permit or consumer,epee impoo e,delmlish,a rtluir eny swnua
Pnorlo la ivunnce,alai
m myui e,the,mm.a f«suchperniuLice.gadumcmenl SI'F,CIALCIRCUI'I'IMISC.
}
that heiuliin9wirh.m tlo tl)oODiakme3Ne Conaeclrx'e Lucvclaw(CM1nper9
p0 ulommcrc-,orli Satin JOnd the
th MBusixeyerptmo Any xCadc)a TEhIP.MEIER OR POLE INST.
a y o y rM he it,evemq Inertfrom uw Ih buil fa the Nkgcl exemgion.Any viohtian N ❑NEW BLDGIADDMON ❑DEMOLITION
4X1 k• Saim]0313 by any opplicam f«e pemlil wbjals the upplicmr to a civil pcwlprof POWER DEV CES
y not Ihenflve hundred G�llom(5500). El TENANT ❑FOOD SERVICE
sts=6 nowner of the popenY.«my employaa wiN wegnulheir sate campewtiar. SWIMMING PCOCFRI IMPROVEMENT
yF will work.Cale!Th,
Cmeisrims ice.U. lice, .belly to owner
❑OTHFJt
a 3_ arta emfessiou Code:The ovu tt crem and!w law;such
nor epply toll owner of Of1Tl.EfS-SWITCHES k
pmpmy mpl.yho ee,fr impnwn therms,real who don'e'uA work deet-or through
hi.own o ue em The provided Ihm wch impmventW are lu inrerded-offered for NHP'RESIDENTIAL PI OCT .'Q
yu.I builder ill bt,ed gaimpovcment issn be didncou,1bmldl fofcpirmoe ion.Oe 50.FT.FLOOR AREA 55Q.FT.
owner-bu0dv will Nve IIc burden of purring lhnt he did rot M1uild a imlxoxc fa pur-
pou of owntu
❑ I,m ower ul rM1c pmpeny,urn mol ,vdY conme«ing wllb 1,..-d caemedom u, TOTAL: p1
cencie"the project(Sec,o(tin wre not aM Pmfevsiom Cao¢)The Cnnhtm cum Li
vc"W di my eh plyloenaweroamiemny who Wilds or impo Ue lhrrmrl.eel QTY PLUMBING PERMIT FEE
Lice.Iruu for wen projccu with ecmtruOurts)littrved ponvent to NcCmtratex MAY 28
0 1 timlaw. PERMIT ISSUANCE 1996
tom cxcm alar. ,B&I'^(or N' fS"
71 _ ALTER-DRAINAVENT-WATERTEA) '
is
:SCO PENSATION DECLARATION k.V!'CIVALUATION
ur I ff under tlACK FLOW PROTECT DEVICE "uIV
heoch
ye pcwlly of pnjury mcof 0e fallowing dcciwlion.c
❑ IlwveWwillntaimuineCenil-IcneofConanuoYlf-innumfar W«ker's Canpcm DRAINS-FLOOR.ROOEAREA,COND.
union,u provided for by Sec ore 37W of the,L.bar Cade,for the perfamarce of Oe STORIES 'TYPE CONSTRUCTION
work for which Nis pemdt u iuucd. FU TURES-PER TRAP
❑1 curve and will maintain W«kels Compenxatimi Im«ence,u requirM by Seclim
370IInf the Latin Corte.for the perfr.r m.ofthe wch for which this pcmrilki¢sud. GAS-EA.SYSTEM-I INC,d OUTI. S OCC.GROUP AYN
My Wuxkefe Cumlrnretim lnsumrce cortin orvl Polity manner ere:
Corner. Policy No.: GAS-EA.SYSTEM-0VER S TEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This Yclimn eeCd al he mmplcled it the permit ie for one haxuhod d flux I$Hp) BUILDING DIVISION FEES
or ley) GR[ASE TRAP PLANCHECK FEE
1 omlfy their in the pexforci cON,woh for wlucb dlu permrr ie issued 1 shell
at employ tinyperwn in coy manner w u to tectonic wbect to dle W'Mm Corepcn, SEWER-SANITARY-STORM G.300 FT. ENERGY FF2
O z calirm lawsof Celifanie.DelcNATER HEATER WIVEN`nI _ECTR
z O Appleanl GRADING FEE
y NOTICE TO APPLICANT:If,ere,mol ing thio CcniBcole of Eacmptioo,you sh.W WATER SYSfEM?REATING
F' become wbjecl to Ibe Workefx C«npclauion pommuces of Oc Lebon Code.you most SOBS FEI3
RethwiN eompl,with wch pmviuimu or Nix pe mil stall he dr red revoked. WATER SERVICE. _
�z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.FT PAID
V 0 Ihcreby wCrm tbu Nert ixecomwcem koNrrg elcaYfa the pHan•m•of Doe Raeip0
4. .-. the workfor which Nin Timor.is iymul 15a.3()97.Civ.C.)
Q F-'
V (e '.Name T TAL:
Icalch Addrtnx TOTAL:
yI cemify Not I hove reed Nis uliplil.flon"orale Ihn Ne ebove informurvn it BUILDING IFC
v] 1.1.gree to romply wiN Jl city end county«divan em xrve law reWingm QTY, MECHANICAL PERMIT FEE
V z WMin,ron tic ,urd rt yauthai:creprnenwivnof Nisciiyto twmponlhc SEISMICFEE
sbovegoer moel pmpemy fa impcnion pcc,,n. PERMITISSUANCE.
(We)egm:weaves ilukmnify onl keep harmlca the Cily o[Cupcninu egvn,xl ELECTRIC ITP
liahililin,ludgmenu,c«ts eel eaprneswhich may In eny wey came egeirW wid Cily
u crtruryuntce afdc penung of Nu premie. ALTER OR ADD To METH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10."CFM)
SOURCE REGULATIONS MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCIIONTAX
Sigvmc of Applicmt/Convecta Due EXHAUSTHOOD(WMUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
x Will lheupplicani cefuwm buildingrccupanl Mac or hoofle,hexmdeue matenel HEATINGUNITM)100,090BTU)
n lefircul by dee Cuanino Municipal Cale,Clb pr ,12 oat the Hrnllh est Safely
Cork,Sternen 255321e1J HEATING UNIT(OVER IIT."BTU)
C]Y. Fl No PAID
VENTILATION FAN(SINGLE RPSIDI Doe ReceiN#
Will th condiment cieml or fawn building acupanl uu en Air Qnl or Mance which
it honoNoue alr amuurdmnb¢r de(ircd by the B.y,Area Air Quallly Alovgemenr OOILER-COMP(JHP OR I01,(100 BTU)
Oisvicl7 TOTAL:
❑Yn ❑Nn BOILER-COMP(OVER I0),000 BTU) ,
1 bevu revel the h000c.lx mmcriele AIR CONDITIONER
re.o 53enu uredo Chopuo95of the Calk. ISSUANCE DATE
funic IknIN n Swcry Code,Seclkms 255115.any and 25531.1 to fy W thu if Ne NEW RESIDENTIAL METH, SQ.FT
_
building don mr artemly havcatrmnl.thol irumy rcpauibilitYnrwtify Oe acupaol
of Ile reyuimnenx which mut h mcx pia to luvaoce of a Cenir.c oI tkevpaney.
Owecraaulhgrioedogeru - Dem TOTAL ISSUED BY.
OFFICE