31195 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL � 'I nC
BUILDING PROJECT IDKNTIFlCAT1ION J J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/&
OWNER'S NAME PHONE: CONTRACTOR'S NAME LIC NO.
1-A254 w 2S eQZ k� fZ 3�1-(L4 11.ass¢k Eb.4S G�S��4 we CONTROLN
ARCHHTCTILNGINEER: 111C NO, ADDRESS:
CONTACTm PHONE BUILDING PERMITINFO
❑ Consultant Fres Paid by Applicant(INHzq BLDG ELECT PLUMB MF.CH
LICENSED LYINTRACTOR;S DECLARATION QTY ELECPRIC PERMIT FEE ❑ •`q=��
I nerenr WI I van Ilnmred uMer proviainas of Chaper 4 fn+vuncrcin¢ JOB DESCRIPTION
QRZ wdth Sxlim'RIUB MDividm]oflhc BaFinCN erd Pmfasionx Cae,ardor IianFc is PERMIT ISSUANCE
�c 0 y RESIDENTIAL
icense0r�full wJeRm`` ���Q�abq - ❑SFDWL ❑KITCHEN REMODEL
-Ft- u Liccvc Clam " LicN
NQ1 De¢ 1a' TCmlmJor V APPLIANCYS-RESIDFIJ'TIAI. ❑ADDITION El PLUMBING RE-PIPE
�N ARCHITI:m DFCLARxnoN ❑MULTI-UNIT ❑STRUCTURAL
Z 1 ullJcrvenl m I shell be ural as brie rccnnb PANELS
Z ,� YP a^o W MODIFlCATION
OZ-Q UPTO NX)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
�r�F-
W licensed ProfeuiomlY01-IfMq AMPS IMPROVEMENT
p9S OWNER-BUILDER DECLARATION
5 W I hreby affirm Nal 1 mon exempt form the Conant sa's License Lew for doo OVER 1000AMPS ❑BATH RFMODE]IREPAIR ❑DEMOLITION
ippiS5..O 1 U following rtnwnSIGNS ELECTRICAL ❑OTHER
t++LL W0 yG which reyuitea a Permit to Cannon,alter,improve,demolish,or repair any arr,eare
.5 F priv to it.nsmnce,also realuirto lh applicant for sash permit to rile a vgmal sWemrn SPECIAL CIRCUI TUMISC.
IFIL MiF 11Ce95CN parAlMllo llC pTvi51t9LL trf the ClmllYloir Lic[nY law fChJpler4
X00 fcommcming wish Sarins]U10)of❑ivi,inn3Ofthc Busirev and Pmfa.irxu Coddm TEMP.MRD?It ORPOIELNST. COMM�AAI
O.6e' Shur u Ieacmp Ihrrtfmm aid Br
Jr basis for e alleged eanptiao.Any violumn of C1 NEW BI.DCJADDRION ElDEMOLITIONLL• Se tion 7031.5 by any applicant for a Penni)subjeOs the appl"nt to a civil Penally of POWER DEVICPS
Zr ❑TENANT ❑PWD SERVICE
m mum lean of bmdmJ dnllmn y emu.
OLasaxmeror Ne prop nrmisyemploym withwagn asale(Sse. W.Business
uwion. SWIMMING POOL ELECTRIC IMPROOTHER EMEM'
will do lFe work,and!l Gs,Conti a ru,Lrcn nal Law d—.9 tra a.'o an o ro r of El OTHER
aid Mofo,iam Crdc:'Ihe Canuoch✓x Lxcnae Law JIc,rxN apply to an owner ul OQILLTS-SWITCIII?S-[OXTURFS
popery wlm build.or impmvca Berton,oro]wen Juas ruck sane deed or a through
-I own employe de prOvaled that ouch ono orveold w uta oro intended a,Rfoo,for NEW RESIDENIIAI.ELECTR Q FT.
.oral-bower will hbui 0,hurimpnrvemeni issold
LedWnost h Ycw4fcorove fon,lee SQ.FT FLUOR AREA vs Q.PT
pwneaoale.er will hnvc de huNen of poving that he dal ort build or impnvc f«pu- ® p
ose d'uwo. 1 • A r
r. 1,u alk p o the prnlr*D mon.,ire a enol summing wile:)The
conlrel t s to
Cun4rvCl the pujcn IScc.]IH4.Bunirrtas erd Prnfa,iom Calc:l The CorltwGra(.I.i- L�
law does omtepplyman oxxrofpropcny who buildswint Conure.md QTry. PLUMBING PERMIT ��� n� �
wen contracts(m w[h pmjm,with a rnnlrurrMa)licemel purwnnl to the ContmclNs or
IZU
Licmx Law. PERMIT ISSUANCE
Lem eacmpt undcr5c. ,Bk PCfm Nis serous
•0. Dee ALTER-DRAIN&VENT-WATER(P.A) uut-t: A'�ai)(A�IION
WORKERAT
S COMPFNSION DECLARATION BACK FLOW PROTECT.DEVICE Tl IHLYfaIJ/
I ver ebyN un rpenohyofperjuryoneofthefolb ingdecl.7:
I have cons! ill mamteine Cmificne.fConsenu0 self-inat OrWnrkdtr Compan- DRAINS-R-COR,ROLP,AREA,COND. STORIES TYPE CONSTRUCTION
motion,as pmvilRd for by scrtinb 3]1111a the Labor Calc,for the prfnrnat M the
work far whieh al Femdt in isucd. FIXTURES-PER TRAP
❑ I have asd will mainmin Wa '.Compcn.olion Lawrance,as rtynnot!by Seo m
37IlOuflho Lahr Code,for ti,,'perfnnrmreeoflle work hu which this permit isuw d. GAS-EA.SYSTEM-1 INC.Y OUTLETS - OCC.GROUP AM
MYVA.6 ,rro" utwoiruusuu�e rarer and Policy numu
ber e: -
Carri¢ g� P PON,No,: GAS-EA.SYSTEM-OVER 4(FA)
CHRIIFICATE OF EXEMPTION MGM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE IM'ERCEPTOR BUILDING DIVISION FEES
IThi,vctiun said nor be campklcd if the perrtdt is Torose M1utitrW ddlnrs(STUB GREASETRAP or less.) - PI.ANCHECK FEE
1 unify that in de pe,f.e Mae wnok farwhich this perndt is issued,l stall
not employ troy person in any sumer w as to becone subject to to Worker'Corn— SEWER-SANITARY-STORM EA,200 FT
ENERGY FEE
Z action law,ofe0ilomin.late
Z O Appicent WATERGRATER WNENT/ELI:CTR GRADING FEE
In NOTICE TO APPLICANT:If,vu matin¢thD Cenifcwe of Eaemption,you NwM WATER SYS UAV"RFATING
h,orbe zubjw w lee Wot1e'Compensation provision,of Ih<Lbm Calc,ye,mon SOILS FEE
� r fonhwithrornplywith wchtrorvisinn,or this permit shdl be JccmM revoke]. WATER SERVICE
Q
7z CONSTRUCTION ioDING,ACENCTagasy NEW RPSIfyFNTIA1,i'LMB. SQ.FT. PAID
U. r Iher by whia sh thndmrt iso Cnn(Seay.rmlemli,C.) cy for the perfororumc of 1 ereipY
U. � the woe for wfiich Bio permit is u..,.. (Sa.J09].Civ.C.)
O F'L) Lertlu'o N. TOTAL.:
lender's AJJm, TOTAL:
yI ceitify law 1 Nve rev)Olin appication ad a We Ihw the above infomwhln is BUI G
Zi amen.I agree to comp,with ell Ciry sad coa ty ordinance,and Forte Loss relwing m QT'. MECHANICAL PERMIT FEE
U tmilJingam4rlxYirm.and wo,by..Oorize o,os nwivr,o Ihk Clly to cmcrafrntbe SEISMIC M.Z
above-orcmioocd pmpvty for inyaction Purposes.
(We)agoee In w.c.iMcromify sal keep harmlec.the City of CupertinoagdmPERMITISSUANCE ELECHU F72
Iiahililies.jlWgmrnN,Cost.,ural cspcw,al which may In any way Isccrue egarnrl said City
n canseyrere f the granting of this peoron. ALTER OR ADD TO MIiCH. PLUMBWG
APPLICA BRSI' NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CED 10,00i)CFM)
SOURC F LAllO MECHANICAL F
.g /. M AIR HANDLING UNIT 111,000 CFM) CON.STRUCHON TA
Sill.1 onotatm V Daae EXHAUST HOLD OVDUCT) HOUSING MITIGATI(NFEE
nIALARDOUS MATERIALS DISCLOSUNL'
W the pari or future building occupam store m hantile h.s..Jou.nwvitrl HEATING UNIT(170 F 00,000 BTU)
no derived by C eninc,Municipal Calc,CTapler 4.12,and the Health nod Safely
Code,Sntion2 3 n)? l HEAPING UNH'(OVER I X010 BTU)
El yes (]No PAID
- V "]_ATION FAN(SINGER RESID) Dem Rcccipl N
W.11 tho applicant or fuse¢building Oecupanl oro c4uipmcnl or devices which BOILER-cUMP OHP OR 100,1100 BTU)
mvit eas air conLvnimnu as rkfred by the Bay Area Air Quality Mermm
teenl
Disarm? TOTAL
Fl yes ❑No BOILER-COMP(OVER 100,000 BTU)
I hive orad the,M1acaadorao matesds ostrannems user Chata,695 d the Cali- AIR CONDITIONER ISSUANCE DATE
Bart Health&Starry Cade.Seninu 255(15,25533 sad 25511.1 uMrrard that if LIC NEW RESLDINTIAL MFCH. SQ.P-L
hudding that civ Cmroently have a mnanl,that it is my rtspm,ibility to notify the a Fant
of de rryuimrrmu xheh mora be ser per 14 L."'.Cetir'.M(kcugmcy.
Owner or uuthodaal agent Date TOTAL: ISSUED BY:
OFFICE