28459 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 28459_
BUILDING.PROJECT IDENTIFICATION
BUILDINGADDRRSS: I SANITARY NO. APPLICATION SUBMITTAL DATI
CA
W E S ME: i 1 HONI!: CONTRACTIRS NAME: , LIC NO: f\`�%
Y1 N/C CONTROL♦
A CHRECT/EN INRERL LIC No ADDRESS: ❑ .
CONTACT. PHONE' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ECH
❑ ❑ ❑
LICFNSL'D t l.en ALTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I Itofehy amem Btn 1 int ftcen.ml lmcrider Peces.s of C.,k- 9(amnundne JOB DESCRIPTION '
0Z with Senion]IX)U)nf DivuionJMthcBWrcv WPmfessionsCMcaml mYliCcmeis
O PERMIT ISSUANCE RESIDENTIAL:
fWlfaa ad cRcn.
Ltccnsc Chi. d ❑SFDWL D KITCHEN REMODEL
FV M 'DauCnnuac. tm APPLIANCES-RESIDENTIAL DADDIIION ❑PLUMBING R&PLEB
W<;6
FF_�wi ARCHITFCTS DECLARATION PANELS El MULTI-UNIT [I STRUCTURAL
Z O to i,.l I unduvaml my plans dW l he wind in public rrcods MODIFICATION
pZ O UPTO200AMP5 ❑INTERIOR ❑CHIMN17Y REPAIR
Licensed Pntfc.airrtvl 2014"AMPS IMPROVEMENT
�yi, OWNER-BUILDER DECLARATION
IY W 6 I hertby affirm that 1 am nemPt fmm the Cownew,,s License Inn'for the OVER I"AMPS D BATH RPMODEUREPAIR C DEMOLITION
3 a u following..(,Scellm]Olid,lLo.erW P ofacines Cosa:Any city sic cuwwy SIGNS ELECTRICAL D OELECTRICAL
0 which rtquim a pe oro common,
w afterhm
,imMova, ollN,lc rtfvcu
ir say swrt
�ftpoor to in irwaoce,also m9ulres the limlieant for such permit to Glc a sigednuicmenr SPECIAL CIRCU[I'm C.
} da,Its,is licrnsed Fursuam to the provision of the Contractor's Isms,Law ocbsptr9
IuW COMMERCIAL,
pO wivrmvuing with Snlion7")of Division Jafthe Buri.and Piofsoeru Code)or TEMP,MSIR OR P(RJ!INST L ,
6 e oC that he is,ramp Nercfrmn and lose hs,,s fa be,ollcgeJ exemplum.Any viMution of D NEW BLDGJADDTf10N ❑DEMOLITION
on Section 703 I S appl
by any icmitfofa pemNe
ut sobs. applicant bJt
a clot peny of POWER DEVICES
�m ❑TENANT C1 FOOD SERVICE
II....,, mtnsrc thin five hurdrtd mlwa(55m). IMPROVEMENT
SZ� wiL¢snwnerofthe the law
isycmployas wiNwaen as thcirsale comperwoon, SWIMMING POOL ELECTRIC
p22p((
will dotbewwn,Code:
he C.n . ,-Licdeda Us,do for s. poly to an ewsims DOTxER
0. fond erry whom 6ida:The Co,thasso Lndl w Inw Josue rot apply w m owner of DUfLLTS-SWITCHES-FIXTURES
his own won builds a improves thereon,amt vendor such work deta,B. through
his own ocosere,s,provided nW such cant is
wart not yn ofcm onned.hn NP.W RESIDENTIAL ELECfR SQ FT.
Wc.ILhoweverill have singorell fixonvint is at he
non IMnofeompktim.the SQ.Ef lt(IORARPA SrsQ.FT.
ewlerfbw s.) will love Uc huNcn of proving Bus he did m W M m impross fo pur-
pognf.ele),
D I,n nater of the property,an<aclwlvely comessicng with licenced comnnan i. TOTAL:
connntn Bre In j¢t ISs.]M0.Dint.atd Pnfnsiom Code:)The Cmtnnu's Imo.
canse lawdossmepl>ly ,,m owrcr Mpnpcny who buil ds oriiftovca Nncun,W QTY, PLUMBING PERMIT FEE
who msufnns for such pmjats with a Cmncta(s)IicertW puntwn to the Canwanors
liarow Lsw. PERMIT ISSUANCI!
lam as,.Pt mSx. ,R&PC for this.
ALTER-D -WA (EA)
Cosner DoVALUATION
te
WORKERS COMPENSATION DECLARATIONFL OW PROTECT.DEVICE
I hereby affirmms IM
under Penalty of perjury e a Bs dcclvmtiom.
I have sod will maintnioe Cenilrcwe urcun¢m loself-insurt fm Workers Cumpco- DRAINS-FLOOR ROOF,AREA,COND.
sales, TYPE.CONSTRUCTIONsales,u provided fm by SecOon 37W d the Lwwr Code,f«Be peffarmana of Bs
work fee which this permit is i.0 wd. FIXTURES-PER TRAP
D 1 have and will nuivaln Worker's Cmnp tine Iesurercc,as required by Smu n
J]OOOf Bs labor Costa,for the perftmrarce efthe work for which this Peeled,is iusu GAS-EA.SYSTEM-1 INC.d OU11ETS
OCC.GROUP AI'N
My Workpn.w
cr'e Cnmc5on le.n cnmicc fool Polity numbsi
er c:
Carrier. Policy No.: GAS-EA.SYSTF .OVER a(Pik)
Cf:R1IMCATE OF EXEMPTION MOM WORKERS'
COMPENSATION WSURANCE GRFASMNDUSTRL WASTE INTERCEPTOR
(Thla tstom reel int c,comPlncd if Bs pemut u fm ors umdfcd do lne,(5100) BUILDING DIVISION FEES
mlmo.) GREASETRAR
PLANCHECK FEB
(Certify that in the an mowrareof thewhetfor which this his,W'liuued,lshall
mem to an oxer muvsrmutu bnumc subject ire Wnrken'C SEWER-SAN FA.200 FT.
P Y Y Ms^n y jc rmpen- ENERGY FEE
Zz pplicnwsuf CdibmJa.owe WATERx R Cf
z O Applicant GRADING FEE
N NOTICE TO APPLICANT:If,C.r melting this Crnons of of f cmption,you should A 'R ;M/f TI
F' become objewt to it Wwn pie Cnmisovtiim argil hal of the Isba Cods,you mu`a sons IEE
forthwith comPlY wind such provi.siwuathis permit sha116e deemed revMW. !RS E
Q
d
CONSal is acre LENDING AGENCY WREST E.N AL PLMB. SQ.FT. PAID RN
V Ihowhichirm Thatfinalis •cdmwnion lending agrncy fnrtheperfosmuse of Doe /5 dka'eOJptA
O F Wevork for which this pcmtit is iswnd LSe<.309],Ci¢CJ
Indere NameAun
U rndcr' TOTAh
Ls AdJscas TOTAL:
I anify But I have mail this application not some that the ebosc inf«nnlion is BUILDING FE hi ,
(A comet.l ogee to omsply with all city and county adirwcu and state laws relining to QTY, M HANICAL PERMIT FEE II���� a.
V z hoildingconvtuctien,uttd hereby euNosiae repm'enwtives of Btu city wcnur wpm the SFJSF/1C FER LUQ
eboaarendwsJ property fee inapeniae puetwe es. ,
(Wc)agrtem rove,irdmnnify and kcr lumJnstha Chyuf CuIa in,again, PER ISSUANCI! ELECI'RICFEM r U
IiabiliB4)udgnteou.<osu eM eaperues which may in very way escrus agaiest ssIJ Cily
ALTER OR ADD TO MECH.
e cvnaegnnta o(theg g¢ 'L PLUMB WG FEE '
APPL ANT UNHCR n' U ILLCOMPLY WITH ALL NON-POINT AIR HANDLING UNITQOIO,oW CF'FT)
S "6t u T N 81L51�� MECHANICAL FFR
�i,/10 1 AIR HANDLING UNIT(OVER IO.IXp CIM) CONSTRUCTION TAX
Acid�em ..room "� Dau EXHAUST HOOD(WIDUCry IIOUSINGMITIOATIUNFEE
IIA%ARIIOUS MATERIALS DISCLOSURE
Will theepplicvtl or finite building occwpasg stow or hidle heraJou rwniW HEATING UNIT GO 100,IXp BTU)
u dchted by the Cupcnim Munwipil Cork.Chapter 9.12,and the Health end Snwty
Code.Semon 25531(x)! HEATING UNIT(OVER 100.(W BTU)
Dy. DNo
VEM11AT10N FAN(SINGER RESID) PAID
Will the eftlicmt ce fuwrt building onvrynl use acuipmew a device which Dau Receipt N
locin barmdous a'ir.onusrJruns in defrM by the flay Area Air Quv)iry Management BOILER-COMP CHP OR I00,000 BTU)
JiMriri[I
❑Y. DNo R 100,000 BTU)
I how tad the herankaos 'ran rtquimrenu undo AIk CONDITIONER ISSUANCE DATE
Oupmfntad] Beifdi-
fmca Ift,Ina,oc Safety CWe,Section.25505,25523 and ihilhl I uMcmntd thn if Be NEW RESIDENTIAL MECH. SQ.FT.
building rksxm cwhich onstareasnt,Butoomyewofa'cestiy Iomtify the arugw 9)
d the rtquimmna which mw be int prier ro issuance of•Cmifuae d(Xcvparcy.
(Jwacr err awhndad vgrnl Daw TOTAL ISSUED BY ;; 1)�N 1
OFFICE