29491 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E LKLTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. n �I
BUILDING PROJECT IDENTIFICATION L f-f
BUIIJ>ING SANITARY NO. APPLICATION SUBMITTAL DAH� WAUDRI!SS: GL, ✓ls4 ira 7 cu fi -
NER'S NAME: PHONE: ONTRACIOR'S NAME: LIC NO:
ua u t o a z NC CONTROL,Y
%RCHITC-UVt4GINEER: LIC NO: ADUR SS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Corttoltant Fen Paid by Applicant(Initial) BLDG ELECT PLUMB MCCH
❑ ❑ ❑
LICENSED don 1 am
Visions AHONof
QTY ELECTRIC PERMIT FEE
1 krtby eRrtn thu I am litvmsd ueder povuiwa of Clsaper 9(cannvcing JOB DESCRIPTION
�Z svitullfi xlOWffiNt. stun Joflk Busir'w and Prof¢siom Cade.eM mY licenseis
O O PERMR ISSUANCE RESIDENTIAL
_ in full,erne and erten.
<U�j liceme Cher,, lie.♦ ❑SFDWL ❑KITCHEIJ RFh10DFI.
Z APPLIANCES-RESIDENTIAL
Q i Dmc Contnaclrx ❑ADDHION 11 PLUMBING RE-PIPE
F- ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O I�,Z l orx]eatvnl mY Plam shall k uad as pub&mcmd+ MODIFICATION
OZ—O UPTO ZIXIAMPS El INTERIOR [I CHIMNEY REPAIR
Licensed Pmfcssiouul 201.1"AMPS IMPROVEMENT
C Y OWNER-BUILDER. DECLARATION
1 hcrtby vfEmt that I vm csam,l ffrom the Cuntnecwls License taw for Ne OVER"AMPS C1 BATH REMODEUREPAIR qDFMOLITION
x 3 a U following ikon.(.Section 703I.5.Hushes otd Profusions Cralc:Any city w count' SIGNS EI.ECfRICAI. cl OTHER
to�LLC which rttsegmnpennh..ennWrvc6idler,ii hn,odemolish,nre.,,any aWaum
y priormits l.uuercqulw rryuireslhe olplicunt lir such pemuua flea agrcd Wl<mem SPECIAL CIRCUITIMISC.
WN tbm he is licenrW pars, rtmlhe,rrikitnh of he ConlmodMs Licenw law(Chager 9 -
vao0 (ewmorm,ingw,0 Smtion laXOol Divisisn 3ofthe Baei—need Pmfcasione Coda or TEVER ME 112R OR PULL!EAST. COMMERCIAL
L y o a that he is eaentpt thcn:fnmi uml the hum,far the ulkyod emotion.Any einlatim of ❑NEW BLDG/ADDITION ❑DEMOLITION
�Wf tv. Smdtw9031.5 by nnyupplicanl farullcnnitsunjects eppliceni tna civil,cnel,if POWER DEVICES
Z> no mac then Eve Imon d dollun(SS(X)). TENANT ❑FOODSERVICE
�O Lasirvucr of the property,ter my cmpinyan wish wvgu os their mk amptm.wliov,' SWIMMING POOL UECIltIC IMPROVEMFNT
will do the work,aid tint,.0m,it not inmux]cd orot4reJ for sale(Sm,TOdG,Business ❑OTHER
3� erd Pmfeuions Code:The Comoc'or's I.icenxe law rhea not not to an owner of OUTLETS-SWITCHES-FlXTURM �
LLLL property who mild,ser improve,,; fm,n,and wlm arcs...h work hmo,lf or through
his owm en,ployeca,povidcd that each impruveream s uc not imcudmi or oevd For NEW RESIDENIAI,ELECTR SU IT.
silo.IL however,the building or improvement la uAd within ore yemof mmplcdon.ik SQ.FT FLOOR AREA LSQ.IT.
n ,huilchm will have tk hmdcn of pro rm,Trot k did nu build or improve for pur-
post,ofuk.).
1,as owrcr of tk not em esdudvely mndacdng with liem,d cos ers to A
mom,rm do projml(Sm.](W1,Buaincu and Pmfeuimu Cade:)Ta,Cmuuroctan Li-
t<nse law cines mx apply m an owrcr ofprocity who builds or im(voves Wcem aux] QTY. PLUMBING PERMIT FEE
aIR, .aforauehp *Iht 6acominatof fi adN.,1.dr,Canaigmt'. LIAR 25 1996
Uceme Law. PERMIT ISSUANCE
❑I am csmot urde Sec. ,B&PC fa this recon
n,.
ALTER-D EN-WATER(EAI yr • yr vera ryALUATION
(Torn Dare
WORKERS COMP SATION DECLARATION BACK FLOAPJ14CT.DEVICE
I hereby affirm uruJQ penalty of perjury ex�of do,fol"ing deelnraivm:
❑Ihnvc erdwill mainuineCenifcare of Comcntm.self-imurt fa Wmkv's Cmnpco- DRAINS- 00 AREA,COND.
aatiea,m not f«by Senimt 37M of do Labor Code,for dee pmforrnence of the STORIES TYPE CON.STRUCI'ION
svurk for which this pmmit is ismeL FlXTURES-PER TRA
❑1 have and will meinum Wuksia Conlcrtmtion Insure,m ne, 1 by section
J'/OOoftk Labor Code,Ra the perfvtrvrce oftk w«tf«which'hu permit is isaucd. GAS-EA.SYSTPhI-I INC.JO
OCC.GROUP APN
C WmknS C«npewrian Inaurwc carrier r h y No.:number arta
Carries Pdicy No.: OAS-EASY -O 4 0(PA)
CERTIFICATECOMPENSATION
I N FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL A. ER .PIOR '
(Thi.mon oak nd k e.tomedl if the permit k for orc hundrM dollars(S 100) BUILDING DIVISIONFEES
a lev.l GREASE TRAP
PLANCHECK FEE
1o,m,ha In the pey mourn,-.,tworkforwnich this penmtls UaueLl,e- SEWER-SANITARY-STORM 1A.21X1
mol employ ony pcnw In any mvnrcr w ns w hccome sun}r m Ik Workeuv'Compcn- ENERGY FI:E
O ill
z moan I Cullfumie.IAtc WATER HEATER WNEN,F1-ECTR
O Appheam GRADING FEE
� Ul
NOTICE 10 APPLICANT:IL after making this Cmifcme of Eaconp''wn,you Aimid WATER SYSTFM/BEAUNG
ahmc suBmi it,the Worker Crmtpenmfmn pmvisionx of tbo LzM Cate,you must SOIM FEE
forthwith comply wim weh lxrokons nr this pertnh dtdl k deemed marked. WATER SERVICE
12
D
5 z CONSTRUCTION LENDINGAGFNCY NEW RESIDENTIAL PIMA. SQ.FT. PAID
L) O Ikrtby offirm Nattkmie acrmntrtrtian lemling nge.ocy fm rise pcAorrnarcc of Date RecciplY'
O — do,work Ea which this Koen is lutcJ(Scc.3(19T.Civ.C.)
faMcla Nomc TOTAL:
} Irndch Addrtu - 'TOTAL:
(•-' y I ttnify that I have read this epplicmkto and Utah,that tk ohove infatuation is BUILDING FEE
(A cmrm.I egra mcomply withill city and cwnq mdiwnm ami state dwarcheingw QTY. MECHANICAL PERMIT FEE
U z buildingmmvutrfirm end krtby autherirs mprng.mg es oftB,c,lymemcrul+n tk SEISMIC FEE -
above-rrenionel por coy for im,smir.pm,m,t,
(We)alpeetosave.indrnmify and km,harmles floc City M Cupvtim agaiesr PERMIT ISSUANCE ELECRICHIE
liabilitiea,jdgr¢mn.rnua and eapen.es which maY in enY waY ecrnm agvnstuM City ALTER OR ADD TO MECH.
in comequrerce of do granting of this pmnil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IOAW CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 0.000 CFM) CONSTRUCTION TAX
Sigeururt of ApplieendCwnacua TAte EXHAUST H00D(WR)UCfT HOUSING MITIGATION FEE
HA%ARWUS MATERIA S DISCLOSURE
'
Will Bit,applicant or fwum building mogon'to,m Inndk hazardous nwerej HEATING UNIT GO 100,0(10 BTU)
u defirtcd M doe CuNnirw Municiryl Code,Clvixer 9.13,ask tk Heath eat Safgy
CoAe,Smirar,25512(a)l HEATING UNIT(OVER 100.000 BTU)
❑Yu F1 No VI=I LATION FAN(SINGLE RESID) PAID
Dara 'Ra i,x#
Will m,ii,lilof,coentmfurore cREiRgby d,B ver equipmentnrdevices ,omg BOILER-COMP QHP OR Bat BTU7
emit hssardwa uir rnnmmimnin a+defind by rite Bay Arta Air QualilY Mawgrncnt TOTAL:
DtR R BOILER-COMP(OVER 10(i BTU)
❑Ya ON.
I hove rCid!the Smitoma mmerials AIR CONDITIONER ISSUANCE ATE
Try 11533 ud under .1 rn ,of tt Cili-
fomiu Hedth&Sultry Gale,Snriom 255(15.25533 wd 25533.1 m orciluM dot if Ik NEW RLSIDINTIAI.MI;CII. SQ.FT.
buildingdoe a is"icy haveumort,For it is it neofaCelityw notifydorrcu.
of tk rtywmmvn'x wmmh n'nxr k nit Odin m ismata�a.,t a curtimme ttra�T.
7—)Q—F
Owner err tntrim izel agent Doc TOTAL: ISSUED BY:
OFFICE