S 3880 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERIMIT PLUMBING-MECHANICAL 0
C 3880 O O
BUILDING PROJECT IDENTIFICATION J o
BUILDING ADDRESS: SANITARY IN APPLICATION SUBMITTAL DATE
OWNER'S NAM)j IPHONE CONTRACTOR'S NAME: LIC NO:
O / B ODS _ NSC CO, OL•
ARCHITF.CUENGINEER: PJC NO ADDRESS: ❑
CONTACD PHONE BUILDING P IT INFO
❑ Cons Rant Fon Paid by Appllcanl(Initial) BLDG Ey PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'ry ELECTRIC PERMIT FEE
I lertby amm,Iwt 1 am limned amen pmvidtms of Doper 9 mlmlmeamg _ JOB DESCRIPTION
�OZ Is th Scadon'7400 1`Divi.doa3,T the Busing end Pn,fa.suiona Co�.am my li.enrcis RESIDENTIAL
F- O in full forte and effect. 19iRMIT ISSUANCIiILI
<V U Imr.Clv. L'c.0 - C1SFDWL ❑KITCHEN REMODEL
i De¢ ContractorAPPLIANCES-RESIDENIkL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z Dere IwderwM."A.shill he used v Public reads / PANELS MODIFICATION
OZ-O ( UP T0200 AMPS Z Z D 0INERIOR El CHIMNEY REPAIR
Llccnscd Rokcvinml 401-I[XIIIAMPS IMPROVEMENT
a []SWIMMING POOIS
OWNER-BUILDER DECLARATION
OVER IOOOAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C Q I hereby.(Seth Na 1 am exempt from Pr Camrns Coc Liana low for the
U to new renewer.(Section'!031.5, 4 olon. and ye.deicna h- k Any city or coumY SIGNS ELECTRICAL 11 OTHER
413 0 which ras i •pmnit m oi.ty, Tic iciporc,fortieth poonnin ae.pur anY sIN[Imt
F'1=0g prior to i,limm,,!p.alvrraryirts po"itpicamCommiclo" Bkasrgrcdmaaevm, SPECIALCIRCUR/MISC.
C GS Nm han isco,won
o S loonurano odepnvisia,a ofdMG Baund 'awl Proelama,Cox erg
41-.00 (urmar—Im withSriuor mH1)to ulls nl th nhc1" xicmdl. A.,li Cidc)a Il?MP.MIiTBROR i'OhB INET. CGMMERGIAL
d d Nar he is.amnp ndCm[rom uhl the hmis Gn Ne allayed acnrytitm.Any viulmion of
❑NEW BLDG/ADDITION ❑DEMOLif ION
x S+� Secdm 7031.5 by any opplacman for a permit subjects the applicenlm a civil penalty of MOWER DEVICES
41-y ❑TENANT FOOD SERVICE
6 D)�than Dvc huaBM dallaa($50)1
Mork,de de, oxyd mmy empWyees witbxayauNei(Sm. Dill. mim,s SWIMMING POOL ELECTRIC IMPROVEMENT
W x311 Bothe wont,Cri y,Ccgelsngimmdeda offearnJ ok(Sec.7UW,Hams os OOTHFR
6}i and,ty wbioas Code:The ConuoclrMs License law data nor appy is an i1hrer of OUTLETS-EM'S-SWRCHP_S-FIXTURES
proven.whm bolds a imposes Ih such
ud.vhO dors such work himself,a Imaugh
his own ow,ove ce puha as Nut such impmv[nwmn ort an im[ake a olYc d for NEW RFSIUIiNI'IN.GLF:CIR SO FT
sak.IL huweve illhad thinpaimpovcmcnl is.sold wi thin utcy[arofctomic for Nc .FLOOR AREA 5/SO.FT.
mxmer-Willer will Fuse We bunko of proving Nn,he diJ at bold a intpmve fa pv-
pose of del.
❑1.n<oxmcr of the.Sm arn 704 ,Beulu and convuliu,windlion.irnnlxas - TOTAL
demo,La t�project apply
nano Bwircu and PrufcIm bat Code)Ole Hereon,
E-
mLewu4msnmopplymeswithn ofpmpcns) immod ni,rimpovt, Cnnim,and QTY. PLUMBING PERMIT PEE
' who mmmckC for.uch pemlats with untmmda(s7lkcnscd Purxtannolhc Cnnvoclor's
Lamuc low. PERMIT ISSUANCE
❑lam exempt umkr k .B&PC fa cis
ALTER-DRAIN&VENT-WATER(EA) VALUATION
0. D le
WORKER'. 'OMPENSAdGON DECLARATION BACK FLAN'PRIUI:C.DEVICE
Ina Ynlfimt umor coney of T�crjurY meoflM rnlloxmge Inn um.c
Ej Ibm mrd will mon...Cunifimmof Cortem mmlf-irtmefa Worker's Cand'a DRAINS-FLOOR,ROORAREA,CONU' STORIES TYPE CONSTRUCTION
W inn,as pruvitkd R.by Section 3710 of the Lilur Code.for the p[rfomuna M the
week for which This permit is iaNxal FIXTURES-PER TRAP
❑1 have and will noimain Workefs Compensation lmuuvrxe,as ox ined by Section
370).DM I� Colic.fa Heperfrm eof the work fa which this permit is i.uuaL GAS-EA.SYSI'ESI-I INC.d OUTLETS OCC,GROUP APN
t My Worl.cfs Canpnwim lnaumnm artier and Policy number uc:
Carrier: POIkY NO,: GAS-EA.SYS IEM.OVER a(EA)
C17R'I'IFICA'I'I!OF EXEMPTION MAIM W ORKHItS'
COMPENSATION INSURANCE GRIiASUINDUSTRL WASTE INTERCEPTOR
(This ceerion need not be, n
caplaal ifthe permit I%for one huMrai dollmx D 100) BUILDING DIVISION F'EFS
a kax.) GREASE TRAP PIANCHECK FEE
I ccnify that I.de,perfarmarc'cofthc work for which this pencil,is i...M l stall ST;WER-SANITARY-STORM FA.200 FT.
nee employ any person in any manner was tU become subject to da ek
Wuer: m
Crryen- ENERGY FEE
zz roman I.wu of CHnomia.Dat. WAFER HEATER WNEMYELECIR
Appellant GRADING FEE
N NOTICE TO APPLICANT:If,alter making Nis Ceniiicam of Excrummn,yu.Nwld WATER SYSTE RFATING
F" become subject u.NC Worker's Compensation povuirms of tk Isbor Cade,yon must SOILS FEE
fanhxith emmpy with such nowinionx or thiapmnit shill be deemed revoked. WATER SERVICE
a �
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL T9.MP. SQ.FT. PAID
V p Ihcrcby affirm Net there isamns0uction!coding agca}fa the pefaman[e of Dete Receipte
Ethe work 0th which this pmnit Is kuwd(Sm.3M7.Civ,C.)
I.caler's Nana TOTAL:
Leedu'a Adlmni TOTAL:
F 0. 1 conify It I love read this eppliOuion end sive Non the above information is BUILDING FEE
N mrt.a.l agreem,comply wind dl city aM cwmy umlinma[s and same law.mWingm QTy. MECHANICAL PERMIT FEE
V Z building masuxcnion.and hereby awlxmire representatives of this city to enter upon The SEISMIC FEE
aliovcm[mlorcd pmpcoy for impction pryoscs. PERMIT ISSUANCE ELECTRIC FEE D
(WC)agar to naw.Indmnndy and kap hkw
anna m,,-City of CuNnlmo agYnm
IiabilimesJalynems,cmd land espen—which mlayln any way aCCme against sold City ALITR OR AILD TO MECH. PLUMBING FEE
in onuryucrce of ee"bog of Nis Boma
APPLICANT UN RSTANDAND WILL COMPLY WTIN ALL NON-POINT AIR HANDLING UNITITO 10.010CFM) MECHANICAL FEE
SOURCE REGI' A
AIR HANDLING UNIT(OVER TO."CEM) CONSTRUCTION TAX
gmturc ApplicdMC tenor Hate EXHAUSTHOODOVIDUCq
IIA' RW US MATERIALS DISCL(lSU HOUSING MITIGATION ITE
Will the epplic future buiding occupaut aatxea handle hmunioua material I I EATING UNIT(TICI IW.11O BTU)
u deErad by Ibe CuBorom Municipal Code,Chap[r 9.12ab the Health end Safny
Cad,Section 255321e)^ HEATING UNIT(OVER 1W."BN)
OYcs ON. VENTILATION FAN(SINGLE RESHOT PAID -
Will thea lieam lar fwum Nildln t u.m n ui t or do dm,which Da¢ Receipt K
pep 8byIm 1 Poen BOILER-COME(31111 OR 100.00)BTU)mit havvduus air mmtadnnnre us JCTircd by Nc Nay Arw Air Quality Marwyenxmt
District^
❑Ya ❑Nu BOILER-COME(OVER IOO.000BTU)
I hest,mad the hvallous materials recoincnrnts oar Chaps 6.95 of ee Cali- AIR CONDITIONER ISSUANCE DATE
format Holth&.Way Code.Sections 25505.25533 and 25513.1 uMemord IMI if the NEW RFSIDETTUAL MECH. SQ.ET
buildingd rtcntl sterno lit is nny rcapnsibility to naifyN t l//.'/J�s /
OfIM
it IaFl I1C rt1U iVWIMC UtuC[NEf91c0
t TOTAL ISSUED BY:
OFFICE