29009 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO I BUILDING-ELECIDUCAL PERMIT NO. 29009 Q
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 9 O O V
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMTITAL DAT
200 C/ ,T-,J`s7- VE Ir�Zq�s
owNER AM I % Ala N4&,-e l $ ,<,93 z THOSE, coy ,crgP„s r�,pu.n LIC NO: �� COXTROL
4RCHCT/ENGINBLPC C NO: ADDRESS: V'�Jl� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cansaltant Fees Pad by Applicant(Initial) E ECf PLUMB MECH
❑ ❑
IPCIiNseD cuNTRAcroor s DECLARATION QTY ELECTRIC PERMIT FEE
I oral oR ivi mem IkensciuMmmndrimaacnnptm'a(my ecxing 1 BDISCRIPFION
�Z Ih Salian'I110U1 of Uiviaim Juf the buuleraal Pmfessiona Code,sed my limnu i,
�O u PERNUT.ISSUANCF. RESIDENTIAL•
full force aM effect.
�UZU License 0. Lie. ❑SFUWL ❑KITCHEN REMODEL
Dam Cnmrenm APPLIANCES-RESIDEMIAL El ADDITION ❑PLUMBING R&PIPE
Z87y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
5Ky Iunls"arxl my plansdwll M used or;public lama. MODIFICATION
OZ=lO UPTOIWAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Prch,,simal ±pl-I000AMPS IMPROVEMENT
OWNER PUIIJ)ER DECLARATION OVER ILO0AMP5 ❑BATH REMODEL/REPAIR ❑Da OLTf1ON
I hereby alum Inv I em exempt from the Cawaxla'po Lice.lav for dm
a 0 i V (allowing.,(Semon I11J11,9mmcss rind Pmfcvim,Code:Any city or county SIGNS ELECTRICAL
MOTHER 12 EYLalGF CX/ST/I�'L�s
aojn whkn rtv,ismapeltnil reranv,uet.war.It for
eirmlt sereor r" eTvmnme Wormuyu AVp 6LK'S VAiL_
pror athe ficosuacol alwlre 1.the iheupricom a lar Compo rmil l License
Lw hetherl SPECIAL CIRCUITIMISC. 10/711- h FATLQ SL21A& L�R
5¢E Ihatleuliccmd purumm t00sLol isi.ils N theControlHu,inNr Licrnafcaw,;Core) 9
ei Jen. O a.hei(olmomxingwim Sx,frosm Xp of Divivi her of Jrt,ed eie awlm.Any
Cute)a TGIP.METER OR POLE INET. COMMERCIAL
d a e C Thu t in, 31-1 b Werefmn uM the basis fm tln cisthe exemption.Any eiul.try of ❑NEW BLDG/ADDTTON ❑FOOD SERVICE
I- condo thorn by anyepplium fvrepermit rub)nrs the applicant loacivil pertly of POWER DEVICES - [I TENANT El FOOD SERVICE
a 1mlcw touthuwhcddolor.(5500)
yempI
�O ❑Lv,ov.mofde gopnty, rmyempbyaudor wages mt 1c(Se,cvmpensWm, SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
JI ria the wad,Co theumcartls not i Urecramoficred s.du, t (.See to an Budlt our
[I OTHER
and,Priy 1boms Calc:The Camanors Lit law Jen m apply to lf owrsr of OIfIL1:T5-SWITCHES'-EUCNRES
a 3 pis mom who huio s,or oo li that
tlemm,ani v m docs such walk himself or Waugh
his mm empbYm,pnrvdcd eic pouch i s!ca is nerve art rut year ofe a plfroredeom for NEW RBSID[MIAL ELF,CITf SQ IT
rye.,builder will ba,,edingarlecof c or,isrWhediol.me year ofcomplwae.the SQ.FT.FLOOR AREA LSQ.FT
owner-build.will have the burden u[pnlving Nm he did nw buil)a inyln,vc Gu par
pma o[sue.).
❑L m owxr of the pnpcny,an excluxivcly cnnVu'ling with loan.rl cunvuturs m TOTAL:
nmvrvcl the pmjx115x.)PW,Baureaa ab Rofcsriaa Cobc:l The Conwnur'v Li-
u tow due,na apply w m owmr of pnrycnr who huilds or improves thtmun,and QTY. PLUMHI P IT FEE
who conlrxu for oral psomeni with itronm la(s)Ikcnrcd pmuun to the Comrvnur's
ketene Iaw. PERMIT ISSUANCE �J
❑I am<aem{g under See. ,11&PCfor T.I m
ALTER-DRAIN&VENT-WAT i VALUATION
7TS'IIL
` Tum
H'ORKER'SC bIPENSA ONDECL.\RATI0 BACK FLOW PROTELT.DEVICE Nov 29. �.
I thereby of 1.uric,pc.toy of scr tory ane i t Bn following dxlaratiom:
lhave sed will murine Ccnif mot Cvnsenuo self-invae fir WatdeCmmpen- DRAINS-FLOOR.ROORARL E• "f l STORIf•S 'PE CONSTRUCTION
,cmoo.a,rumviJwl fur by Sec'tion 37W(,I the Lalwr Cool,far flue pcRanuae of Je _
far which will hypo perrnil is iasunl. FIXTURES-PER TRAP yUr��i In
El 1 have urd mainly.Wohdan� �[a.,m ncgylcd by Stenion16
s C
JTW crane LMlr Code,for de peRurtnantt of l od,for which this permit;.i.ewrl. GAS-FA.SYSTTJN-1 INC.J OUTLETS
My Ww ',Comsuccsanion lnstwntt cu sed Policy ruorn ,see: OCC.GROUP APN
Carom Policy No.: GAS-EA.SYSTEM OVER J(PA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASEBNDUSTRL WASTE INTERCEPTOR
(Tho senior oad na be cwnpMcd if the pemtit is fur Ime hwdrtd dollars
DIM) BUILDING DIVISION FEES
a loss) GREASE TRAY
PLANCHECK FEE
1unify Nat in the con, e.veof the bac for scolm thir permitisi.uucd, shall
baremployLaws
enynlmnmer w,mlo becwrc rubjen nth Woheri Cvmprn- SEWER-SANITARY-SIK)RM EA- FT. ENERGY FEE
O Z nation lawn of Celifunia,Dalc WATER HEATER WNENT(ELECTR
z O App as GR DING FEE
wN. NOTICE DOAPPLICANT,
1.the
If.Cent mzkl.g this Ccnif etc of Eacmpt:M Yw annul. WATER SYS TEAf/IRPATWG
beemormfront,i to oxo y the Wakds Com a our I , pl m,stair nor eth<Lalboma,J,Cada you muse SOILS FEE
fonhwith nxnplY with ouch pmvisiom ar tlJr permit shall4 domed rtsmkcd. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAUL SQ,PT PAID
(..) O Ihnehy off nn tlnuhrrt i.w eondNCliun lelding vgency lin the p<r(umtace of Date Receipt
Or- the work fur wbich W,pcmul iv imuM(See.JW .)
I,CIv.C
V Lear cr's Nan¢ TO AL:
LcMely Addrea 'TOTAL:
yI anify Lha 1 neve reel thi,wpplieatinn aal seem that de Wove ildamadun i, BUILDING FEE
to emiI reen.can ply with all lily old cauntylNinnncemold wtmc law.«Ivingto QTY. MECHANICAL PERMIT FEE
U Z baildingcrosaaction,wl thereby au..<rtme ..,earofthhcitymenlmllpJll the SETSMICFEE
above rnemiomd pmpedy f-iry s ticn purp.Ises.
(Wc)agree w mx,indemnify scroll kap harmksa the City of Cupcninoegulut PERMIT ISSUANCE ELECTRIC FEE
Iinhililicx.jwlgrwrim costs and c.apcnscs which may in anyway azar egui¢a sod City ALIHRORADDTOMECH.
in cons lexe of athe gmrning of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
SOURCE EGU N5. MECI{q LAICAL FEE
AIR HANDLING UNIT(OVER 10, C )
CONSTRUCTION TAX
ort clA cMVl Detc EXHAUST HOOD(W'/OUCT) HOUSING MITIGATION FEE
HAZARDOUS MA'ngoccuS DISCLOSURE or URE
WIIIthe
ee future ago.Clorgcorear handle�IJoand Safety
11EATING UNIT(TO 1g1.IXIB BTU)
u,defined by I�Cmcnim Municipal Cootie.CMpm 9.11,aryl Ins Hwlth old Safcry
Code.Smim 25531(e)'! IIGTING UNIT(OVER I W,000 BTID
[:1 Y. ❑No
VENTILATION PAN(SINGLE RESID) PAID
Dem Rcairyl
Will the a pp ouraact aramort building xaeeTuse.Air maJMoomIwhich BOILER-COMPIJHPOR 101J."BTU7
mil hvard�mpo air amnmivnta m Jefnvl by thl Bay Arca An Quality Mmegnncnt TOTAL:
Contain1^
CI Y. L]No BOILER-COMP(OVER IW.000 NTD)
I have lead the harv,bu rlweriala rtquirtmemc lvtrr Chapter 6.95 M the Cali- AIR CONDITIONER
ISSUANCE TE
amnia Health&safety Cube,earimu Zthat i is my end 25534. mderswnJ Inv if de NEW RESIDENTIAL MUCH. SQ.FT.
ofbaslo,ruJounce nmhichndy have•I metroecurat.IWl itisuance of a Gerticatcfiry to o Ocscy the acvpom
ofthe«yuirtmenta whieh.m,t he mel prnrmi,ruarwe ofa CeniTra<nf llavparcy.
Owrc—ounmoirzlot,em Date TOTM- ISSUEDBY:
OFFICE