30075 (2) APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEWIT NO. 30075 C
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL O O 5
BUILDING PROJEM'IIIENfIRCATION 3
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTALDAD
2 o i 5 7- ,?V Z'4.n G 18�l 6
OW SNAME: PHONE; ONTRA R'S NAME I,IC NO:
% N/C' CONTROL
�.RCHITECT(ENGINEFR: LIC NO ADDRESS. _
CONTACT: PHONE: BUILDING PERMIT INFO
b>S-3
LICENSED
Feu Paid by Applicant(Initial) F PLuntei
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby¢Teton that 1 am llremm miler Proclaim,of Clorfrer Y¢cnfmr.+nP JOB ESCRIMON
WOZ with SMlon]U(Xoof Doomn Sof the Rmiav and Pmfenbm Cde,eml eny lialnc is RFSIDENTIAfL
Few= infullfaavd� G.o /' PERMIT ISSUANCE
aUU Uccnu CTosn Lic.N y0Q3%�� _ _ ❑SFDWL \Jr��G:I•TCHF.N REMODEL
Dae Conroe • APPLIANCES-RESIDENTIAL ❑ADDITION '�.J PLUMBING RF.-PIPE
I,-py
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
ZOauv
Z I.mlerstl my P)mpato
s short ht as public aN
cns MODIFICATION
OZ-a UPT0200AMPS
r�F u1 urc Profa.imW ❑INTERIOR ❑CHIMNEY REPAIR
d•Hw-.1 OWNER-BUILDER DECLARATION 20I-I WBAMPS IMPROVEMENT
y Q I thereby affirm that I em"'on'x from tic Cmr.l«s Licrose Law far,k OVER I(XXAMPS ❑BATH REMODfLREPAIR [I DEMOLITION
k O R U following retour.(Sorb..7031.5,Huninus onl Iholi,i,ns GWc Any city m county SIGNS ELECTRICAL El OTHER
which tyuirts a Amor to mruUuct aor,,i r,mor.Jemolob,-repair any unreture
�LL�S prior mils iuuarhee.elm reyuims the appliamt fnr.ah pemtiuo file neipnm elolemem ` SP17CIAL CIRCUIT PW.
�)- that he is lice punuml to the Movi.ions ofthe Contractor's Lkxnse Uw(Chat errY
X00a (mmrneadng with Section]Oro)of Divisive 3 of the Busi.aril Prfa.i Cmc)a TEMRME- ORPOLEINST COMMERCIAL.
EL :
e LL that he is esempl lbereffom and the naris Gr Inc nllegm cacmplla.Any lnnl ion.1 C NEW BID ADDRION C DEMOLITION
It �tim703I3byanyapplicurufaapemlilsubjccts Nc"I.nlloecivi[,c t,af POWER DEVICES
= a' nm mart than Dsx huo,tned Jm[lvs(5500). ❑TFI:ANT ❑FOODSERVICE,
2ZC ❑ I,os owner oflh prvpmy,rr my empluyxs with wupes as lhir Wt,cumpn.uian. SWIMMING POOL ELECTRIC IMPROVEMENT
= wJl Jo lbs wah,uW l rthsortwe and inleMmmofferm foruk(See.]0a-l.Buuress COTHER
F
I�ilend Poferninn.Crile:The Comradors Licence Iaw die,not apply m en owner IT OUTI.EIS-SWITCHES-FIX'IVRES
a 3 pmpeuy who hoiWs or mr roses lhnron aml who does ueh wurlc himself a throush
his ow rrr loym.faovideJ that.ah impmvemenn arc not inhd oroRenm fm NEW RESIDENTIAL ELECTR SUET
sale If,tsowever,the buidir,or imMoomenl is sold wmninmo,emofcanpletirm.th .FLOORAREA $5Q.ET.
rcr-buinler will boot,the Modcn of mvu,that the did n,l build or imE for pur-
lxuMsalc.). TA � In
❑ 1,as owpmp
owner of the any,stn eaclluivcly conwith=ing Internal contractorsto / p
cortstruct the,Mild(Sec.IDN,Buunm.and Pmfeniom CaEc:)Th Cormaene,U-
whc sa law dos,.9 apply ,,annwarof pnperty wlon buids a inNnwcs lhcreon,and Q'IY. PLUMBING PERMIT 'FEE J(I� sL
ocvehYDfa.uch Pvjalx witheconlncla(sl liccm[d purswmllo fie Conuacrars
Liana Law. V'Y 199
❑ I olnesemptunler Sec. ,H&PC for N'nreason PERMIT ISSUANCE �I`Yr (J
Ox'nn Do. ALTER-DRAIN&VENT-WA1ER HA) vUI VALUATION
WORKER'S COMPENSATION DECLARATION f UYl)
I thereby oR unler BACK FLOW PROTECT.DEVICE coo �—
y C,mC. ....'Cryont,nft If-i for dmlaaxCo {/CMCJ
❑ omasum wleci fo lb,Se limn 3X00 of the, to old,for the Workers of ther. DRAINS-h100R ROOP.ARPA,COND. -
sntim,u pmvislm la by Section J]Iq of the,Labor Code,for ate potornornce of We STORIES TYPE CONSTRUCTION
work for wbieh this permit i.i.wm. FIXTURES-PER TRAP
El I lwve am will ortmmon Worlorr.Cmro,maPm Numb¢,u"t irm by Section
37M ofte labs Code.forme pefmma dito work for whoh this permit i.iuucd. GAS-EA.SYSTEM.I INC.C OUTLETS
.
My Worker.Comperuairm Insurance carrier andWicy YllumhvOCCGROUP APNr
e.
/ Cvnicc Policy Na.; GAS-EA.SYSTEKI-0VERaGEA)
Cl!ICH FlC P.OP EXEMPTION FROM WORKERS'
Er)
PENSAIION INSURANCE GREA.SP/INDUSTRLwASTE INTERCEI'NR
(This aolwn need romp,....if Pe permit ufaaehwdrm Jo1Ws151 W) BUILDING DIVISION FEES
or les'.) GREASE TRAP PLANCHP.CK FEE
I eerily Port int pert rtltma orkf 41,uJr permit is mora I'bal1
oil t,mpby anY baby rvt� ub}m to JheW SEWER-SANITARY-STORM IA.2110 PT.
z wino Iowa P a l a ENERGYHE
ApplKem WATER HEATER WNEW(ELECTR GRADING FEE
y NOTICE TO AY 1 mg cmc lc of Excmption,ym sM1uuld WATER gVS1EM/TkEATINC
h " heom.subject the Water's Canpenssliun provision of We IaF.,r Cork,yw natal SOILS FEE
forthwith.*xith such pmvi.vn or this Permit"Ibedam revoked. WATER SERVICE
Q
MCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.FL PAID
U O Ineteny err that Pat,iea anwanw lerdingayea'y earn[lherrmmanet,or Ume RcecipN
� � lh work roc which lhir[lemtil is mum[Stt:.Jlg].civ.C.1
ULender',Name
W, Lrnlcr'.Addmss TOTAL TOTAL:
0. 1 aui ry that I have rent this appncarion and vete That Phe above inforrution a BUILDING HE �
to corre<1.l ayra to wine al cby aril counU oNilalm and.tn¢laxa mlmingm QTY, MECHANICAL PERM IT FEE
L..12 buihEm"un4rvc nn, crthy ewlaxi'm mprcenntivea nl Ni.city memm Ppm Pe SEISMIC FEE
shove nJ. inlspecuoo parpmcs. PERMIT ISSUANCE'
(We)fig m save cls mify and keep lannlev the City of Cu,temrw aCainu • ELECTRIC IHJ? g
Ilabiliticr,judgm ts.uv¢ t,xp<ma'whkM1 tory in any way accrue el{aiml.eiJ Ciry ALTER OR ADD TO MECH.
carob o thegrani gMtbi. PLUMBING MUI
APPI 'AN aU DERST DS AN II.L CO Y WITH ALL NON-PO NT AIR HANDLING UNIT(TO 10.000 CFM)
SOU CE RF 11\TION MECHANICAL FEE
AIR HANDLING UNIT(OVER I0,IMp CI'M) CONSTRUCTION TAX
Si eofA a Due EXHAUST HOOD OVMUCp HOUSING MITIGATION ME
11 ZARDOUS MATERIALS DISCLOSURE
]1l th rt,li.orfmure building aco,mt,ort orlor&e onom so,mucriul HEATING UNIT fro 100,000 BTU)
n der by the Cupertino Municipel Cade.Chepher 9.12,and Iht,Health aM Safety
Choc,timrion 2 332fa)7 HEATING UNIT(OVER IIO,gp BTU)
F7 Year C]No
VENTILATION FAN IS INGLE RES I D) PAID
wiB the upplicml or lama Witting urcupml tort,equipment a Jevlm which BOLLF.R-COMP(JHP OR IOO,INp RTU) Dae R.,l N
error air
( lornudwu cnnlemivnu a,Jefiocd by the Bey Area An laulity Menagemrnt
Distridl IDTAL:
❑Yo No BOILER-COME(OVER 100,000 BTU)
I have os]the hvallour IwtedW,i r c,iamcnrs uWer AIR CONDH IONER ISSUANCE DATE
Chaper,6.Y5 Mtk if be
farofingli l kSafoylly Corte.Mvemiols255a5.is my of1d255y1.1 unlvwrd Pet it Phe NEW RESIDENTIAL MECH. SQ.ET.
W thing doe.me cwtenlly hove o¢rant,that it is my rcgf.Cortifto conotify the aapum
d the teeNiremmr,wnicn mr.,t the ton prior In iaaa,hee ora certirleut,orDan,arey.
Owner oreutM1ud.m ycm Dye TOTAL: ISSUED BY:
OFFICE