29148 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29148
BUILDINGADDRESS: SANTYARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE CONTRACTOR'S NAME: LIC NO:
NIC CONTROL N
ARCIUTECTA NGINHER: LIC NO: ADDRESS: ❑
GDNTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Frig Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATIONQTy ELECTRIC PERMIT FEE � ❑ El
hereby eR Jw l ann liters d wdm pro.isina ar c„apla 9lcantaaina JOB DESCRIPTION
woz IhS[Ctiml]gg))afDlvisboJMlhc Busiaaerd Rofessiam code,mdm license is
00 'n y PERMIT ISSUANCE R CIF DFNTIAI�
nfall aa and offal.
QZW Dame Clue C .N ❑ADWL _ ❑KITCHEN RE MODEL
APPLIANCES-RESIDENTIAL []ADDITION H Q d Use ConllYla El PLUMBING RE-PIPE
5rn ARCHTH:CPS DECLARATION F ❑MULTI-UNIT PANELS
ZOnZ� IumSlxtmd mYpWsstwllhuscl os public maxd. MODIFICATION
O Z— UP TO lfp AMTS
F+,nFLlcenrW Pmfc.eiooel ❑INTERIOR ❑CHIMNEY REPAIR
201-IgM1AMP5 IMPROVEMENT
�YE.4 OWNER-BUILDERm the
OVER I"AMP5 [I BATH REMOD TIJON
y �Q I herb,.P r a Ohm I ertt nud gram the Cmnamnoda:Any
U.fm the
x 3 a V following rcasan.(S.aSim'IO7I3.Businns and Re.dapo li Cade:Any city on cwn7 SIGNS ELECTRICAL ❑OTHER L
41 C which it,i.s nµmill n mnurun,ober.move.h .it 1 a rtlair any suuclwe
O doot he iHiasueaanumna 1uim lac vpicop,. far Conparmil l Lie .Law(Chlemenl SPECIAL CIRCUIT/KfISC.
Lo{Qay } ( he.an, NparummmJe pmvisinnsof tfeaBaca ohs License i Chulver9
x+ 00 lmmrcanng wnthSalxal]LOBI ufgvuiw7 d'Ibe Huti�.srd Prafeviara Cale)a TEMP.METER OR FCOI.E INST. COMMERCIAL
a that nc is cxcmq Jertfnmt.Id de nui.I-the,Hlcgcd c.acmpt'cm.Any vioWia a ❑NEW BLDG/ADDITION ❑DEMOLITION
4 S o ]0113byvye limlfo a mii.wajmsih vppliamlovcivilpnnlDof POWERDEVICFS EIITNANT n
ZY .1 nae than floe hadod]dolWs($5001. ( .
=6 I.nawncrafthepr y.or myamploynswillwalnutheusalernrtBemviarn, SWIMMING POOL ELECTRIC IMPROVEMENT' 1,FOODSERVICE.
y A
y� G will Jct thewo&,aM the uncture is mw inaalolimoffocd for vak(Sec.T)44,IT.., _ ❑OTHER C�
u] aM Prolcviom Cole:Tie GmuurNs Licrnrs law doer not apply Io an oxnar of OUTLETS-SWITCHES-FIXTURES
Ixopeny who builds or improve.Ibtn'Cn,and win doer such wo&himself ar Jvnsgh y
hi,,,.a employcm,pnnidal IMI such impmven ares are real Imandpl a offered for NEW RESIDENTIAL ELECTR SQ PT ���• Z On
ole.If,�hmwcva the building aimpnrvemem iv wld within acYcur nfampiaion.lac SQ.FT. BARRA t LSQ.F[
owner.builder will hove Jc buNen a proving that ha did not build m improve for par- Lj ja �� 144' rC
ofwa , ,��`,�o `" Ta2 l'S
of sae pmm pcny,acscln•ivay convectingalmr
with�ic .to •�
ua� v.i Je pojat(5a.](W.HusimrW Profcvians Cade:)Thc Cnnlsanols Li- 2 t`� 1 ^
anm law dm mepply man owarof pmpcn>who wildsmimprovn lhcmcl,erW QTV PLUMBING PERMIT FEE 71 .700 VV�� ``� Ina
Li ..La.
w
IGnmch pmjeeawith•convsta(s]IialaW quvwumthe ConvacuYs
Liana xw.
(] e.amnpbl
aer ,Bh PCbar qwn PERMIT ISSUANCEia rev
ALTER-DRAIN&VEM'_WATER(EA) VALUATION
Ownc Dae
WORKFR:S COMPENSATION DECLARATION BACK CLOW PROTEC'E D17VICE
hereby arr abler penally of Pffpy ane a(the fallowing d Lara a:
�❑ I haveand will mainwinaamif v¢of Com tioulf-Irsumfw Wartr Compen- DRAINS-ROOT,ROOF.AREA,COND. J
sanion,as pmvidd fm by Smion 17M of tM labor Coda,for the pcdomunce of Inc STORIES TYPE CONSTAUCTON
wort fm which this parrot is natal, FIXILRNS-PER TRAP
❑ I nave vd will Wain worker.Ca .• nn hou. e,m re0ulml by Section
37Mof Ort Lobar Code.for Je Xrfc-rune ofthe work fa which this pconut is i.suai. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP
My Worker's Conlemmicm Insuaae caner and Policy numbre
number a : APN
Carde, Papcy No.: GAS-FA.SYSTEXI-OV FR 4(EA)
CI7RTIIICAU70171?XEMMONIROM WORKERS'
COMPPNSATION INSURANCE, GREASMNDUSTRL WASE INTERCEPTOR BUILDING DIVISION FEIS
(Thi. a.turf to be aonot lIf the prnldt is fuoa boatload dollen(S l M)
ix Iccs.l GREASE TRAP
I anify thn in Je ped'mrmnaof the wo&fa wh ich thio N.,is is.N.I ozi PI-ANCHECK FEE
not employ any person in any manor so m to become wheal In the Worken'Compen- SEWER-SANITARY-STORM EA.20()FP.
ENERGY FEE
z O AP
,0 olion Law"of California-Dun,
WATER HT:ATI?R WNENT/eLECITI GRADING IEE
ry NOTICE TO APPLICANT.IL anm making this Ccnifcalc of&a.ataimt,you swuld WATER SYSTEMIIRFATING
I. ^," bnvta subject to(Ie Wo&o's Compewlim powisims of the Laha Cada,you mus SOILS FEE
IX I:.t fathwith canplywithsuch provuinms or this permit"I be damcd rcvckM WATER SERVICE
d Q
Oz CONSTRUCTION tuna 4acIldNDINdling Y NEW RISIUENTIALI'IMB. SQ,FT. PAID
V O IherebhiAWWVllerc uecW(.e.3n7,Ci,C.) cY fa the pedarmaae of Uatc RecapN
W .. One wo&(or which thispmnit i.isueJ(,Sea.3qD,Civ.C.)
In 's Nems TOTAL
O V :
LL) Isakr'I Addms TOTAL;
a. ccnify that 1 M1evc reed thib,application arnd awe Jw Jct above iNarwlan is BUILDING FEE
rncartct.l.grccmcomply who all city and county arJmmaa and time laws rclaingm Q]Y, MECHANICAL PERMIT FEE
.0 Z aildiogcauvunion.sal bat avthcnac reprtrery
nuti.es of this city to enter um ataSEISMIC FEE
''• above mcntio 'open,for In.pectian purporn. PERMIT ISSUANCE(We)agnea I,, ver,indwnnify and knp Iwmtkas tae City of Cupenirm against ELECTRIC FEE IG
Iiabilitks,jWgrteas,arae and.apemes which may in any way accrue against said City ALTERORADDTOMECU
in axaseyueace M Jr grunting a This peon, PLUMBING PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10.001)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CENT) CONSTRUCTION TAX
Siguwm of ApplicanVCimnm'Inr Dale EXHAUST BOO)(WNUCq HOUSING MITIGATION FTE
HAZARDOUS MATERIAI S DISCLOSURE
Will Juapplieem m fuwrt buildimgocavlanOtmemnardle haasdopa manearml HEATING UNIT LTO 100.0(X1 BTU)
e+dcfad by the Cupenioo Municipal Cala.Ch,ac,9.12 eM Je HnIN and Safe,
Code,Sabot 255]11.)? HEAHNG UNIT(OVER 101.000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RFSID) PAID
Will tnc applicant a fumrc building oceup.nl u,a aciuipnanl a&k %which Daft, Rncalg N
•emit hemrdous dir cmgemiwn6 es definW by Inc Bay Ann Air Quality Motugenent BOILER-COMP CUP OR 100.0X10 BTU)
WsaiclF1 A
Yo R
F7No HOILE -COMP(OVER I W,"BTU) . s
have read the lames maaua urtyuurntaxsu A95 of the Cali-, AIR CONDITIONER, ISSUANCE DATE
hmda IIT &SWay Cale.Sam la25505,25537 aril 2555 qnper 11.I urndvserd Thal ifthe NEW RF_SIDENT1AL MECH. SQ.FT.
wilding dos as turnip,h.ve a Imam.That o is my eegif a Cclity ca e o fy tae acvpan
' a(lie regairtranu which mal be 'no,to i.auaac ofo Cenihrue of(kcupmcy.
ITvm m vWtanzcd.goal U.0 TOTAL: ISSUED BY:
OFFICE