30799 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION
APPLICATIONIPERMIT - PLUMBING.MECHANICAL. O7 C�
BUILDINGPROJECT IDENTIFICATION
BUILDING ADDRESS: � 1 SANITARY NO APPLICATION SUBMITTAL DATE
In
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:SpN CIF :f0 NAME,��� KASS LIC N��
CONTROL#OO
CHITECI ENGINEER: LIC NO: DRES
Z Jv I Itits �3
CONTACT PHONE: BU ILDING PERMIT INFO
2,(:)1-6Z90
,( I—`v Z 90 E-1ConsultantFcea Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
Fl
• LIC .'SFFJJ) ACIDR:S DECLARATION W
I thereby moon mal I etn hcenwd ands,pmviclmnc of CluPer 9 Icommene'm QTY ELECTRIC PERMIT FEE
XzZ g JOB DESCRIPTION ,
00 wan Scctim 7(100)nf0ivision 3nfdc B�si�ns wl NofcuiaaC vml my linmcis PCRMITISSUANCE
F In full fore.seal effect.
His
.UZ W licrnsc Lic.M _ WTI ❑KITCHEN REMODEL
' NQS c Cnmmclur nPPLIANCIs-RCSIDGM'IAL AUDITION � ❑PLUMBING NH-PIPE
ARCHDECTS DECLARA ON ❑MULTI-UNIT ❑STRUCNRAL
,20 Z Ioakommd my'lm,Dull tK used u publicre<o ha PANELS MODIFICATION
Oz.- .- UPT0200AMPS [I INTERIOR C1 CHIMNEY REPAIR
(:41- L'cm 1Prof.i"wl M-11p0AMPS - IMPROVEMENT
.gxfn OWNER-BUILDER DECLARATION
pS,
'0s' 1 hereby vfErm thm 1 oro c.acmpl from the Condanrr'n Liaenw law for the OVER!NK AMPS ❑BATH OO�)EI( PAIR [I DEMOLITION
>d 06 U following ancon.(Sntioe NO 13,Batimu and 1'ndessiau Code:Any city or count# SIGN'S ELECWCAI. ❑OTHE
u 3 LL which¢quint a relndl to craumat alar.improve,dcutoldl,or afro,my nnucnvc -
t'v.O� pnormiuissuueetal.soregaircs do,itwiam for such prnni to flee signN'unt,.t
NSPECIAL CIRCUIT/MISC:
Thal hsk liaio N pursuant to the provisions of do Comelat's Liccn.sa Law
uI�00 (ccanr %with Scetion ItTo))of Division 3 efdc Bu,irau tied Prufeui"m Code)or TEMP.MEDUR OR POLE INS'L
a a e oC rhes he is saemq therefm,n herd rhe basis for me eIkW eacmpmon.Any violation of — g[�(WART
El DEMOLITION
^,y
Section 70315 by any applic rot for n fxnnil vuh{e,rite appham m a civil penal,,of POWER DHvICFS Y'Jk€rfANT Ii�JY�I{ OVIP FOOD SERVICE
F Qmg Cao tMn Evc mocked dollars($5W).
❑1,rot owner of ths pmtoori or myempk ocs with wages m lh,ir sok comfrcmvion. SWIMMING POOL ELECTRIC IMPROVEMENT
will do du work,end the swcum is nw in,sMN or olfsred Far.1e(Sec.tow.Bmiresn 1 10 THEIR
and Professions Gds:TIe Crm,ra aor.r Lkxnv Law does as apply m no owns of OUTLETS-SWITCHES-FIXTURES
d 3— Paulsen who builds or improves Cvmn,amid who dens,such wart hlmseB-through ,
his oun employees,provided Thu such intpmvcnrnu arc not imeNcd or Wo rN for NEW RFSIDEbIT1AL ELEM SOFT.
sale.If, the halldirIlo,mpmvement iesold within(me Yarore" r's,,Cc r SQ.FT TOOK AREA 5 Q.1",
sur-builder will have CN
Ce bucn of puvin6,br k did not hurdi- irtme:for par- 1 'O 1 17—
> prs
Lof sown).
❑, es"weer Mlhcpfcgtc0,1 .Brnit.ncly<ontfacting with:)c Ccnoi a- 06.
trunnel thecatnas (See.o1Fw',vrsrt of ro wincionnsnk:)Thevi,s n.Li-
ccmc law docs rat apply m w owner of progeny wtto builds Irc igeni mves Corson,herd QTY. PLUMBING PERMIT FEE
who cam's for such projttrs with a wnlnc,u(s)licensed pennant Inde Contmnor s
hr"°mss law. PERMIT ISSUANCE
Imscaempl underSm. ,B&PCfor Cis ratan
(Inter Dam EN
ALTER-DRAIN&VT-WAT (E
ER A) VALUATION
WORKER'S COMPENSATION DECIARXHON BACK FLOW PROTECT.DEVICE
C I hertbY affirm urdc,perWry of perjury arc of me following deeWuians: 6-11
�
J lhnveaM wRl melnlvn aCttdBalc MCaucnl mt.elf imuafar Wukcr'nGmpcn- DRAINS-FLUOR.ROOF.AREA,CORD. STORIES. TYPE CONSTRUCTION
norm,as pmvidN fur h,Sanion 3700"f the WMv Code,fm the penannvrcs of We
ot for which Cin ftcrmit is mirA FIXTURES-PER TRAP
1 buve aN alit meinuin Wcdi Compseution Insert.,as oo irN by Section
37W ofde LaG.Core,for the perfmmarccofthc work for which thin permit is ianued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.DROOP APN
My Worktr's Csmpsnswon In%rm canierend Policy number are: GAS-EA.SYSTFJ.1-0VFR4(PA)
Car,vr. Policy No.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COMMNSAI'IONINSURANCE GIUi SIIINDUSTRLWASTE I NTERCHPIUR
I (VISION FEES
- fThis.atimrccd res be campMNif the psrmitufor«e hualrN doll.n 15100) GREASE TARP 1
or k+s) PLANCIiP.CK 6
IccnifYCain CsprrGmlunreof the work rnrwhich thisry•.rmhis fors Coo,,n- SEWER-SANITARY-STORM EA.21g)FT nut employ my person ism ahacan uh'cet,n alta M'nhen'C'omlen- ENERGY FTE
,� udon law m f rti a "—`Y WATER HEATER WNFM/PJECIR
O O ApPlianl GRADING NEE
rjl NOTICIi TU ¢LICA I':ILaOeP n,thin L ni0 t of 13acmpfton,y.should WATER SYSTINU T tEATING
become sub* to the W«teYs wino Positions of tho lobar Code,you ma SOILS FEE
forthwith comply with such ,rvisiom or this permit shall he dccmN avokod. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F-L PAID
V O IhocbYaf firm thuthea isernmauction lsulingapency f"rdepMormucsof Dale RcaiP
4. .. tie work for which IN,prnnit it iw LScc.3(197.Civ.C.)
O U 1<rdcT's None TOTAL
[Il Lcodcr's Addtcss T T
04 1 unify drat1 here a,d Cis epplicmian ami suit flat,me above m ormadun is, BUILDING FEE Gin—
(A correct.I agmc to comply with all city and cranny adinarce,aW,,mtc laws alining to QTY. MECHANICAL PERMIT FEE
V Z holdingermuucdm.herd hsahyoattt«ia aPecnutivesof Cis city mm'uupm de SEBMICFEE 101'nllo
abovo-mciml(med Popery For inepee con fturpewca.
(We)ague to ossa,imlonmfy and keep hornless the City of Cupeninn ogeirvl PERMIT ISSUANCE Bf.ECfR IC FEE
Iiahilitics,j Wgmcnt.s,hats vnd efpcnsm which nay in vny wvy eaxruc againu uW City
in rnmcgmrrx of the psmivg of Cit pfTtil. ALTYA OR ADD TO MECH. PLUMBING FEE `
APPL1 AAT 'N -RSTANDS 'D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT JO H),M)CFM)
S U EKIL R) TIONS. MECHANICAL IEE
AIR HANDLING UNIT(OVER IggIO CFM)
�j CONSTRUCTION TAX
Si war plisanJCnn r Dmc EXHAUST IIfN]U fW4)11CT7
kIA US fATIi (ALS DISCLOSURE HOUSING MIIlCAT10N FEE
Will thea"Hiciatrc b Idim�omparR ousorhmdk huallous,,mmol HEATING UNIT IID ItI ."BTU)
u defined by Cs Cuprnim Municilvl CNs.Chapter 9.12,vol the Hahh and Sarc,y
I Cta1a,Steri'25532(a)'l HFAPING UNIT(OVER IOnt,(gM)0 rU)
I]Ya -1 No
VENTILATION FAN(SINGLE RESID) PAID pale HecmrPM
Will the applicant or room building c cuI,ml aw cyui Ma,m or rkvices which BOILER-COMP(3HP OR I W.qp BTU)
it h„�.Juus air camamiwtu u defnnl by de Boy Arm Air Quolhy Mamgmem TOTAL
mer,
E]Y, El N. - BOILER-COMP(OVHR IO(l,l)(OBTU)
llnve,rsdde humdwv mucrials r mtncn Wide Clupry 6,95 of de Cali- AIRCONDmONER ISSUANCE DATE
fomia Hmlth&StJoy Cods.Smiwts 21X)3,]5533 and 21534.1 undcrturd Cal if the NEN'RESIDENTIAL.MECH. SQ.FT
berth.,dna not aramly haveuanent,data is my twin ihili,Y to notify tha oevvpml
of de squirms.which man le con Prior to issaocc of a Ccniftau of Omrfurc,
—flwPoor ar omhnnsd ugem Dan ISSUED BY:
OFFICE