28555 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.FILEMICAI PIERMUT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 28555
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIS
102oo U R v
OWNER'S NAME PHONE: CONTR RS NAME LIC NO:
A I `vC ' _^I X10�] NIC CONTROL I
• HTECT/ENGI EER: LIC NO (/ ADDRESS: s ❑ I•� /�'7 S V
SuN7nNV
CON'TAC'T: PHONE: BUILDING PERMIT INFO
El Consultant BI.1 ELECT PLUMB ME
GI�FG 5I0 -2_2_1v-'r021
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I heRby mrrrn tit I an Iiamed wider pmriwu a cropper 9(c«nmmcing JOB CRIPTION
"Z with Sction7")ofDivi:i.3.fthc Busi.and Prefectures Cede,aria my liameix , RESIDENTIAL
410 p PHRMIT ISSUANCE
FW. p: in full Toms and effect. ❑SEUWL ❑KITCHEN REMODEL.
6F.VZV Dan�nsaClm IocI APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RH.PIPE
N Q so Deo Cnnlmcl«
'=so ARCHITECTS DECLARATION pAN'EIS [I MULTI-UNIT ❑STRUCTURAL
ZOvn^ I used m public records r MODIFICATION
OZ-
UI'TO 21XIrN1PS Ck ❑INTERIOR ❑CHIMNEY REPAIR
TO Eiamcd t 20140010AMPS IMPROVEMENT
,...II WNERHUILDIiR DECLARATION OVIiR 1000AMPS
❑BATH REMODEUREPAIR ❑DEMOLITION
1Y' 6 1 herehY elTrm thw I em exenlpl from the Contrstm'x Licettu I�w fa Uc
KOaV folbaini sero .(Section7031.5,Business arts Hufessiw Cole:Anyiny«n"wmy SIGNS ELECTRICAL �OTM�
4131x, which raquitex a Permit in rnnswn,eller,improve,drnwrsh.«tapair any•wnure
I�'LL'0 r�wto Wpl 8 SPECIALORCUUTMISC.
met
Uc rcm me
to fikesiaw(Ch,(u9
Syfii } thnt he is iiarnsal putwnm le the provisions 3 the GOvlmries,a.iccnselaw(Clopn9
W�C,O (cm"ms"cine•'ith S.mr7010)of Uivisim3athc Business evd Pmfe.aims Code)« TEMP.METER OR POLE INS!. COMMERCIAL
a a Cha he is esam x treat.sod tk lexis for the 01,M c.cmpim.Any violeliern of BLDG/ADDFUON ❑DEMOLITION
Stedm 7031.5 by any applicant for.amtit vehj,1a the up,I.nua a civil Penalty of POWER DEVICES ANT ❑FOOD SERVICE
not true then five hundtcd doll.(5500). IM OVEMENT
< ❑ La owner of the prgrny,or my employm with wages m their wle compematim, SWIMMING POOL ELECTRIC
O will.10 the w«Lund the structure lsnn meati«dieted For alta(See 700 1,Businea.s []OTHER
3 artl Profeoi.Code:The Cmtnetors Licewe law does tot apply to an uwrcr of UTLETS-SWITCHES-Fl%TURPS
pgeny who Wild m impmvm therein,wd who doa such wort 1-oc—o'through
hid own entrant pmvidN that such iar mvat ere not ima dol«oReeN for NEW RESIDENTIAL ELECTR SQ FT.
eealc.If,Wwe ,the building or itrtpmvement is sdd within oayearcefcon,ldion,the SQ.FT.FLOOR AREA LSO.FL
owner-buihlcr will have the When a purring that he Nd not build or improve for per,
lame a sale.). 1
❑Les owner of the 1",terry,70a am exclusively cpm Ikrnsad comrmr, m L'
com.ttren. (Sec.]04Y,Bur yasimue TheCorvaven, n
nxlaw d«srwt not pmpny wW buildsmi thecomm,aria Ql'Y. PLUMBING PERMIT IEE
wWcmtrectn f« pmjav withnvinttat«(sl lianxd twtheCmtmnora -
Lice.Law. PERMIT ISSUANCE.
❑ lam axe titin See .B PC G.Chia tmson
ALTER-DRAM R VENT-WATER(G) VALUATION
.owa. Int `
WORKERrm ams)er S COMPENSATION UECLARAII N BACK FLOW PROTECT.DEVICE `� j_0
I bwiUnmiui npmdtyofparjurytneoof to followlf-inscre Worciectaniom: ) rC
(]or. mid icledoirpy SeCmifcwaof Ctmxntmself-.fro nW«kda Cnmpam DRAINS-IL(X)R,RIXIh.ARLA,COND.
canon, pmvidM fm y Sctioot]00 the labs Cak,fm prfurvuae of the � H a � STORIES TYPE LUNSTRDCTIDN
1:7k fo wbichthis it is issued FIXTURES-PER TRAP
1 I h a o'd will t n W to Ins a tnryiml by Section -
37M the Lalli t work feew t treat is bound. GAS-EA.SYSTEM-I INC 4 OUTLETS ^ErtnCGROUP APN
My oricrs eau" tihard Felt,
an Policy I GAS-EA.SYSTEM-OVER 4 TEAT
CER OF T)MPEN ALa'�INSURA CF,OM O ERS' C 11 Uf UUf �t t
GRFASFIINDUSTBL WASTE INTF,RCIH'TOR
BUILDING DIVISION FEES
(Tbb smile ncd not he ifthapetmilua f«o (SUITE GREASETRAP
bet) the
FEE
lanif mllxp otmsoccuftle oro- f« this permit is in Imtull SEWER-SANITARY-STORM EA.](10 FT.
e any parson m any master so a to b subject m the Wurgeri 'onipen- ENLRGY FEE
X mtior laws of Calilnmia.❑ataWATER HEATER WNEYT/ELF,CTR GRADING FFP
z Appliam
y NOTICE TO LICAKI:IL after meting this Cenifiate of Exentptinn,y u shauMl WATVR SYSTEM/TRFATNG
becone cu tto tM W«kern Cananommmpmvi'rensofthe Mbar Coda, mmum SOUS FEE
W' forhxith ly with such pmvislam This hall be demcd ravage . WATER SERVICE
d Q
= z ON U . 0 AGF.Nra�- NEW RESIDENTIAL PLNIB. SQ.FT. PAID Data Recci M
I yeffi th novo tlggflQllfl Nc perf once of p
O tMwnrg 'which tit. '.3 rvC.)
1<odcrs 'urc s ` TOTAL
U Ce'dar's ddr.• TOTAL:
�+ CT) BUILDING FEE
[.. 1 nifY Cha ha read Uri. appicaion c Cha the eWvc itdomwior is
h carrcn. agteamcm ywithdl dtyardc mdwaaRandmaelawsmlatin"', QTY MECHANICAL PERMIT FEE
U ,Z bwldi mnshumm,o'd harvhy ou repexnorivd of this citymcmcr upiw the SEISMIC FIE
above Taxi properly f«� tyoscs. PERMIT ISSUANCE I
(We)agree w as mlfy and 4tep.Wtmtbx the City of Cupertino against ELECTRIC FEB
Balm tic.'Jovflme Ve etd examen whits may in vny way rxes,apsnraaid City ALTL'It OR ADD TO MF.CH. PLUMBING FEE
in c roe g"nting of this prmit.
API ,ICA NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO TO."CFM) MECHANICAL FEE
SOL'. REGULATIONS.
AIR I IAN DLI NO UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Si,msm,ofAppEcmUCntracter Data EXHAUSTHOOD(WOUC17 HOUSING MITGATON FFP
HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future,Wei occupevt sl«c«Mrdk haurdotu normal HEATING UNIT(TO 100,000 BTU)
as dcfincd by the Cupertino Municipal Code:Chapter 9.12,net the Health aid Safety
Cote,Seation 25591(0)? `� - HEAPING UNIT(OVER 100,000 BOB -
❑Ya ]�No VENTILATIONPAN(SINGLE RESIDE PAID
Will fix aPWKa^I«furore W difing ocvpeel use a wpmr,m«daises wtvich Dote Rcxiq 0
1 havallou air am mninavo m definad by the Bay Area Air Quality Ma"ogcmem BOILER-COMP CHP OR 100.(10!1 BTU) TOTAL
•Davin? BOILER-COMP(OVER 100.000 BTU)
E)Yes Xn
I at rapst Uie harndws materials occur.utdn Chatter 6.95 of de Cali. AIR CONDITIONER ISSUANCE DATE
forma Indth R Safety Cade,Sm+ 25515,25573 and 25533.I uelaruard IMC if the NEW RESIDENTIAL MECH. SQ,FT
WOdi orfs t,that it is my rapmsibillte to notify Sc«xupanl
a tequ prior in romance of.Crnifi of pea'
Owna«vu L ISSUED BY:11-W
OFFICE