30466 APP ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
•. CnT OF CUPERTINO BUILDING ELECTRICAL PERMfr NO. �O
BUILDING'DIVISION APPLICATION/PERMIT PLUMBING.MECDANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S.YAfi1E PHONE: CON'IRACDIR:tiN LIC N(l:
ILEA/ NIC COMROLk
RCHITECf GINEER: LIC NO: ADDRESS=. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cnnwltant Fees Paid by Appllcant(Initial) BLDG i ' ♦NUMB"t MECH
LICENSED CONTRACTOR'S DECIARATION QTY ELECTRIC PERMIT FEE
1 lwrtby affirm that I am licensed ander promions of Chapter 9(a.nmerwing JOB DESCRIPTION
DMZ with Sect000]000)MDivision 3afthe Business ad Pmficssi«u Codc,ad my license is RESIDENTIAL
0l) full face and clfm. PERMIT ISSUANCE
aF.UZ�y License Cbv Uc.X - ....❑NNcc��SF__...DWL ❑KITCHEN REMODEL
N6L Date Contractor API'IJANCES-RCSIDENTIAL �DITION ❑PLUMBING RH-PIPE
�y ARCHITECTS DECLARATION MULTI-UNIT El STRUCTURAL
ZO K IundvstuW my plans shill beused m Public rscvnds PANELS. MODIFICATION
OZ`--'0 _ UPTOM)AMP5 ❑INTERIOR [I CHIMNEY REPAIR
�iF"{y Wcrosal Pmfcssiaonl 201-1000AMPS IMPROVEMFNF
Y ..•..]]11 OWNER BUILDER mDECLARATION OVER "AMPS O BATH RRMO ' F•PAIR [I DEMOLITION
K Q I hereby off=that 1 un ucmpt from the Camtracm Code:
:Any c Law fa d¢
y.3 Ver.F following semrrm.(Semon 7031.5. t,aher. ad Rc.dccons Cole:Any city or county SIGNS[LE ICAC ❑OTHER _
,� which required a permit to mm iib t,dtm,nmpmsc drumlin t m rcfvv enY Hrtcturt
F-u'O� dintheiHissuarccosomyuim thcapplicantf«such prnnit to file eugnM swcnmt SP TAI: CUITMISC.
th�Wis i nssdpmsuantm )ou'Di.sision3 heGCBoon sal«nmUwlCnaptu9 COMMERCIAL
�CpO (eorrwencing with Section]000).Division Jafthe Basions end Pmfasimn Codc)m T21 1 :R OR POLE INST.
d�n� that he is exempt thcrtfmm and the beds f«the alIcVd exemption.Any viWuitm of ❑NEW BLDGIADDITION ❑DEMOLITION
h Sation]031.5 by any.ppliceru faaprmut subjects the applrad toacivil penning of ER OTENANT ❑FOOD SERVICE
F=Ous more than fate hundred dollars(SSW).
❑I,uowrwrathe'e,croY,or my rmMoyses wmi wages u their solemrpemve,ien. SWIMMING E IC '`— IMPROVEMENT
N
will do llac wurl:.nd the suunmc is am inde dcc«offered!fa sak(Sec.]0.W.Bmm. ❑OTHER
W 3$
and Pmfesswm Code:The Cmu 's li
tromccme d
Law rcmowocr
s ,apply,n an M OIIftLTS-SWITCF S TL
-FlKS
noprnY wW build err improves thereon,and wW doers«n w'«k limned simer h
his own employm provided that such mr orm,cnems arc tun imeded or offend for N fl ' HAL®.E SQ IT.
side.If.lwucser,thc Wilding«ion,ansamrn,isnold wiWlnuoryerr.compl,t the FT.FLOOR AREA VSQ.FT.
mer-Wilda will hese alit burden of pot'ing that he did eat Nuld or oo,mve fu fora
pose of sak.).
I,its rwmer of dye ptoperty,amexcWeivcly c.ing is in licenced Nnaacm6 to TOTAL:
asrwrva the pmjct(Sec.70.41,Bmine.0 and Professirns Cole:)The Conlracto',U. .'T
. cense law doestwtapplytoanowocrofprniwbuilds inobuilscsticnmr.ad QTY. PLUAIBI P MIT FEE AUG 2 7'1996
who mnwcu fm such pmjccu with a cantrct«(s)licensed pttrsutumt to the Convamofs
0_iolaw' PERMIT ISSUANCE
❑Tuna rSec. .B&PCT thistrmon
ALTER-GRAIN&VENT-WATER(EA) VALUATION
WORKER'SCOM SATI TION BACK FLOW PROIEC`..DEVICE
I hereby affirm unser perWtyof pmjufyone tbef.mcm,deeluuims:
1]Ihavcad rill mewtaieeCmifwve of Cvnscn,mself-' .,T f«Wahcr's Conten- DRAINS-FLOOR,ROOK AREA.CONE.
vainer a prvkla!f«by Section 3]00 of the laboronoa«eCode,for the perf .the, SfORT[S TYPE CONSTRUCTION
work for whicT this Peron,is issued. FlXTURFS-PER TRAP
❑ I have sd will m.inuin Wockefs C«npensadon Insurance,m re,u'vnl by Section
37M oftbe tab«Cuk,for the perforrmrwe.the work for which,hu Permit is imual. GAS-EA.SYSTEM.]WCJ OUTLETS OCC ROMP AM
My Workers com crocition Imumne carrier bol Policy dumber mc
Came,. Policy No.: GAS-EA.SY.STENI�OVER J(FA)
CERTIFICATE OF EX L? PION FROM WORKERS'
COMPENSATION INSURANCE GRI:ASFANDUFTRL WAS7H;IbOTRCEPiOR
(This section tteW nod be compkbd'tfdte permit W
it is formic dolhoo,SIE) 1 DI DIVISI FEES
m less.) GREASE TRAP PLANCHEC
I certify that intheperfornience.dtewMfor which this permit is i".M l shill SEWER-SANITARY-STORM I:.200F1'.
no,crol my Pers«,in my mmmnr eco u m
to became suhjct b the WorkaV Comped ENERGY tEr.
O Z section laws.California.Due WATER HEATER WIVENTAELEC R
Z O Appii.l GRADING T
NOTICE TO APPLICANT.If,after making Him Cerins of E.aemption,you dm old WATER SYSTIMT REATING
'F' become subjatto the Wohera C«nprn.utian provisions of Ne lahar Code.ymt naw SOTT E
W .'�-i fwthwth compty xitb s«h povisims«this permit shall be Jeered rtvokeJ. WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
L)Q1bereby air that there ise nvuwedon lending usgency for lltepafomww<of Dare Reccipt0
the words for which this perch is issued(See.3097,Ci,C.)
0 Fm LeMefs Name _ _ s TOTAL:
WIsders Addrtss TOTAL:
G 1 edify that I have read His ii,licaion and start that the above information is BUILDING FEE
y c«rtc(I agncc m csmnymly with all city vol toady«din.ne aM atatc lewx rtlating m QTy, MECHANICAL.PERMIT FEE
U Z building conswction,od hereby euWarim rcprese tmivcs ofthis city to crer upton the SF.ISMICFEE
'` above-mendsxcd property for impaction wr,tc:a. PERMIT ISSUANCE ELECTRIC FEE
(We)ay¢to mveq hdemnify i d keep mromecs the City of Cupertino ageinr
IiabiliGm,jWgmrna,mus ad riperus which may in any uuy accrue against mud City ALTER OR ADD TO MKIL PLUMBINGFEE
in convatucrce of am gmming of this permit.
APPLICANT UNQERSTAXIDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNT'r(TO III,IXXI CIM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 111(X.CFM) CONSTRUCTION TAX
Sigrume of AWlicam Conoact« Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE „-
Will heaWlicenierrfuture Wilding«cupmstore urhwdle lwmodus material ffxTING UNIT TO I IxLootl]ITT)
ac dchned by th,Cuputum Municipal C,lc,Clwprcr 9.12,ed Bw IIa1tM1 ad Sofcmy
Code.Section 25532(.)? HEATING UNIT(OVER IN0,M)B'I'U)
C]Y. FIN. V17M'ILATION FAN(SINGLE EMU) PAID
Date Receipt M _
VJItWmr comm«future banding by Hoc
Air madMiwswhich
I bmur�Mus air mntamiwn,vs dcOnud by tM Huy Arta Air Quality htunagunwnt 'HOLLER-COMP OHP OR I(p,IXq]ITT)
iWid? TOTAL:
E]yes O No BOILER-COMP IDVIiR IIX109111'I'U)
I have rad the hicmmusnmrerieh ,under, Ch,,,d95 of the Cali- AIKCONDHIONER ISSUANCE DATE
5,255 ry u
Gmia HWIb&Softly Cade,Scelionz 25.505.25533 end 25514.I urd.rmmval that If he NEW HKSIDIiNfIAI,MECH. SQ.FII
- buiROngdncc rm tswhiclyhosc beoict Wmit isnry nxof.0 odlemwmil ymhmmac,
a[tW,equimments which nusstWma prior rn iswanz of Ccnifcate of 0avpwey
(hncc«am1miudagrnt Dam TOTAL ISSUED BY:
OFFICE