S0768 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECINUCAL EMIT NO, O� 6 p
BUILDING DIVISION APPLICATION/PERMIT PING PR G-.M IDENgICAL J v
BUILDING PRIIIELT IDB.\TIPICATION
HUIhDING AUUNF_SS. / SANITANY NO. AIY'IJCATION SUBMfITAI.UA '
075/ T � 11
OW { ML /� PHUNP.: CONTRACIOR'SNAME. LIC NO: N� CONI'ItUI.M
ARCHIT/E//FSGINEIiR: LIC NO: ADDRESS: ❑
- BUILDING PERMIT INFO
CONTACT: PfIONE
e ❑ Consahant Fees Paid by Applicant(Initial) I1LDG Et3EC PLUMB ME
LICENSED NTRACfOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 heuby dTnn hurl 1 am lianrcd under provision of Chapter Y(corerrc«ing
CMZ with See
70001 of iv 3afNe euaiMarw l4ofnsims Code,Wmyliame is RESIDENTIAL'
WOO PERMEr ISSUANCE
��� in full force and effect. K 370 ❑$IVWI. ❑KITCHEN RI1.fOD1U.
t-.U uesam�i 0�.}T'���70 —3
—' lice APPLIANCES-RF_SIDENIIAL �EHON ❑PLUMBING RI....G
,n6y Date / Conuixuw r�
ARCHITECTS DEiCIARATION I'ANEIS ❑ 1ULT1-UNIT ❑STRUCfURAI.
~h Z I umk nand my plans shall be u.l o"ablic Mcordx CHIMNEMODIFICY
REPAIR ZOm0 UP DO Z(MIAMPS REVSRIOR ❑S IMMINGP OI.
1- L.icensen Pmfessioml 211.-IBOUAMPS PREVENIENT SWIMMING fVOIS
OWNER-BUILDER DECLARATION OVER "AMPS ❑ ATII REMODEIJREPAIR ❑DEMOLIT.ON
6 I hereby affirm than 1 am exempt from the Csmuarto liana law me the ❑OTHER
X C 1 U frollessaing Milson.(Section 70313.Ban. nit Profes,icos Cade Any any ox coonly SIGNS at FCIRICAL
shich MamM,t.Print to Imearnmet eller.immortals.demnhsh MPms any"I'M
EE',�6 pri G swnw.
also requiresN Wlis tto ,aahl 1file a.igned statement SPECIALCIRCUITIM LSC,
rmal he isI' oad puri tI N<pm in, fit C las u 1'.(Chap"9 L:
COMMERCIA
y.d0 (rumornem,with Senkn 7(M)of Divisa,n?of the Rua rico,end Potor"irm.C�loM TEMB METBR OR POLE INST.
a o that he is exempt thaefmm and the loci%for dae alleged exemption Any vioWima of C1 NEW BLDG/AUDITION El DEMOLITION
Section 7031.5toyany applicant forepemtit mh*Mthe.Pp.iconl nacivil letultyof FC)N'ER DEVICES El TENANT ❑FOOD SERVICE
F_Z_Y non hm1n th"n five hundred dollars(55001. IMPROVEMENT
Q ❑L Cs rwner a the Praleny.at my emploeni ith wagcc As their ale«unpensaion. SWIMMINGPOOLELE C ❑OTHER
€� will do the wwk.and the urpo is tet intended m offct 1f«sak(Soc.71Wf.Buc'ouu
L3 IM Rofrnions Cask:The Canino Lier.law docs rout apply turn mutter d' OUTLETS-SWITC -mmitFS
ptopeny who hamidx m improves the n,mail who dtw.such wart hlm%clf airIhrougn NClS'RISIUFMI 1, ;Ll R SV I'1',
his own employees,pmvidul that such iinpuvenniuC me trot imeMed m n.fnM for SQ.FT FLOOR ARRA SISQ FI'.
rule If.hmvevn.Nc lulkling air improvct«m is sold within.ycor of cmnpkti,m,the
«r-NdlJer will trove that hNca of pmvine tool he did ter buikl m impnwc fro rot
pareorsale). TOTAL. P All)
❑L as rote or the prin .am excheively morrucling with Iireao comrxnus to
[numum the project(Sec.701x,Busirre%.s std Poem sion.c Code)The Comae .c u- D�'`^
tens,taw docs mut apply to an ownrr of property who builds orimporves themes.ano QTY. PLUMBING PERMIT FEE Gy
whornm
mclsfornuch Projects withacamrmdy
v' licen.dw
puent none Gmtmnla G �J1aA
19
License Isw. PENMI'r ISSUANCE 1!{J
❑ 1 an,exempt moor'Sea. .B A I'C lis this M.xm
A LTI?H-DRAIN k V IiNT-WATER(EAI rcH fh°fi1DA„GN
Qw¢ Dec
WORKERS COMPENSATION DECIARATT08 H
g 011l DEVICE
1 M1eseby vRrm utdm perW ry of p<rjwy nru of the follmriodeclarnmens:
❑ Ihavc and will al0lnlahl•Crnificac nrC«ttcolm¢If-inmc far Worlds Comprn 1 S- OOR.ROOF.ARPA.COND. STORIES TYPE CON.STNUCIION
.anion,a.provided ort by Smioo 1700 of the lahK CMe,for ohs perfanv«c
work fm wnich this,earth la issued. Eld'NRPS-P[H THAI'
❑ IhaviceM will naimuin WmkNs Co,nlwnwninn In ora. S MS-FA.SYSCIIM-I lNC.40tTfLES
TTT a
pglof(he 1-0o'CMs.fmthe 10111--a"floe:"Ah hie In IliawW, OCO.GHOUI' nPN
caWokcl pcgcut 1 I�a.r✓ruMy No,: GAS m: GAS-PA.SYSTEM OVER J(BA)
Carrico TT�R ��11'' Pthat No.:
CERTIFICATE OF EXEMPTION FROM WORKERS GRESSWNDUSIRL WASTE INTERCMOR
COMPENSATION INSURANCE BUILUING DIVISION FEES
(This oration neN oro M completed if No,Krum is Intone huntrN"lan($100) GREASETRAP
PIANCIIECK FRE.
lay any What in me any mato as to aoak
wnijesteh ix permit ixikmCun,lnI SEWER-SANITARY-STORM PA.2W 'T nm cmploY any petwat in any namrr.m ux n,hccuw euhj«undo Workers'Gmtpen- ENERGY FEB
z Winn laws of Culilarnew.Dare WAG?R EI HATER WIVHN'I IELECIR GRADING FEE
z App.iczm
NOTICE TO APPLICANT:IL vftef making Nis Crnificute of Evcmpti,m,you should WATI7R SYSTEMo TRFATING SOILS FEE
F = h«ome cubjcet m me wader.Compenation prus him.,of the Cant c,.k,ymr mutt
a farthwith r«nply with%«h provision,«thi.pemit shall ba dcerrcd revoked. WATER SERVICE
G
CONSTRUCTION LENDING AGENCY NEW RESIDF TIAL PI.MB. SQ.PT. PACU
I Mreblolfimt tlwl there is a comlrominn kndiel-1ral fm thin pcUumance of Dma Ru ' x
WO the wmt Gar wn'mh this pcnnit ie ixaedIse.AI97,civ.C.1 )rAL:
0 I_emcee Nome I OTAL:
r W Ixfd ,Ahtrea, BUILUING FEE
1 realty than 1 have read this aroplim.and Lac dost the"hove information is
U1 gut py wi y Y c QTY. MECHANICAL PERMIT FEE
rn WiMicla mmm ,,yAm and[num adiruoc<saM ciao Hw%ulaio ue SEISMIC FEE
U Z buiditp coounmiand h[TebY auduuiae ralnerrnwivec ofthis city termer"pro the
above-mrnoiatM pml'cny fm imp«tion ptrganas. PERMIT ISSUANCE ELECTRIC FEE
(Wel agree to rove,indemnity at,keep hunt,do City of Cupenins against
Iiohilitica,jMgnroh,ox—M espcoav which niay in any way aacma against mart City ALTI}t OR ADD TO MITCH PLUMBING FEE
P a AND',Y DERmmiNDS AND WIL
APPLICANT DERSTANDS AND WILLC P WITH ALL NON- INT AIN HANDLING UNI'I'1'IO W)UM) MHCIIANICALIIi
SO LATIQNS. b p
/ /.y ” AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAS
Signature of ApT4och, C tar / Data ! EXHAUST HOOD OAGDUCO HOUSING MITIGATION F li
II Rutureh twoch osmancor UNE
Will the mpplicent m future M1uidin8'�'<upont slue u IwMlc horurdouc material IIHADNG UNIT(TO I(MI.IxIB BTU)
as dufiewd by the Ca,mma,Municipal CMC.ChuMar 9.12,aM the Ihulth unit Safety I11W INC,UNIT(OVER I WOM)BTU)
Ccuc.SCaiun 255320.)!
❑Yes L]No VENTILATION FAN(SINGLE RFSID) PAID
Data NariptM
NJI Ne appli[anlor Pomo Wiona,upont use agatpnenl or devices which BOILIJt-COMPOHPOR IM.0001ITU)
emit hA,AM,m art[omapinam m skfined by that Bay Arta Air Quality Menagcsmlt TOTAL
IFwict7 BOILER-COME(OVER 100000 BTU) _
C]Yet, Fl No
AIR CONDITIONER ISSUANCE DATE
1 have N the h Coo
Se materials 5,2i 533 ts armmo iS Llwpn+r�95 of the Cali-
fomia HraIN K,e Cut.r a Section,t.hen,25533 s25514.I unL,wyhi Nut if arc NEW RESIDENTIAL MI:CII. SQ.1'1'.
offs,Q docs ai,Ih%whiish hn most
a tenant,that it I,my responsibilityoira notify4the«torpent
of de r�;uirrnrnos whish muv be mm prku to iswnrce ofe Cmifcae of(knpany.
Owner u au0roriaN'oon Dae TOTAL: ISSUED BY:
OFFICE