28732 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL O n
_ RUILDING PROJECT IDENTIFICATION o L
BUILDING ADDRESS: .SSANITARY NO. APPLICATION SUBMITTAL DATE
3
OWNERSNAME - PHON COI. TOR'S ME: LIC NO
�.\ NIC CONTROLx
ARC /ENGINEER: LIC NO i R� (ZdS q/L ❑
CON 4pr- PHONE: - BUILDING PERMIT INFO
Cf _ w V ` ❑ ConSWlant Feu Paid by Applicant(Initial) BLDG ELECT MU MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 omen,inform don 1 em IittauO vakr plovis of Chafacr 9(rnateming 10B DESCRI ION
WCZ 1thSadon7000)of Diviai lofde Buuneu erd Profu.ivm Cala.and mylkrnuie RESIDENTIAL
FLLO in full fora am R PERMITISSUANCG
aV Lkoix Clu. SIJcx } ❑SFDWL ❑KITCHEN REMODEL
Dmc Convenor APPLIANCES-RESIDENOAL ❑ADDITION ❑PLUMBWGRE-PIPE
ARCHITECTSDECIARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O t2Z I uMcrmmd my plane andl d uscJ a.publi<rtreda PANIJ S - MODIFICATION
OZ— UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Li`T"sed Prof wool
OWNER-BUILDER DECLARATION 2DI lap AMPS IMPROVEMENT
C�df
0.' I hereby vff Joel 1 um exempt from rite Cdnlrecmr's Licence Law for the OVER HMAMPS ❑BATH REMODFJJREPAIR ❑DEMOLITION
3 CLL.V folluwin6 rcavm.(Sedum 7031.5,Baorm,a and L'rofcuims Code:Any city or countySIGNS FJ,F.CfRICAI. ❑OTHER
LL which nN.i n.permit d,mvmict.alter,itrtpnrve,detrulidt,tr rtfair my.n.�.are
prioraniC iaeuuce.aNanocm.lhcapplicaru for inch pmnit to Oka.iped ornament SPECIAL CIRCUIT/MISC.
fv�y�y tat he n liccn.cd Prom.othe povisionx.f ld C.aacty.Ixetne Lav,(CTupter9
OCOO (comnmKin6 with5mion 7000)of Division3dde Rutins.gal Pmfeasimu Cook)or WWR METER OR POLE INN .. COMMERCIAL
a that h,il uemP tM1arfmm mut the d..i.for Ne 01cld e.<ntpitm,Any amnio m of ❑NEW BLD ADDITION ❑DEMOLITION
4• Swim 91011 by any amlicem for u p of oihjcns the ePNkanl m a civil facially of IV WHR DEVICES^N El TENANT ❑FOOD SERVICE
f�0cot'tarsoNu lifthfi, chill.
❑Lo.owvood, the fropeny,umy empbyecs wi00wages r k'v cote c.ntpen.im. SWIMMING POOL ELECTRIC OTHFR IMPROVEMENT
virin do the woM1..rd the stmcturt u rar'unendal uoRvM(u sak(Sec.7D14,Busircu ❑ETHER
Gand Pmf¢.kra Code:Th,Contractors U...o,law doe.ran apply to an nwter of OUTLETS-SWITCHES-FLXTI3RES
^ pmperJy.m Inddt or impmvm'dht and who doe....h wtrlt himwIf or through
his own eniployaca,Pmvidel tlwl.mh imProvmrcma are not imemld or ofIc"For NEW RESIDENTIAL HLEcrk SQ PT.
uk.If.tuwcrcr.Je WildingtrimPnvctrcnl i,cold within.ncyca of rontpininn,Jd SQ.PT.FL00R AREA SING.IT.
owner-W Oder will love the Wako of povih,Nm d did not build or intpove for Pr-
pomofule). p.� R
I,u owner M Iht Fro n
sty,am exclusively comctittg with liRn1 contraction,to AI-t W
con 0 the ptoiM(Sec.7044.B.irvocs mol Pmfes,oms Coda:)The Chhv.or.U.
a
c law do.,,Mn pply to Pnrp
un owcernTcny tio bai
wklsir mpmo,itmc
irton,and QTY. PLUMBING PERMIT FEE
^ I11Y�u
U
whno cos airs for such hcio s with a contractoK.)Ikcnrul Purxuant to de Cmllarnrra APR b.e w.LaPERMIT ISSUANCE
1 w e.emP uakr Sec. .B h P C for this rcn+m
Owner Da¢ ALTER-DRAIN&VENT-WATER(EA) I Ut U OLS'
WORKER'S COMPENSATION DECLARATION HACK nOW PROTECT.DEVICE
Ih=hy affirm under penally of perjury tone of the following dec.utitov,
❑Ihnve.d wi0 meimnin aCmificme.fCmaem meelf-Nwrtfa WmkMs Campem DRAINS-FLOOR,ROOF,AREA,COND.
.ion.n Po.idnl for dr by Section 37M of the IaCade.for the ferfuouae of the STORIES TYPE CONSTRUCTION
woo( wbkh Numu
gat. w i . FIXTURES-PERTRAP
ve and will im mtin Worker.Compmaerion Irrmnncc,n,mSaiml by.a mn
9700.1'the lady Code.for the gerfmrwce of the wnA for which this tu0xwed, GAS-Ink.SYSTEM-I INC.4 OUT - OCC.GROUT' APN
My W'orkcr' Gnrpctua Inmr fits JPulicy nuK' '
C.nicc Policy No.: rt �Ll GAS-ES.SYSWA-OVER 4(EA)
RTIFICATEO FXENMON FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
i-Thi,arcW rut completed if Nt lrnoil is fume Nrcil e hudoll.($100)
enim be
or kss.) GREASE TRAP PLANCHECK FNL
I certify that in the perfomath.of Ne work fm which Ni.Profit i,kot d.l ahell SEWER-SANITARY-STORM EA.21X1 FT.
rot employ any pervnn in any manner.oa a.to hccmrc subj to the Workers Compcn- ENERGY FEE
Oz .ion laver.(California.lou WATER HEATER WNE PELECIR .
z ApP Xoom GRADING FEE
y NOTICE TO APPLICANT.If,after making floo Crnifcme of E.enynim,youshould WATER SYSTF.bV [ATT,N'G a SOUS PEE become mbjtt4 m the Worker.Compcnmti.n praA wo,of the Lahrde
Co ,you.0
Hal forthwith comply with.mch pnrviniaa or thin Pmril Dull be Jcc00ad mvokd. WATER SERVICE
Q
7X CONSTRUCTION LENDING AGENCY f NEW RCSIDENIIAI.PLM B. SQ.FI. PAID
u
I Meby aA that that udamd( uctim kr .gency diagfor J¢Iz+(u.nena of Date Rmdp N
e wk for whichm
this pc0it i,ivuM(Sm.91197,Civ.C)
I"" the oI<rdcrr Name TOTAL:
V larder.AdJrc.0 TOTAL'.
0. I unify than have teed this applicmim end gain had the ldrve information i. BUILDING PEE
h moect.l epee toromply with entity and minty ardinarces and swelewc rtimingm QT'Y MECHANICAL PERMIT FEE
V z buddiog awenuction.and lir ebyiuoi ia<regm0wi.c.of this city mn rnJupnn the SEISMIC FEE
" .Eore.meaitned property for insPclim P.Pose. '
(We)efpce at leve,indm
enify ed km ..
neep hndcthe City of C.Pcr m egaiact PERMIT ISSUANCE ELECTRIC FEE
liedlitie,judgmcnu,msrn and capcnccc which nmy,in any away uccmc aeaimluaid CityALTIiR OR AUU'IO MIiCIL
mneeymntt.f the gmnling of Ihl.permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000 CFM)
SOURCE REGULATIONS. MECHANICAL PITC
AIR HANDLWG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigawrt of AppliwmVC.ntmcnr Date EXIfAUST HOOD fWMUCT] HOUSING MITIGATION FEE
E HATARDOUS MATERIA/-S DISCLOSURE
Will the applicant or futum building uuupant slur or handle hag mmemil HEATING UNIT(TO 100.000 BTU)
v dtRtd by di Cupertiw Municipil Code,Chafer 9.11 and the Hnhh said Safety
Code.Seedw 25532(.)7 HEATING UNIT(OVER 1110,000 BTU)
❑Yee Fl No VPNTI IATION FAN(S INGL.E RESID) _ PAID
Dote ReccirA N
Will the applicant nr foam building rcchin B uce t.Air Qa tr device.which BOILER (3HP OR 100.000 BM
emit herallous air cootnmiwnn ea dcfnM by Jd Bey Arte Air Quality Manag<trcnt TOTAL,
BOILER-COMP(OVER 100,000 BN)
❑Ye ON.
AIR CONDMONER
Iluve mad the Ward—matcr.la mluitcmcnr.uMcr Chywcr695 M'tht Coli- ISSUANCE DA
fan. col Ih A Sefny C.k.Smimx 15505.25599 Ord 25]00. unxlctsaN Not If td NEW R nESIDE+ DIAL MRCH. SQ.IT
N, gdm rot curie J mK a feaanf.dot it u myre.pwtabdily lu ify Ne cupmn
M rr, mustdcon Prior to iuuacce U aCrnif of
sd t TOTAL: ISSUED BY:
OFFICE