29940 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAL PERMfF NO. (�(� (� A4 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'-MECHANICAL. L J J
BUILDING PROJECP IDENTIFICATION
B ILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
II$/3 Tri,i 5 c`' el-fi%no CA 9svly S�
NER�v �C-I HO=T ONTRACIORS NAME, LIC NO:
.NA N/C CONTROLM
NRCHITECP/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY V ELECTRIC PERMIT FEE ❑
I bmcby Horn'mat I. 1 hnnsed ander pmvidtns of Cmip",9(eommench'g JOB DESCRIPTION
ftiZ with SaYwn 7")of DivivinnSof the Buimn and Pmfrsaions CMc..rd my liccme is RESIDENTIAL
itil form
00 PERMIT 65UANCE
m nr.C1j.m arta'.
U U Ej licaoc Cl.aa Dc.♦ ❑SFDWL ❑FLUSHING
KITCHEN REMODEL
F�GL Dna Comnctor APPLIANCES-RESIDENTIAL ❑ADDI770N ❑PLUMBLNG R6PIPE
ZOM I ARCHITECTS DECLARATION ❑MULTI-UNIT (_1 STRUCTURAL
NN[LS
I unA'rwN mY plans+hall be u d u wNic rmmds MODIPICA'I']ON
OZ�, UPT0200AMPS [3 INTERIOR C1 CHIMNEY REPAIR
F Ln t:F5 lacatsal RofasimW 201-1000AMPS - IMPROVEMENT
OWNER-BUILDER DECLARATON OVER 1000AMP5 ❑BATH REMODELREPMR C)DEMOLITION
❑�px Q I hamby aiDm'that I.m evening from the Cmanaotor'v License Law hr to
xaLLV following'raven.ISn'tinn]0715,Huxircxs wd Nsffcxsinns Code:Any clly or county SIGNS ELECRICAL ❑OTHER
F O which vicinities. rankm rmstn L alter,imt demolish, o'slain any Soucarrc
prior to its Lssmince..Isu acquires the applicant for such penin to fk a sigma atramarm SPECIAL CIRCUIT/MISC.
E;!IY mat be is li aual pars•,,••to the povanims a aha Cmuradon"Licence Law(Ch nag
��O (caarrcrcing wit Smim7O )of Diviaim3ofthe Basircssmd Pmfemimn Code)m TEMP.METER OR POLE INST. COMMERCIAL
th
d at hr,uempt ticmftum and tc hook for tMa dlegcd s.cmplan.Any violwhm of ❑NEW BLDG/ADDTON [D DEMOLITION Smomm70313 by any a%dlcemfor a pcmnit.ubimut the applicant to a civil lxwlry of P)WF,R DEVICES
�oo ❑T:NANT ❑FOODSERVICE
f-Z} nn Hare than five hundml dawn(S5W1. IMPROVEMENT
a0 ❑I,ns owrcr of die lnopeny.rcmy cr%Royrr.wit wages as tcirwk ronnpcasmwo, SWIMMING POOL ELECTRIC
anddothewomi Cdtcatwrtueisnot intaded,Law oirvrot aMly ]w4,Bwsiveu OTHER
and ioiy whoru Cade',The Sonars'a lacena Law aM,mc not A hi m an owner of 011'I1.f:f5-SWITCHES-FIXTURES
Pmwny who Fanuc or improves'henna,wd who akKa wch wank himself or tr'ugb
sa own omrfy,vi,vm.IN pmvidcd ria.such Smit is kI w am not intr of car onion fa NEW RESIDENTIAL ELECIR SQ Ff,
ones.r-bo4tevn.tbe,,,the gmiat 4 rmeviilaaMxiid! ooeild or
SQ.FT.hl(IOR AREA SSQ.FT
arrcrfvikla Bill heats the buNen t{paving'iron he did rcx Ivied m impovc for wr-
M le).
1,vx urcr of me Pn'pcny,am csCMsivcly comr.cting wit liannred comr.cum w TOTAL
conwuct thn njact(Sar.7014,Rmircu end Profs.mos Code:)The Cmr—norat,
nsc law ditties nes apply to an owner of paoismy a Its,bWilds ormain sthmia..rd QTY, PLUMBING PERMIT FEE '"c 8
who codrxca far wch projms nim a mntracta(al licrnsed purswnt Io tk ConractNs 'y
Liana law, PERMIT ISSUANCE �A� 9
I] lantc.ernplimdcr Sec. ,B&PC1m,h,.,on �V
Owrcr Da ALTER-DRAIN&VENT-WATER(EA,) Li/I
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE VVr.
I hereby affirm under penally of Pajory ons,of the hdlowing declarations: lrlf(h! a
❑ IMve"will mvinuin a Catificmen
r of Const to self-insure fm Worker's Ccrr ea- DRAINS-IT RDOFA
A,COND.
canon,eon pmvicN for by Smion 3701 of Inn LaM'r Cade,for IIIc p ofnmwnee of the STORIES TYPE CONSTRUCTION
work for which this psnnit is issum. FIXTURES-PER TRAP
73 11uva and wiR maintain Wort Cmutimast Imwr>r,as re ti' by SMiin
37W of doe Labor Cade.for dire perfumurcc of th work for which this person is iswal. GAS-EA.SYSTEM-I INC 4OUILETS
My%Am's Cornpsn.is.ation Imorrtier and Poky menhir ere: OCC.GROUP APN
Carrier. Pol'ic'y No.; GAS-FA.SYS'nW-OVF,R 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEnNDU.STRL WASTE INTERCEPTOR
(This smron rcNriot Is,compkled if Fia t is tomos huNrd dollen(SIW) BUILDING DIVISION FEES
arid) GREASETRAP PLANCHECK ITE
I mrify fort in the penoramome ofthework forwhich this Permh is Land,I Shall SEWER-SANITARY-STORM EA FT.
m employ any peninn
in say ruam w an aro bsmme snhyct In do Worker.'Camcn
f . ENERGY FEE
zZ satin lava of California.Data, WATER HEATER WATN'T/ELT:C R
Applicant GRADING FEE
h NOTICE TO APPLICANT:If,Orr taking this Ccook.ie of Eawnpinn,you".1,1WATER S Y STEM'T R FATI N 0
f' b«vnc subion to the Wort is Cumpcnamion rosi.sioms of Ilbs Ichor Code,you must SOILS FEE
Q forthwith comply with such povisinru in this Permit Shall 4 deemed navam, WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.ET PAID
17.1 ithereby dhrm tat tleais arnnstrvcaionlmding agrncy fur alar perfarraun<o! Data, Rcmip0
Iltn<wwlr foi-wtich min wm'it is i.syrd(see.Tan.cis.c)
O E" Lender's Name TOTAL:
Li ndcen Addrts. - TOTAL:
y I catty that L have red tis vppl'cwim Sad awe this Jae vbove iNerrwivn is BUILDING FEE
VI corrca.l agrswamply wit all dry anlcrosnry ordianasaril sure lawsrdmingn QTY. MECHANICAL PERMIT FEE
U baildingconmmctim.not l¢aby aulMMee repmrenmtivn oftiscity to entm&"thae SEISMICFPE
above ni naammd pro my for impaction pnH s. PERMIT ISSUANCE(We)Mom Io uvea indemnify and kap haoNcs.the City of CUl ionmo a Iairy ELECTRIC FEE
',h:itin.judgvarnu.coni,ardcapcvcs is hkb army to any way wervs agnimt said City ALTER OR ADD TO MECH. PLUMBING FEE
w dat" epee of the Lp.aing N W s pamit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 111.0X1 CFM)
SOURCE,REGULATIONS. MECHANICALFEC
AIR HANDLING UNIT(OVER IO,OX)CPM) CONSTRUCIONTAX
Sigvtum of Applicant/Caooaaar Due EXHAUST HODD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will d1eaPpliant in marc huilding aCeapdnl Stam ar handle lwwrdoua materiel HEATING UNIT TO 100.001 BTU)
its&Imed by the Cupcnim Municipal Coda,,CloiNcr 9.12,and th<I Ieallh and Safety
Code,Smims 25532bo? IIEATING UNIT(OVER 100'"BTU)
• DYn ElNo PALM
VENTILATION PAN(SINGER RIitID) Dam Remipl
Will me ai,cor or car mem building fCa'paB as.An,Qu w dcvicn which B(IILF.R-COME'(311P OR 101,18X)BTU)
I IwnNwa.ir mnwminanu a ACEart M1y me Hay Arca Air Quality Marugenem
D inimcil TOTAL:
0Y,, L]No BOILER-COMP(OVER 100.000 BTU)
I hove red tM hazeNmu nwadnls amnoocnd nada(halter 6.95 M the Cal i AIRCONDRIONPA ISSUANCE DATE
From Hw1th&Sar Cade,Stdinm 2!IND.25533 and 21534.1 wdcmmnd mat if the FEW RESIDPIH'IAL MECH. SQ,fT.
bui dim docs not cvnently have a Icrunt,that it is my ospruil'ility to ngtry tk acvlum .
N theoamin iwhich vara be ren prigto uveae a.Coif.a Occvparcy.
Oxrcr rr authorized agent Dau TO'1'A4 I ISSUED BY:
OFFICE