28743 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEGTRIctI. PERMIT NO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MF.CIIANICAL 28743
BUILDING PROJECTIDFNTIFICATION'
BUII.DINGADDRES,S �w SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' NA `.a PHONE` T2JS CO�pc CANE �✓ u�< LII ^ O� N CONTROL#
YRCHHEECT/PNGINEER: /c LIC NO. AD PSS: G L
O.
CONTACT. - PHONE: BUILDING PERM IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PooUMod MECH
LICENSED CONTRACTOR'S DECLARATION. QTY ELECTRIC PERMIT FEE
I Itertbr a inm wt 1�licensed under provi,i.m of chapter 9(camrrcaing JOB DESCRIPTION
eco with Smtivn]01g0 oflFviaion3oflhc Business and Ro&F.io"Cd vtdmy conmis RESIDENTIAL:
�n�full f. and Irna, T
" ? �y'/; PERMRISSUANCE ❑SFDWL ❑ ITCHENREMODEL
g.Z(y Li ^ Lie J / G APPLIANCES-RESIDENTIAL ❑ADDITION LUMBINGRE-PIPE
lay ARCHTT1111 ' CIA TION ❑MULTI-UNIT fSfRUCfURAL
1 mdmstaM my plasm sled I be useda pudic mrnn8 PANF.I S MODIFICATION
OZ-� UP TO 200 AMPS C1 INTERIOR [I CHIMNEY REPAIR
� �ly li[casd Pmfcerimnl LII-1000AMPS IMPROVEMENT'
-<<..]]II OWNER BUILD#?R DECLARAi OVER lyX)AMPS ❑BATH REMODE➢]REPAIR 0DEMOLITION
l1 hemhy affum that 1 am caempt from rhe Cutnrmtnr'v L Icetus Low for the
1 C�U following reawn.(Sadie 703 L3,Businaa and Profession,CMe:Any city or-cwnry [I OTHER
hick requite a panni to consdauct.Wier,impostm
,demolish,con rep it any,r i
lurt SIGNg L'IPCTRICAL
F-LLO prior to its inn. e,eBo requires the appli[w for such pmmit to Bk a sipav]anstrncm
SPECIAL CIRNR/MLSC.
f�Y ihu he is li xo,ed pnuantbthe pvvisirmr of the Contramor'a l.icrnac ltox'ICTtNcr9
�-p0 (cormmwing wiN Smiion RpO)ar Divi+ivn7of Jc Busircss and Rufe,awazs Codc7m TIMES iR OR POLE INS#'. COMMERCIAL
6 that he is exempt thertf.and ibis basis for the alleged esertplon.Any violation of ❑NEW BLDG/ADDMON ❑DEMOLITION
SctirngU7l.5 by any appapplicant applicant for u scrout aubi the to u civil penalty of WW1?N UBVICFS
y ❑TENANT FOOD SERVICE
ZY
no,mac then fan hunJmd dolWa(SsfKl).
�"� ❑ Lsa oxmrofltr popcny,or my empinym with wogs as Ncir role mmpetuaiw, SWIMMING POOL ELECTRIC IMPROVEMENT
rill dofework,Cothe he Coeistrottmeakd Lo.does
aloe#Sec.oan. vivoa.f ❑OTHER
I�il-� and c ofwho to Coo The Caotnctnr'r Landow t do don ret apply to if omr of 01711.175-SWRCHFS-FlXTURFS
a 3- popmsy who W ilJr«improves thvmn mrd who dors wch wort hirt.elf or Wough
his awns cmpinyecr,provided
Hai vF,7ntr vc not inteedcd m o1Trnd far NEW RESIDENTIAL EU:f.TR- SQ PT.'
sale.IL howcvn.lhc building Mimpvv iv vilJ within nuc Yarof romfiction,tla - SQ.II',Il00R AREA 55Q.PT.
nwar-builder will have the bu a n' IMt he did ort'(Id or impave for par- �7 pN,
pmeofssllJ. ,,//�� L'/
❑ 1,uo Mthe v,s eclluive)ycont4idalicerosed convenors to TOTAL: Oct mruvun th )cn ,Buvncas F non. a )Too Cmuener.Li- V 0 19
Wore Tgw Ir to an.x,tc�xho buildamimpove,ihCleon.and QTY. PLUMBING PERMIT FEE 95
wMconvwts .n . projsu iNan )ImervN',vanc n,fla,Cmiractor',
❑[caaa,Taw.I.--corp er5oi H&PCkirnakr[san PERMIT ISSUANCE C��'Uh�'UF'EH flu
Other Dae ALIEN-DRAIN&VENT-WATP.R(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I herehY�rm.rvkr psmhy of perjury one of ihr following dcelmwn s,
❑I have and will nuinteisa Ccnificnteof Conrelum xRr-insae for Workers Conrpcm DRAINS-MOOR.ROORARFA.COND.
ss0ov,u pnNiJed for by Section J]pl of the I�ber Ctdc,far Ile perfmmnm.f the l STORIES IYPi;CONSTRUCTION
work fa whicblhiv prmit ia,va . FIXTURES-PERTRAP
E] 1 have it will maintain Wnrkm's Coon,' atinn I ationv,.s reyuirN by Saturn
]TIO of the lsMr Cook,for the perfwm.rxt of do wort for which this prrmit it issued. GAS-EA.SYSTEM-1 INC.J OUTTEIS OCC.GROUP APN
My Wtrkef'a Compenretioo Itnwrtnce earner and Policy Dumber art:
Cantu Policy No.: GAS-PA.SYSTEM-OVEP a(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASMNDUSTRL WASTE.INTERCEPTOR
(Ihinsntim rcN mrbecmtpincd if the penmii in fmurc hutdteddolWn($1()(11 BUILDING DIVISION FEES
.r less.) GRPASE TRAP PIANCHECK FEE
I terrify that in the perfo.nrona ordin,vi Tor hichthis pnnituissucJ.lehall SEWER-SANITARY-STORM EA.m FT.
nm employ any person in my�y'm w u b1'�'�lto t prem ENERGY FEE
0Z utionlaw,of Calif«n'w. tt WATER HEATER WNEt E:L.ECTR
,Z Applicator / y� ORADWG FEE-
y NOTICE TO APPIJ IL aper matin#this cmif tc of Earntryun You sl odl WATER SY:STESITREATING
a ;
becsons,s.hjcn talk Worker,c.mpct,varon provisions of Ne Ichor Code.you rant SOIUS FEE
YJ forthwith comply with.such provisbuns noribistoo shell he ailed revoked. WATER SERVICE
Q
Fes" z CONSTRUCTION LENDINdin,al Y NF.WRESIDENTALP MB. SQ.F. PAID Uok Ra ipq
1hvcbya7vm ethane iism(rv. l7,Cue agmry fade perfamurce of
O ihC cart for wfiieh Has permit it isutd(Ss.l09],Civ.C.) -V
N. TOTAL
Irndds
Lerrt.0
end 's Add
1[mify tMi I have read this epplicarim ud slate 1Mt the shove infmraliim is BUILDING IYIi
i.. ti ecrrm.I agrmmennmly with oil city nwlcmniY rrzdiwrae,and wmlaws mL tinges QTY, MECHANICAL PERMIT FEE
V Z building cononatbm.and hcmhy aulhnnit mitescntativcn of thio city to enter upn the
SEISMIC FEE
`� above-vlentiooal propmy fm inspection prpu PERMIT ISSUANCE
(We)germ m orae iMcnuJ[Y and keep hnnnAv the City of Cupertino sgeitau ELECTRIC FEE
Ii"itics.jud,.. .ur wd eapvac,which oris.,in any way..agaiw.ssid City ALTERORADDTOMECH.
in moaegs.o[eof the graving this permit. PLUMBING FEC
APPLICANT UNDBRST S AND WILLC&PLY WI N-POINT AIR HANDLINGUNR('IU 10.000CF14)
SOURCE NEOULA 5. MECHANICAL FEIi
AIR I IANOLING UNIT(OVER 111.000 CPM) CONSTRUCTION TAX
M ppli— on Dart. EX HAUSf HOOD(W/DUCT)
HAYARDOUS MATERIAfS DISCLOSURE HOUSWG MIIlGAT10N FEE
Wonthe applicax«fuiurt building.crnpeni atortmM1aedle hamdom murnd IFATING UNIT(81100.000 BN)
fined,y tic Caileron.Municipal Cede,Chiral 9.12,std the Health and SWciy
Smicn 25532(a)? HEATING UNIT(OVER 100,M)BTU)
Yes El N.
VFMIIA'CION FAN(SINGLE HP_SID) #'AI)
Dae Receipt
Will thew icaront w future hiding by are B use eyul t,Ci or devim which
crest hsmdiaa.Wrcmuroivenu as dcfiocd hY the P,Y Arta Air QuWiiy Afaugemrnt BOII.EN-COMP(JfiPOR IWJeq BTU# TOTAL:
WRQ? BOILER-COME(OVER IOD,"BTU)
❑Yes No
I have to the M1aznrdeus nwicnidsquirt Ia amkr Charter 693 of the C.h- AIR CONDITIONER ISSUANCE D
Emmis Health&Sofvy Calc.Satins 25305.25537 a 233:11,1 a,rav ad Oat if rho NEW NISIUEWTW.MEC11. SQ.FT
hild'mg doesto nunmdy haves knvN.Naii it my rtsprmihiliryt.reof theantpnt
Nthe mquimncn[c wM1^h veru be met prim iv ixverct of a CmtiOcme d'Orcitprcy.
Oxrtm err wtlwn d agrnt Doc TOTAL: ISSUED BY:
OFFICE