30066 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I < BUILDING-ELECTRICAL PERMIT NO. 30066 O O V 6
BUILDING DIMION APPLICATIONIPERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUIIDI.NGADDRESS: SANITARY, APPLICATION SUBMITTAL DATE
OWNER' I_ PHONE: CONTRACTOR'S NAME: LICr4oNO:
HI NIC CONTROL#
•ARCIf1ECUENGINEER: LIC NO: ADDRESS: '-C_ 1.' E3CONTACT: PHONE: /y £- E1 `y� "Kr V BUILDING PERMIT INFO
.n IPL n -45' ?9/—/000 ❑ Consultant Pas Pald by Applicant(Initial) BLDG ELIi PLUMB MECII
L "F
LICENSED,COO CONTRACTORS DECIARATION ❑ � ❑ ❑
1 h<t< d(thw I am licensed under QTY ELECTRIC PERMIT FEE
by pmvufm Chaper9(romm lI JOB DESCRIPTION
µO C00 Z i f]If onnd! if(Division Jaf,k BtainasW Pmfasiau CoJe,Wmy Beenvis RESIDENTIAL
F in full fore W if I T'FA01ff ISSUANCE
CWF J � i O 12Y637 V ❑SFDWL KITCHEN REMODEL
QWUZU p oils r" ' Lie.#
�Qi D.e Confou r✓ / D /fi APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCNRAI,
zb`27 ; PANUS .
1 mxktxmnl my plans shall he meal ns pontic TION MODIFICATION
pZ`C UP'10200AMPS ❑INTERIOR ❑CHIMNEY REPAIR'
I•.�kLLl Licensed PRofevimal 301-1000AMPS MPROVEMENT
�Yf, OWNER-BUILDER DECLARATION OVER 1000AMPS BATH RCMODEIIREPAIR �DENOLRION
C C 6 I hereby sff.the,1 am cacmp,from the Contnedir's Licerar Lew for the
K Wm U fdloving reawo.Section n313,Business W Itofcasiau Cock:Any city M county SIGNS L'LECIAICAL OTHER
3 W which rt9Uirts a Pelma to coronoid,cher,imprt demolish.or repair any sinuOure,
0 priw,oits issuene.al.mrtyuim,he applicant for such permit to File a signal susbeincat SPECIN.CIRCLLUFNISC.
p G� the,W is licensed pursuant wthe posisimsnf,he Cornntnols Litems Lai, Che,der9
OD (cuntmercingwith Scetitm]Ipll)of Divisim3nftM Nmingc end Pndavindx Gde)Un . 'UlMP.MEFERORPOLEINS'1'. COMMERCIAL
W
a CC
that Ie is exam#therefrom and de basis for tie dlegcd exrmpion.Any violation of C NEW BLDG/ADDITION ❑DEMOLITION
�a• Section 70315 by Uny apPlicun,fot.permit subjects the oppllavt to.evil prodly of POWER DEVICES
`� seer mac
than Bvc hundred"der,(5300). ❑TENANT ` ❑FOODSERVICE
�QMENT
❑I,uow�af,he taopenY,amY employees with wagetutbc'v wleromprntedm. SWIMMING POOL ELECTRIC OOTHERIMPRO�rl
.M lsuhe amt.We, swcwrtismt,LictosmnReredforsak(sec.o an coiner
of
63$ pro tray ;1W CNor irdr theoers License Idw dace hoer apply to if owner of OVI'IJ.cfS-SWITCHES-Fl%TURES / �^
his ry ri who builds m oided dx thnrunt,eM who due.such sum{:himself a d til lot
his own employee,pntv't i, tMt such ine rn is sold .c ort ar intdn&d or.alldned lis NEW RESIDENTIAL[LECfR SQ FT.
wk.IL however,the huilJingaimpmvcnent is utlJ within one the SQ.FT.FLOOR ARTA S/SQ.PI'.
wrcrbuilder will lwv<the buNrnof proving that he did not build or mprvve fu cu- Q pp•��
post of sale.). r
I,a owner of IN,proprt y.sonexclusively contracting with Ikennsed mnloactm to TOTAL:
the project(See.7014,BUdnexs W Profcssiwti CtNe:)The Contru,es Lu-
camseLast, t,w,apply,oanowaeroflmpertywhobuIcs,wimprovetuhaeouW QTY. PLUMBING PERMIT FEE JUL �2
whomn,r vs fmwch rynja,a withacontmetm(s)Iicrnsd pursnlittle,he Contttars 1996
License Loss PERMIT ISSUANCE
❑ lam eacntpn un&cute. ,B x PC for lore twro^ CITY tr a
Dee ALTFR-DRAM&VENO'-WATER IFA) --VALUATION.1
WORKER S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby elfin under prndry of perjury one of the fdlvsvieg declaratiora:
❑Ihavead will maintainsCmificve of Convnt,o telt-inwefa Wakes Congrn DRAINS-FLOOR ROORAREA,CONIJ. STORIES TYPECONSTRUCfION
tabun,as provided fa by Section 377 of the Ichor Code.for the perf.e of the
.r fm.bich this pe.I,is wised. FIX'NRIS-PERTRAP
lave and will muintain WotAcr's Compmcalion Insurance,v or;.iml by Sind.
700offie LtMr Cole,for the perfomterce uftlw work forwhichthls prow ix ismad. GAS-IA.SYSTEM-]INC.4 OUTLETS OCC.GROUP AI'N
My W pewtinn Inaumttce carrier and PUlicy numbe art's
CatricL y—j Mred j�Lpoliry No.: r �7�y-�L '] GAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GRIASF/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
ml.-,v7 murection rectitis bc-ompMedifthcpmni,uta arc hadrN Johan(5100) GRFASETRAP PIANCHECK FEE
I certify that in tie peofonnonce ofthe wort for which this permit is iscoed,I shall ,SI:WER-
SANITARY-STORM EA.310 FT
not employ any pemm In any manner m v tit baanc subject w di,Wurkrn'Compen- ENERGY FEE
Z satinalawRof Celife-ii. Dale WAI17R HEATER WNPNVELECfR
O Applicant - GRADING FEE
N NOTICE TO APPLICANT:IL after making this Ceruftewe of E+cmptim yom shaJd WATER SYSTEMffRFATING
F' ^ became subject to the Worker's Comryersonsoo provisions of the,Iubor Code,you mat I SOILS FEE
UW fathwith comply.ith such laovwaru or dim,perm&Wall N<&s irtvnked. WATERSERVICE '
D
.U. Z CONhTRUCf10NI.ENDING AGENCY NEW RESIDENTIAL PLM B. SQ,FT. PAID Dae Rarttpp
Ll 0IhaeM1y alFinn tha„hert isscoaswctimt ktdine agency for the prrhrmence of
0 thew«,fa which shit patnh it issued(Sm.J1YJ7,Civ.C)
Len&/s themeTOTAL:
LnticlAddrtv
I erthWoo, , TOTAL:
G ctify is vecad I ha , this epplicatian W swe Oc a
Oat uhbove iMormeliw is BUILDING FEE
rn correc,.I egrcewntmMy suint allnry Wcamryadiwrcas W.srac laws relating to QTY. MECHANICAL PERMIT FEE
V Z MdNing rntutru and hereby emhoriae repevntmives of,hia ciryw ente tiMai Me SEISMIC PEE
^ abase<-vevtiomf pnyrny for intpcnion ptr,l PERMIT ISSUANCE '
(We)iit wsave.Inknmify W keep hvmint the City of Cuprnino against ELECTRIC FEE
liahilities,judgmrna,cons and expenses which nay in any stay atmagbinw said City ALTER OR ADD TO MECH.
nvqucntt of uhc granting of this permit. PLUMBING FEE
APANTUNDERSTANIS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10,00 CFM)
.'OU ]E REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I10.000CFM) CONSTRUCTIONTA(
onusadur ate EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or for=Wilding occupant more or hWlehvnNaus material II EATING UNIT FIT)1(0,(00 BTU)
es defer by lite Cupertino Municipal Cork,Chap,9.13,end the Health and Safety
CtJe,Section 25592a)R HEATING UNIT(OVER 100.000 BTU)
❑Ya No VENTILATION FAN(SINGLE RPSID7 PAID
Dee R.igY
Will the,applicant or fmute Wiklin{aruparn use equipment or&vim which
eBOILER-COMP(OHP OH I W.000 BTU)
mit hadaa rnrair coouminws as&fined by the,Bay Area Air Quality Matagerrcw TOTS
UsaxT BOILER-COMP(OVER 100.1100 BTU)
❑Yes t[y No
thecae neral de laaardtuurvuerinlx uwdcr Gaper 6.95 of de Cdi- AIR CONDITIONER ISSUANCE DATE
mryirt
Gt wltb&Gtfay Cok.Sections 35N15,255]3 and 25534,I wulentund tMt if the NEW RI'SIDP,NTA1.MECII. SQ.FT.
ildin does nor cu nrndy`havea,enent, nt it ismy rcsporaibiliy I 'fy occupant
tf the whiNtmtu be mel aI=ofa CrmOal f putty
O Urauthodaedagenl f Dae TOTAL ISSUED BY:
OFFICE