30134 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. JK�k O 1^4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF,CIUNICAL JK
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: � SANITARY NO. ICATION SUBMITTAL DATE
CQL07zr/,-"7C Cr.2c !id Z/ l e/ C ..
OWNER'S AME PHONE CO. ACTOR'S SAM1 LICN
N/c CONTROL
•ARCHUTCr/E2,IGINEF;(: SSD LIC NO: ADDRESS: r p �f ❑
CONTACT': PH!—'l/-+`M�-/V Ne: C /L BUILDING PERMIT INF
ElCO
onsNlent Fety Paid 6y Applicant(Initial) BLDG ELECT PLUMB
96f3819 2 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
px z wt I hereby alxrt thyl 1 wn Rcentad mover prnvidans of Cruptcr 9(wmmeocin, JOB DESCRIPTION -
Wp thSection]UUtgof Din, Jnfthe Busl'p'-yam Nofcuiona Cock, Wmy lkensele R STp pFNTIAL.
�W is full forte IT W. G C-7 .k // PFJtMfr ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
<FU�j IJwmse Lic.x i 1-' APPLIANCES-RISIDEPOIAL ❑ADDITION Ll PLUMBING RE-PIPE
NQL Uatc Comrut«
ARCHITECTS DECLARATION ❑MULTIUNfT Ll STRUCTURAL
ZOrn? Turd a my pla^s I+/M/'siudldl.Pill nttrordx PANES MODBlCA770N
O Z..� D f), �k��� UPT0200)AMPSAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F'�1-W L' ^H 201-1000 AAfPS IMPROVEMENT
th NEnoc IL Ffr DECLARATION OVER HMAMPS ❑BATH REMODFJ/ EPAIR ❑DEMOLfTION
yqx C 1 hereby.Neem that 1 rot exempt Trani Nc Contractors License c ty o for tha
W 3160 wbichecreawn.(Satin]ouraoBusirneuandve.dcsion Code:Any can ancourt' SIGNS ELECTRICAL OTHER
LL7 r/Q� which rryuim a pc aw M uu tL 1,.per,Improve,h eirrit t or e a sigfir any suucuuc
1".�.0-1 piormnsiacuana,el.w rtyuirm'Jr,sitaicanl l«e«hpisrun LHlea:iyia,Ct anent SPECIAL CIRCUIf/MISC.
2 JurkuIkrnscd pursues to ths pmvisiass a(theCmuticmta Littvc Lew.Cadee9 -
p��LpO IcomtrcncinB wish Semim]000)of DivuimJoftk fluvntessaM Pmfeasions Cade)or TEMP.ML-1'ER OR POLE INST.
a M e' Jan he ix eumpl Nercfrom e t Ila basis fns the alleged exemption.Any penalty
en ilty of ❑NEW BLUG/ADDfI70N ❑DEMOLITION
My Satim]031, by anundIed MI.($penmen subjects Jx applicau tuecivJ pemltyM PoWER DEVICES �7ENA,YT ❑FOOD SERVICE
Z�, na mmethm five huadred Jdlen(5300),
0 ❑Les owns afthe propany,ar my nnplaycdx wish wagesds their.wleumpn.vtion, SWIMMINGPWLELECI'RIC OTHFRVFJAF.NT
y wtOm Jeu.eN Je Nc Conaistroti Licens«urtcasesnr apply ,,an cone,of ❑OTHER
a 3� and arty wfi oes Code:The Cmttrmis Licrn.sc Isw doe rot apply m 1f mvmr of ON1JTfs-.WITCHES-FUTl1RF5
prpcny who Wilda nr improves thcrt and who at e n work hl tJ or or endhas
Ns own employes,povihd thou such impovcold w we not inemlM a oRuW far NEW RESIDENTIAL P1CCfR SQ FT.
sole lf.howner.Je Wilding«imptovemrntis sold within mcYear ofcmtpinim,tne SQ.Ff.FLOOR AREA S/SQ.IT.
owrwr-hander will have the bardenofl'rov'tog that he,did not build or improve for car- JO n
poseofWeJ. `1 g�
Las owes of the oncarry,am eschsivelY ccon.6o�with E¢ned contmwors m TOTAL, k
,.,,he project Da,c.7IW4,Business ort Pmfo,siona Cada:)no Canua,hor,L.-
1.
i- JUL O
1.l,w doe cat apply tom owner of propct who bailor m lmptove thwcou and QTY. PLUMBING PERMIT TEE J '(
[...a.vvcu f«such pojau with a codrenm(a)Iimucd punruant m Ne Conn nm's (996
Lignac law. PERMIT'ISSUANCE.
❑ Tem excmp uNcrS«. ,B&PCT«Nis rtanw
ALTI?R-DRAIN&VENT-WATER(EA) VALUATION
(T rr Da¢
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
I heeby affirm muter perupy of pejury orc of th fdlowiog dalnrwkvn
I hevcand will maintain eCenixcale of Consent maelf-insure far Workora Compem DRAINS-FLOOR.RODE AREA,COND. STORIES TYPE CONSDtUCfION
.anion,v orwides]for by Section 3700 of tine Labor Code,for the,pe f.e or the
wank for whidt Nu parit is owed. FIXTURES-PER TRAP
❑ I have and will ntvmaio Worker's Compenswion Inver.,,ayuired by Sc of
37Waftnc lasnorCode,f«Ne perf«rtwaccafthe wank for which thrs peanut aiswd, GAS-EA.SYSTEM-1 INC.4 OU`O fS OCCOROUP APN
My Workms CwnJ'enuuitm ir and Pulicy no rt
cmrirn SAL CxO 7_�'C- Policy No.:2YTP IS ow GAS-EA.SY.SmNM0VER 4 HLG
CHRTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCFJTOR
BUILDRTG DIVISION FEES
(Thu d section renm is ctmplwed ifile pomp it f«ane hmxlrtd dollwx($IW) GREASETRAP
or lee.) PLINCHECK FEE.
I anify than in the perfmrrtance ofthe work fur which this permit is iouriIslash SEWER-SANITARY,-51ORM EA.2W FT.
not employ any penin in my nunne.so man become mhject pt the canker:Cmnpen- ENERGY FEE
z ,Z swim laws d'Cithrorn.Date W'ATTR HEATER WATE VELECTR
O Appiesat GRADING FEE
In NOTICE TO APPLICANT.If,after m4inp this Cenillcwe of Eeanplpm,you should WATER SYME!"UTREATING
becomw
e bject to tthe W«ker's Commns
peanvar pavoioof the tuer
nCode,you must SOILS FEE
I forthwith coni with ouch pmv'isi«u«this permit shell be deend revoked. WATER SURVICE
aQ
� z CONSTRUCTION iso ON LIiNURJGAGENCY NEW RESIDENTIALPLM N. SQ.FT. PAID
Thereby eR that Nero'uecad(Sec.i 7..Cim agency fa the pa(mtwac or Dee RsnptM
U Jewoh it which tors pump i.i sam(see.3ml.eiv.c.)
C) U Leasicis Nome TOTAL:
IU2J IudwY AJrpns TOTAL:
00 I cmify Jut I have read this appllcaim sad awe taw the snore informanim is BUILDING FEE
C4 macs.I+arae.m comply with ill city andawnry oNinmm at we Pawnrclatin8 to QTY. MECHANICAL PERMIT PEE
UZ, buildio6 nrasroctian.rand hereby antoware rpca..Nv M this cirym enter apmde, SEISMIC FEE
above-mentioned coea,for inupctim puxtoses.
(Wo)agree to aave,in dantnfy and kap lunnkss the,city of Capnhm'itinv - PERMIT ISSUANCE ELECTRIC FEE
IubJ'vin,Judgtrtema.cos W calsmcs which may in tiny way accrue egeimt said City AI,TERORADDTOMECH. PLUMBING FEE
in wmmptem of the fusion,c is permit. _
A PPL .ANT UNDER DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OO 10.W)CFM) �J Q
SOU 'EPEC ' ONS. V MECHANICAL FEE
0005
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX
ort MApplientlC r ate FXHAUSTHOODIWMUCT,
R OUS MATS-RIAU DISCLOSURE HOUSING MTTGATION FEE
Will the apple uwm hulWing«cupam smm or lu,dle havnrdaus mmmal I IEAoNG UNIT(IT)IopJYMI RTIA
sa def cad by the Cupertino Municipal Cale.Chapter 9.12,and the heath and Safedy
Code.Seclsos 255724)7 I{Ekl]NG UNIT(OVER I W,000 BTU)
❑Yes [_1 No - VpJcTIIATION PAN(SINGLE RESID) PAID
s will the applicant or force humin t use the Radp x
g byv B cquiptmtlay Mocawhich BOILER-COMP(31iPOR 100,WI1BTU)
eachDisc ict, un air contamiwnlx as tklinN by the Buy Arta An Qmlity Nenuprntrnt TOTAL:
DtwrctT
❑Yn Ellis. BOILER-COST(OVER IMSOD BTU)
I Not,red lk hareNmu Mesial,re9ui.n,vale Chapter 695 of the Cvli AIR CONDITIONER A ISSUANCE DATE
forma Health&SRely CMe,Seactims 25515.2553]and 25534.I uNwwrd but Buse NEW RES 11)ENTI Al.MECI, SQ.FT
W ilding cl not carnrndy Tuve a main,Nat It is my reWmsibilhy to notify the«cupmt
.fttr rtquirtnen.which ream,at oat pian m ia,una of•Cer ifrwc of Occo any..
Ownenr euthtrird ogcm Date TO`fAL: ISSUED BY:
OFFICE