30764 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE SALL POINT PEN ONLY
CTTY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO /I
BUILDING DIVISION APPLICATION/PERAI1T PLUMBING.MECHANICAL. 30764
O 4
BUILDING PROJECT IDENTIFICATION
lfi�
kESS: , , SANITARY NO, AP`PUCATOrrN�rSSUBBMMIIITTAL DATE
`L P ) E �� CO T B. /1 NIC C�(�J�p�Ry[)O�LX
ARC /ENG LION A $ �!- - _ _,LI`R/ ❑ �.
CONTACT: PHONE 6 wY' '7^Y-�^IM•/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
_ I ❑ ❑ ❑
LICENSED CONTRACndDECLARATON• QTY ELECTRIC PERMIT FEE
I IxRrami b),, tnel l an uren,ea,roarer pmNamm or cnepmr 9(a,m+rcndnR JOB DESCRIPTION '
eeZ with Sectlon]OW)of Dlviviou3ofiWBusircsrand Pmfeasitm Code,andmvik<nwis PERMITISSUANCE RESIDENTIAL
fufin",l fmuN c �j j.f
�FUZrFj license Iv Lic.x �3�Zi, ❑SFDWI. ❑KITCHEN REMODEL
N6� Doc Conuacmr APPLIANCES-RESIDENTIAL [I ADDITION [I PLUMBING RE-PIPE
F,OyH AHCHTI'ECTS UECLAkAT1ON PANELS ❑MULTI-UNIT []STRUCTURALZ O J Z 1 undnm
eramnd my plan,shell IN used public ,,A d, - MODIFICATION
OZ UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
I.icen,N Profcuiunal- PILI-HXXAMPS IMPROVEMENT
SQYs� theOWNER POWDER
aa,ttrmov,CeATON OVERh"iAMPS ❑BATHREMODEVREPAIR [I DEMOLITION
a0 I hereby,Ilion an 11. Hemp imm ohe Cnni ns Coc Linmc city
o for the
3 L IUF.. following,i a (Section ann,ar,Business arxl Professions lb, Any city m county SIGNS ILF,CTHICAL OTHER
ly LL W y which rayuir�x v f¢nnit to u+nnwm,ober.impinve.dentalleh.++repair any ewchw _
prior to its' a ol,o manures.thppl rsof for sitch Permit t rile a uhgned smA,wAt SPECIALCHICUITIMISC.
A. Nath, 1 win a tt 0,pn for C onsi seal ha ICsJ, 9
QQ fa mmc g 'Ih5 Ii ]INIB) fD '. n 3 tlhcd 'n .iA olod l,x 'rEX1P ETER OR POLE INST r-
L x 5 y Put h pt Orc I d IM ho.aa f theOIegW cxcmPl A ) 'olaion of �. 0 NEW BLDGIADDITION ❑DEMOLITION
W--y Setion T03l.5 by Any npplunt fr 'emit euhjmts the umL n evil pew%y of POWE CFS -
not nvmIanGvehuntlxccdollars WOOL ❑TENANT El FOOD VICE
1-=Q (3I,a,nwrcr of they IpmY,of mY cmpinyx,wish wag,ae lbeirnnle compenmtion, SWI G ECTRIC- - IMPROV
-Jyy will 3,0h,"Alf,cost mera,alua is rxn imaNimm oRerad I—ele Sec.pkq.Busioess ❑OTHER �� `�'
end Profi iune Cak:The Gmva¢m'a L.,a.law does my apply ,,un owner of OUTLETS-S C11 XTURES
Imcy.eny who builds or imprmer thcrtvm and who doe such work bunralf onNough
hi,own emplayme, maided cut sucn impmvmrcnu ere two inlcA&d m oHcavl for NEW R F IAL . SQ FT.
sale If.Mesmer,the mo1dingafiAaoo,mentissold within+m yevr ofcnmplmioA,the SQ?PT R EA' LSQ.F-L
wner-builder will has,Ibc burden of proving mm he ddidemr build or improve fmpar-
pr,e (ole). - TOTAL'
C]1. wc,O'he prosect n lulirly trening with l'crncd com.oa m
.-.11 the p ,al lSc .]IW 13 es AM Pa f u ne Com:)The C Ahavi.A U- FEB O R[z
C�
cemia Lw eoaa ma applymAfo.,of pnpeny who Nillrmimpnrves themn,and QTY. PLUMBING IT FEEfy/r'
wr+oommctFrma onuwima rot ti glecn � no�amtatae t 1 (�r
LiLUY�Hj�N�
en¢lsw. PERKfIT ISSUANCE
• ❑ lam cxamp unhr5a." ,P&PCfor lhirm.iwn
Owner Uwe ALTER-DRAIN&VENT-WA ) VALUATION
WOkKEHSCDMPENSA'110N DECLAkADON B ACK FLOW PROTECT DE VI E
1 brnby affirm under paully of perjury arc of(he'Allowing deelantimr.
lam,•❑ IluveardwillmeinuinaCmiGDRAINS-FLOOR,RODE AREA,COND.
sai,n as provided frc by Soxrim 3]01 n[the Lahx Conk.!r Mc perfotmarcc of Ibc STORIES . TYPE CONSTRUCTION
work fee wmch this Pmrann ie armee. FIX TORPS-PER TRAP
I lutve aha will mammon Warkds Com,nsainn Ienumma,aw re,inJ by Salim
30110 ofthe Lader Ccitonhc peffarouna of the work for which Ink pennil is isnocl GAS-CA.SYSTEM-I INC.G OUTLETS
My DCC.CROUP APN
M+ ,C n q etMm Irtwrnrc,artier vnd Policy sae:
Conic. Policy Na: �' r GAS-FA.SYSTENCUVFR l HaA) '
/yS T'CER CA OF EXEMPTION MOM WORKERS' -
GG ISL" COMPENSATION INSURANCE GREASUANUUSTRI,WASTE INTERCEPTOR
M.wctionrcWnol beemodarviifthc pamil ix famiehundred dallaaHIM - fU VISION FEES
nrlc„) GRPISETRAP PLANCIIECK
I,coif,So mbe rf.AeaAfjbAmk for which this permit isinatxsl.leM1a11 SEWER-gANITARI'-S'IURM FA.20(l FT.
nR employ an nn vl ba'amesu6j¢toA the Wnken'Cmnprn- ENERGY
Winn Le 1e WATER HEATER WNENTA?LECTR
Appli t GRADING FEE
y NOTIC' A C ler making Ihiv CeniBeac lir Ea<mPtiw,you.hwlJ WATER SY,SrFM/IREATNG
boot eb”'In Worker's Compensation provisions of the Labor Code,ym must SOILS EEE.
Ila Q fvohwithcanoplY with+tn'h Psovisnmx m Nis permit shYil be fraenal avohd. WATERSERVICE -
z CONSTRUCTION LENDING AGENCY NHW RE9IOEI3TIAL PLMB. SQ.FT. RAID
V Ihwcby affirm lM1V lM1ca i,acm+Wctian koMing ega¢y Rrllta perGxn+aw<nL Dao cctp
kTa ti Ibe work for which Lha permit le;.,mast(.Sec.309],Civ.CJ
f-+ lenders Name - TOTAL:
V lenders Addaww' TOTAL
Hy I ceriaN th t I hu -d m epplk r ad vac Out lia alove A erma\m is - BUILDING
h corrccl.I gr I amply mall ity and rymdinalcc AnJ.w :alai ngw QT(.. MECHANICAL PERMIT FEE
U Z buildi,mon"muctoo,nohereby ohmlre rye. omivcs of An'''I'm terupm the SEISMIC FEE I�
above-mentionedp of fee nry:cuon pur,ascs. PERMIT ISSUANCE
(We)ago=w save,iMcmnib,"keep haemkw the City of Cupeamno against ELEMIC FEE
Iiablldies.judgrnem ...1,emle.penseswhkhca,in.,.A,varve vgdnst sad Co, ACTERORAIIDTOMECH. PLUMBING FEE
in canseoryerce of the ming of Nis pen
APPLICANT UND S ILt. OMPLY WITH ALL NONMINTAIR HANDLING UNIT('rO l 08(10 CFM)
SOURCD MECHANICALFEE
A IR HANDLING UNIT(OVER 10,001 CFM I CONSTRUCPION TAX
wee pplinn ¢oar -o
Daur EXHAUST HOOD(WTUCT HOUSING MTPGATIDN FEE
HAZARDOUS MATERIALS DISCLOSURE ..
Will the applicant or future budding ocwpant ourcoxhandle hwamou,material HEATING UND'(TO I C0,0M1 BTU)
as donned by the CuNvlmo Monied n Code.Cllnpler 9.12,a Ile HcaOh And Seely j
Cade.Salim 25533(v)? HEATING UNIT(OVER I00.00r,BTLD
Yea ❑Na VEN-NIATION FAN(SING LH RESIO I - PAID
Dole Re¢ipp
Will Ibc applicant or tutu,building oc2upenl saw¢Inipmcm or mvrccr which Dole
0HP OR IW'Nx)BTU)
•mit havardoun av arltaminentl es statin 1 by rhe HaY Arta Air Quality Mvwpmxnt
Diuricl'
Dyes C3 No BOILER-COMP(UVEB 100.000BTU) TOTAL:TAL:
I hive aaJ As,hmurdnus A,,ne alit reyoiremenlz under CTupee 6.95 a the Cali AIR CONDITIONER I ISSUANCE DATE
L�f
Health&Safety Code,Sertinm 25505.'3533 Arta H53O.1 An&,,u d!Abut if the NEW RESIDENTIAL MECH,. SQ.FT
ag tors eM momently have a tenant,not i1 i,my a.sp+minkry to notify the occupenl
nagvAArnenlewhich muule metpoorm i.zmneo(v Ceo&iicmeof ftire,s ."Am"arleedegenl Dntc TOTAL: ISSUED BV
OFFICE