30722 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30722 O 7 2 L
n
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J C
BUILDING PROJECT IDEYIIFI
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l 6 T & ( 535-3 3 ri,-)A646
OWNER'S NAME PHONE: CONfRAC1OR'S NAME
& -TOaE p Ae5i sm� CONTROL«
1RCHITEC'UHNGINEP.R: LIC NO: AIjDRE&S:
s7.5 �. �� c iUo _ .
CONTACT: PHONE BUILDING PERMIT INFO
.'
9O0 (] Consultant Fm Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ Elharchy afrmt mw m..ran.a al.kr pmm.hm,of ctmptn v matrm,emms JOB DESCRIPTION
�OZ with Sctim]B00)MUivisim Jofd"BusircuuulPmfcuion.CMc vW my license i. RESIDENTIAL:
O PERMIT ISSUANCE
F hll Grrce ud eRat.
F� License Cloxv IJc.N ❑SFDWL E]KITCHEN REMODEL
to Z Duc Co for APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
p.Ow ARCHITECT"DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z I ordcnrmd my,planr ehull be ,,.d to blic"cord. I'AN131 ti
Z O tt�� pu MODIFICATION
OZ—p UPTOMAMPS
F I: Llceroed Prolrvimd [IINTERIOR ❑CHIMNEY REPAIR
VIII-IIMMIAMPS IMPROVEMENT
gyX OWNER-BUILDER DECLARATION GM Li
czemp fOVER If100AMPS ❑BATH RFI.1(-7pGl/1;F.p1IR El DEMOLITION
of eRrm chatchat1 em orm the Cmdares cense I«w d" 1��
Ka6�6 I hereby.0 following rraeoo.(Scarion]0313,Bu.im.w and Professions Gdc:Any city or cmunty SIGNS ELECTRICAL ❑OTHER
LLLLII u. which rtquire v permit to cm.vuc4 eller,Improve,demolish.or r,.,my,.t.
F'LLO rtgv'un pp pclmil to flee sigrledswctrmt
pri«wiu iesuana.alu thea licun for w SPECIAL CIRCUIT/MISC.
—p0 p. ( he islimg Saar uothcpromlistofthe Cammewrn License Iasis Co tm9
(rommcrcin"with Ssim]UW)of Division Jofine Bwimw ord Pmfuskns Ctdc)m TEMP.METER OR POLE INST. COMMERCIAL
a y o C Hw he i,exemp Blncfrxn and dr buil for the Jlcgcd czemptioo.Any—I lto"n of ❑NEW BLIXi/ADDfT[ON ❑DEMOLITION
LLXI �+y Section 7031.5 by any epplica t for a permit suhjcets the eppllr nl to a civil pennlly of PD P,R VICLS EITENANT ❑FOOD SERVICE
n.mr"men Dvc hmxl"J dollar,(SSW).
F�aO ❑I,uowmr of the pmpcny.«my cmploym with wgnullcirsdecompcm,vim. SWIpm LELEcrRIC IMPROVEMENT
will do the work,and thuslrunum is nm imendcd«offt s]for salc(,Sm.71(m Busilrss BOTHER
and Pmf nisiom Code:Th,Comr.nar.Liretl.c Lew does twc elgly to m owner of O FIXTURES
piny who hilts,or improve dsc"tm,and who doe,such work him,elr or mruugh
his own employXv,pnwWad that such impnrvmmntz nm not intended on o acid for NEW RE WHA E SQ Ff.
sok.If,M1axever.th huildine«impovcmcm is soul within om Ycanofr«nPMim.de F 1.00AMRFA LSQ.ff.
-baildn will h.vr me W rdcn of proving That k did ml Wild or imlrtnvc f«por- ff VV
� M �r, DEC
L a owner M the ac.7( em ezcll ard!con.sims,with Bernd ant .nm to TOTAL: 61996
cmwuct me prol«t(Sr,.]Oat.Husitr.'as erd ProfatMvu CdeU The Ctntrenors t;-
anu law does nM apply'.anowmr of pmpcny x'ho Wilds or improves meoron,ami QTY, PLUM N�ERMIT FEE
who cmwca Ban h Pmjcu with...tract icrn i paboaci In me C..Ias In
�
�La. PERMITmister Sec. ,B&PCrm mirrwwn PERMIT ISSUANCE UI'.'L UrG n 111 VU
Oxmcr GilaALTER-DRAIN&VFM-WATER(EA) VALUATION
WORKER:S COMPIIISATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby alf under penalty of pr,ors,of me following hclmuiau:
I lave and will maintain a Cenifw-e¢of Con.mnt to ulf-imutc(w Worker's Cori DRAINS-Fl,OOR,BOOP.AREA,GOND, STORIES TYPE CONSTRUCTION
sation,w provided f«by Section 3]W of me Lai C«k,f«me parmarb a of de
work for.Eich this Pmnic a is•ic FIXTURES-PER TRAP
JU]Woflhc LaWs Cods. s
forma perfomurc< rwJ
dscM f«which thspsrouiis usW. GAS-E..SY,SIEM-1 INCA OUTLETS
MVW«kda Com yt. I yq�ec and Polity numb _ OCC.GROUP qPN
cr: � HT6 LCM Policy No:
l7 wl 17 GAS-EA.SYSITAMOVHR 4(EA) 11
CERTIFICATE OF EXEIrIPINON PROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
(This union and not M complmts if the Prnnit is forme hunmd mdlma(SIBP) BUILDING DIVISION Fl?FS
«lc F) GREASETRAI'
1«Wily 11ur in the ary conterarc Mmc wvek for which this 1Fmtit is issud,b,bl ENERGY FEE FEE
SEWLR-SANITARY-STORM HA 200 FT
nut empty any pawn in any manner a nt w M1nvxm xubjo'I m tlm workers'Gnnpcn- ENERGY FEE
Z xatim Laos of CJifomia.Date
Z2A licent WATER HEATER WNENf/ELECIR
w cRADm'a Etc
y
NOTICE TOAPPLICANT:If.Com Yokingort.Cisioncamof I Labor Coda,
sMwW WATER SYSTFSVIAEATING
WF" become.ubmc to the W«kch Coors mar don arnvisi«u of th Tabor Cade,. tmv SOILS FEE
� foMwdm comply with with pntvisiommmis pnmic shell he deemed revolts. WATER SERVICE �
a0
OZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIDSB. SQ.PI. PAID
U 0 l hareby aRrm chat dem is a mn.nuXtion lending agency for me performnme of Dem Rcccipl N.
� .-� thewords for whlchthis Pc man sl vanl(,Src 3110,Civ.C.)
0 U Linder•N. TOTAL
I<ndcr'I Addmu
a 1 cmify thor I have read that epPl'wvdm std.,,,^dlu me vbove infmmuim is BUILDING FEE
IZ1 a.,.I.grcem comply with.11 city.d county Cohmaii cold Li Los a"Imm". QTY. MECHANICAL PERMIT FEE
U Wildin"conutuclion,md he"by aullgrim rePmsenlvivcs Mlhiscity en cmerttplm the SEISMIC FEE
solve-mentio«il popery for inspection purpose.
ON,)ag"e to sevc idsmtdfy.nd ketp lu .dtc City of Cupcnim.geiter 1 PERMIT ISSUANCE ELECTRIC FEE
Iiabdllie,jadgmcnk,oats and caper.which miry in try way«arae against wid City
In.vs,acmx of me"Taming of oris permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AN WILL C PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO l0,(Mp CFM)
SOURCE, ]ONS.- MECHANICALFRE
01 AIR HANDLP:GUNIT(OVER I0.0XICEIB CONSTRUCTION TAX
gigw 'I'S MATERIALS DISCLOSURE
Pro, EXHAUST HOOD WTcUM HOUSING MITIGATION FEE
FW]ARTH)
Wic tbeapp
Ulk tmfulu WiMing«.vpaotarorearhendleheasrdousmvtenal HATING UNIT(TO I W."BTU)
ur dby the Gupcnlnn Municipal Gds.Oiopa 9.12,std the Halm vd Sarny
Cods.
Senior 25532fa)^ HEATING UNIT(OVER 100.000 BTU)
❑Y E]No
VENTILATION FAN(SINGLE RFSIDI PAID
Will dr.pplicara«fads.Wnots]by IM m y Ara.i irtlenct il,M tt.which Due Rndp N
bn,".Avs air cmtmniMnls n,tkfitrd by the Bey Arc.Air purity Memgcnent BOILER-COMP 17HP OR 100,000 BTU)
DislrinP TOTAL:
EJ BOILER-COMP(OVER 10i BTU)
' ❑Yea
I lova rets the huardmu ntarcriel. Chaises AIR CONDITIONERforriISSUANCE DATE
rt.l 533 an urdtt 6.95 of do Cal,
Hasidim&Slurry Cdr Ss Tar 25505,25533 vrW�5Yf.1 mhrsud Bort Jdr NUN'RESIDENTIAL MECH. SQ.Ff.
hiltling docsnoreurmalyhave t,mart,chat it isic rs af.Comm�mify IM1etaaasy. t
i Mmc rqui"m[nD whicM1 mor is mal to uwurcc of.Cttdrrntc ofOsup.ny.
Owmror nm osimd egtnt Dote TOTAI= ISSUED BY:
OFFICE