29231 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUNIBINC.-MECHANICAL 29231
.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBSII'I'1'AL DATE
OWNER'S NAME: PHONE - CO ACTORS NAME LIC NO
OM
:
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u / g/ Ola/ -2 3 3
N`C CONTROL#
L CHITECDFAGINEER: LIC NO: ADDRESS: ❑
0 Mo
CONTACT. PHONE BUILDING PERMIT INFO
❑ Consultant Fixes Pald by Applicant(Initial) BLIXIHLECT PLUMB MECII
4 SDur S- 60 M ❑ ❑ ❑
LICENSED CONTRA ORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hcrchy affien tum I an Eeenad a,under pmvi,iaof Crpt
eer 9 feommeacing JOB DESCRIPTION
CZO with Section 70)(tar Dirislon 3 ufthe Bronav end lhrknlune Cu4,mxl no,ov,ave is PERMIT ISSUANCE RESIDENTIAL
W— in full face end eR
aUt Lie Cl' n`L9 .Lic.g •6Z33ES9 ❑SFDWL ❑KITCHEN REMODEL
F7W Ihm 9D i, Ctntrvctor I fall Ala SOue.� APPLIANCES-RESIDhiAL ❑ADDITION ❑PLUMBING RE-PIPE
FyZ lunJeewuldm ai ARshall be u.NS DECLARATION
PANELS ❑MULTIUNIT ❑STRUCMODIFTURAL
,OZ=� YP� W ON
UPTO?(UAMPS ❑I (NTERIOR CHIMNEY RIiPA1R
Liccnad Pnilc.ai,.l 101-1000AMPS MPROVEMENT
a OWNER-BUILDER DECLARATION OVER IOOOAMPS ❑BATH REMOUEUREPAIR [I DEMOLITION
N W'Q 1 hereby anon that I tun exempt form the Contrxmr's license L;w for the
O d O following rea.wn.(Section,7031 s,9usibaax and Pnrfcuians Cock:An t OTHER
Any city a cont Y SIGNS ELECTRICAL
F LLO� which rtyuim x permit to cun4rvc4 alter,imptovc,demolish,a repair eery sWcture
-2] priabie,iasttantt.eLo requires Jc epplicem fasuch permit mlikaugoM vaknrnt
to SPECIAL CIRC RTNISC.
that he is licensed pursuant-the ptovidrau of the Contractora License La.(ChaNer9
aJ'p0 fcnmmereir,.n anion 7f0fitDiviairm 3ofiha Bt ireev and Pmfcuiune Cak)a TEMP.METER OR WLE INST. COMMERCIAL_
6 e IY that ha is exempt dacrefnm and the basis for Ne alkgd exempiion.Any violetim of
qx LL ❑NEW BLDG/ADDD70N ❑DEMOLITION
Station 7031 S by tiny applicant for a permit whi"Oe-applicvu to a civil pwalty of POWIO DEVICES
W—vr ❑TENANT ❑FOODSERVICE
} twitnxac Nan Eve nunJrd Julian(SAllp,
� a0 Q I,unwaT of the pnyenP ar ntY cmPloycn with wo0a'na their mk amtprnwtion, SWIMMING POOL ELECIli1C IMPROVfA1Fb1
will Pr the work,and the he Conere era intended a Law
duefa mk(See..so Busircu ❑OTHER
L3 prat Profeviora Cad:The Contractors License Lew dos no,apply to lf owns of VIIEfS-SWNCHPS-PIXNRFS
hpropertyi.own wM Wilds a improves ther da i nd who disnut wen wr to ded!or or thnmgh
hid own ouse ere<a,WHO, Nat wch i ssam is ,art on intended!a offered for NE IDENTIAL ELECfR SQ FT.
sokeIf,hwern,ll the have dBaen of
iswM wiNinarild or iemrptetherPr- SQ.FT FLOOR AREA, vSO.FT.
Cin-hiller will have Beix burden of paving that he did out Wild or improve fn put-
' pns,afsalc.),
s ❑I,seowbar a the property,am rxclu ively ecotneting with licemd contnnen to TOTAL
caunuct Be Prcieci(Sex.76t4,Business and Profesimta Code:)The Contnaers B-
rixLaw doernolopply to ari of prper,who huilBor impne-Oc-on.and QI'Y. PLO GPE IT FEE
who cmnuacis for such pmjecu with a convutons)licensal Pursuant to Ne
LiComncturd
ccmc Law. PERMIT ISS
IameaemptonderSec. ,B&PCfanhisra.wn
Owner Uk ALTER-DEAL V - ATER(EA) VALUATIONN�
WORKER'S COMPENSATION DECT.ARATION BACK FLOW PROTECT. ;V f 3 /,D (0 "
I notchy affirm ualn pcmlry of penury oneof the following declnrmion.c l-
ISaveandwillmeenWnaCenifiateofConienuo pelf-irtmue fa Worker'a Camper. DRAINS-FLOOR,RODE AREA,CONE.
/ wind,u president fee by Semon 37W of No Leber Code,for Oe prdanatee of do STORIES TYPE CONSTRUCTION
wart fee which Nix permit n cared. F XDJRFS-PER TRAP
Fl I lave wJ will Imrinhn Worker's Compcescum hcwrnbac as natured by Seaton
37W ofthe lsbx Code,for the perfomwes,ofthc woo for which thiopermit u issuW. GAS-PA.SYSTEM-1 INC.4 OUTLET
My Wns-1, -}C)pr��i�° ° ( and Policy ou �j qi. OCC GROUP wPN
r Carries, J�Saf / e,1DdearrrnPclky No
�•+J 779 CAS-IiA.SYSTCM-0VER4(EA) -
CERTIIICATE EXEMPTIONOF EXEMHON FROM WORKERS
'
COMPENSATION INSURANCE GREASMNDU,STRL WASTE]INTERCEPTOR([hid.bad era he conpinM if Ne permit is fa one hundred"[.(SI W) BUILDING DIVISION FEESarlm.J GREAS�,TRAI' PLANCHECK FEE .
1 certify that in this,perif ri of lc work fa which Nis permitis isaad.I shall
era employ any pervm ion any mm�rcr so n to becarc subject to Ne Waken'CoolpeEE
n- SE1S'ER-SANITARY-STORM PA.200 FT. ENERGY P
O z aerial Lsw'a of CatJmnim.Core WATER I[EATER WIVENGFIFEGTR
Z O Applicant GRADING LLE
fry NOTICE TO APPLICANT:IL eftn nuking Box Cendr.te of Exemption,you sbaeld WATER SYSTEM/IREATING
a
become ecoe subject to the worker's Cnmperwnon Pruvisium IA
or Use bor CaSOILS FTLde.You mum .
a � .fonhwith conTly with wch provi ors or this prnnd shall he deemed revoked. WATER SFAVICE
Oz CONSItUC7DONLEbIDINGAGENCY NEWRESIDENTIALPI.MB. SQ.FT PAID
U I hereby eBirm Nat therein e<-nmreation lendingagoncy fur Uroperfurmanceof Date Reaipl0
[A Sts work for which this Permit is iaamd(See.3097.Ci,C.)
O U Leder,Name TOTAL:
fenders A k reea TOTAL:
G1 certify Our 1 hove real this epPlicutirn and cafe Nw the above inlhmation is BUILDING FEF.
y axrect.I agrte-comply with all airy and aunty oNirubau wJ awe Dwa mlvUngm QTY. MECHANICAL PERMIT FEE
U Z budding camtrvctirn.and hereby tiuthance repescvwivcs of this city to enter upon the SEISMIC FEF.
soave-mcntiasd pmpcny for inspection pork,a. PF,RMI'I'ISSUANC17
(We)agree m save,mdenmify ed keep hnnBeku City of Cuptmim egeini ELECTRIC 117E
Iinbibbea.JWgrrcms,m sad expense which may In tiny wy endue agalrut said City -
in edits,Brom,of this permit. ALTERORADDTOMECH. PLUMBING FEE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TIb to,"CFM) MECHANICAL FEE
SOURCE REGULATIONS.
MR HANDLING UNIT(OVER 10.0MCFM) CONSTRUCTION TAX
Signature ofAppliemVCnmmeta Uwe EXHAUSTHOOD(VI)LIC7 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the irpplicent or for=budding oacupaa Nae or Badle bertinlaua mw.edal HEATING UNIT 90 IOf1,Of1(I BTU) m
ad defrad!by the Cupen'mo Municipal Cnde,Ceapler,9.12, ad,L-Health and Safety /
Code.Sttvrm 25532(.0 HEATING UNIT(OVER 101,000 BTU)
/ [3Ye, FIN. VINHOLATION FAN(SINGLE RFS I D) PAID
I/ Unix vipl M
Will Situ oplicomatutu-handing reap.- AeyuiirQ 1kJmicawhich BOILER-COMP(3HP OR 1W.OW BTU)
mit harnNous av...a.',ar refined!by Nix Hay
A.Air Quality Mwugmsnt TOTAL:
District, BOILER-COMP(OVER IM,001 RTU)
❑Yes ❑No
25
I havered the l ardor nwcials requirearena udn Cluxi&95 d the Cali- AIR CONDITIONER ISSUM'CE DATE
Tarda Health&Safny Cale,Savors 25505 25533 and 2551[.1 u dersord Nat if Its NEW RESIDENTIAL MECH. SQ.IT.
tilling titer aacwenOy tJeve nenLl Lv my rerpxLsibilitym notify he avvpw
myitemenn which rl l_ mins rda Calf o[ /.�/-a
meed agc 'lyre TOTAL ISSUED BY -
OFFICE