30534 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL s PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 0 5
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ll Qy ` ^ je�VII e-0 ,1^ _ SANITARY NO. gR[_ICATION SUSUBMITTAL DATE
OWNER'S NAME: (O (PHONE: - CONfRACIDRS NAM , LIC NO: M
C --CONTROLx
ARCHGECT/ENGINEER: - LIC NO: ADDRESS: /1
3 ❑
9,
CONTACT V PHONE: - BUILDING PERMIT INFO
❑ ColLvltant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
01 ❑ o
LICENSED CONTRACTORS DECLARATIONELECTRIC PERMIT FEE
1 Iterrby.fEmt mat I am licensed under provision,of Cramer 9(commercing Qom' JOB DESCRIPTION
.O"0Z with Sstion JBW)of Divisiasn3ofthc Btuittcssmd Rofemions Coq myl'ccnais RFSIDFNTTAI�
FOO in full force and cRcn PERMIT ISSUANCE
�m F;^ _ ❑SPDWL ❑KITCHEN REMODEL
UU Licrnsc ClOsw Lic.A gppL1ANCES-RESIDENTIAL ❑ADDITION ,(]PLUMBING RE-PIPE
.F7W Dam Lontmcm.
ypy ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
ZO 7,a- I understand my piens shall be used ax public raaJs PANES MODIFICATION
OZr--O UPTO2 AMPS ❑INTERIOR fyCHIMNEY REPAIR .
(Jeemsed Ptuf.moal - 201-I W)AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
L C1 hereby affirm Jut 1 am exempt foto the Contractor's 1"Ianse law for the OVER IM)AMP5 A El RATE REMODEUREPP PAIR DE�)�4OLFU�ON
Carl
x 3 L U following deacon.(Seamon]031,5,Business road Pruru,lm,Code:Any city or county SIGNS ELECTRIC [I OTHER ,� S'NLWQeLS -44 42A
u1 - which regains a permit to enmWrveL alter,impmva demolish,ur r ver any oracrum It
0 prior to its i,.,,,also requires the.pylicam(asoeh pernImNcosi6nMetetentent I SPECIAL CIRCU
That he is historical moratact to the royiours ofthe Connaetura Liam,Law(CouPter9
X00 (commencing with Secann7")of Division 3of to Busin—osi Po4d,,cros Code)nr TEMP.M O L INST. COMMERCIAL: ^
IY p)m C that be Ts exemp tM1em[mm and tM Iasis[or Jin ell,gedacmgion.Any violation of [INEW BLDG/ADDITION [IDEMOLITION
lltiy Section 00315 by any applicant forapemtit,.bjens the.PPlicam to it civil pcwhy of POWER DEVICES EITENANT ❑FOOD SERVICE
FZqyY not nae men five hundred doll.($R0).
❑ IMPROVEMENT
F� I.as owner of the Moen,or my employees k romp
with wages as their sonsndao, SWIMMING POOL ELECTRIC ,
_ wd l do the work,std the stmaum is not menh`d or offcml for sale Sea.106M,Business C1 OTHER
1304, and Professions Cute:The Contractor',Liam.•Law muss nm.pply to un owner of OUTLETS-SWITCHES-FIXTURES f.f
pr.,oy who bmMa occo posex ff-cm:and who by tach work himself or mmugb -
his own employees,pnovidW That smft improvements arc nut inierded m off fa NEW RESIDENTIAL ELECIR SO ET.
sale,If,however,the bui lding or i mpmvement is sold within orcywr of compldion,the SyQ,FT.FLOOR AREA 5/SO.FT
ILII
er-builder will have me burden of proving thin he did tot build or Improve far per- f A i D
post ase sae.). -
1,a,owner of the properly,am Business
rely emnacdng win,- contradoI m TOTAL: -
wse Lo me es jus (Sm.o am owner
and 14 wtio,hai Cole:)Tlx Contrectax ts- �T
cove law does nus opPly to am owner arpmpeny who nnildx or imPmvex lhC2ott.and QTY. PLU LING PERMIT FEE 10f]C
wM10 wnUansfa such pmjMswith acontmnod(s)I'tccnscd purwwt mtM COnwctMs w7�7V ^
Loan.Law. FI?RMIT CC �rYr
I am exemp order Sm. -,B&P C for this reason V}r,
(rUf Ll'i J '
Owner Dale
ALTER- VWATER(EA) VALUATION
'
WORKER'S COMPENSATION DECLARATION BACK PRO CE -6 1�
I berrby ellirm oohs penalty u[pepury oto o(the Cdlowing dsWetion dd
'. •DDR R,ROOE Al tNN�D?!� STORIES TYPECONSTRUCIION
,.Jon:as provided fa by Station 3900 or the labor Cede.for sererk firt which This permit is issued FIXTUR
L] 1I have std will maim an Workers Oompenwtion[mmsecre,a,requited by SectionJ900,Tthe LsAaCode,fcrmepuformatwv mthe work for which this permit i,issued. GAS-EA.SY O OCC.GROUP APN
MyWmk,,c',�p urnia cg carrier and Policy number am: ,
Cenicr: h'd II.� '�
policy So,: 1 �V—a� >—qL GAS_EA.SYSTEM- (EA) - ..
CERI'IF1CATE OFCOMPE COMPENSATION INSURANCE
FROM WORKERS' // GREASMND' RL TE INTERCEPTOR n
COMPENSATIONINSURANCE 9 BUILDING DIVISION FEES
(Thissection Iced not hecramplelelifirs,pemtit s for one hundred tloller,(SI00) GREASETRAP-
orkasJ PLANCHECK FEE
1 ccnlfy Ifdt in the peimorm tee of the work for wh'icid this pemtit is issue(,l shall
not employ any person in anyn,mtner so Issas become,object to sere Worker,Cosmic- SEWER-SANITARY-S1T)RM EA.211(1 Ff ENERGY FEE
zZ action Laws of Cnlrfumia.Data WATER HEATER WNEN IELECIR
yO Applic.m GRADING FEE
h NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTE CREATING -
F Iewme w.h ict In the Work&,Gtmpenstaion pm,Wcvx of Ila Ldbm Gde;yse most SOILS FEE
Wforthwith mmpy win Hoch provision,or this permit shell he deemed rewtkW. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.fT PAID
V O Ihereby aff that there is a comwetion adding agency for the performance of Date - Rcceipx
C4 n- m
r e work for whichmi
mita pert is issued(Sea.3099,Civ.C.) -
p U Lender's Name TOTAL:
s W Lender's Address TOTAL:
I certify that 1 have need this application said state that the aMve Infer ion is BUILDING FEE
U t1) coaxer l agree to comply with all city ane county admared and date laws minting m QTY.. MECHANICAL PERMIT FEE
V building commotion,and hereby acamodmmPrucornivexofmis toy 1. upas the SEISMICFF,E
above-noxiomnxd property per inxpecdon purp,eio. PERMIT ISSUANCE
(We).,ore w wvc,indemnify sod keep barmlea the City of Cupeniint.gmw ELECTRIC FEE '
liabilitiea,jmlgtnettu,mdwaN expenas which may in any way aceme egalnexam City ALTER OR ADD TO MECH
om d,roce of the grunting of this promil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CFM
SOURCE REGULATIONS, MECHANICALFEE
AIR HANDLING U fT(0 ,fgk9 CFM ' CONSTRUCTION TAX
Signamm oTAppliesnVCoodd for .Dine EXHAUST HOOD( U
' HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FTS
Will the.,licant orfar.hollhngazupanrsuxr or handle bax.rdou,material HEATING UNIT' B' ) ^
u defined by the Cupertino Municipal Calc.Chapter 9.12,and the Health and Safety
Cotic,'Scadmn 25532(.)? r - HEATING UNIT R I
❑Yu RtNo VEND LION FAN(SINGLE RFSID) r PAID
Will the appliuwm or future buildin t use t or devices which Date Raeip x
g by men equipmOs BOILER-COMP QHP OR 1(10,100 BTU),
emit i twNous ar emntmmnentc a,defines by me Boy Ams Air Qudiy Muwgememt'
District? I
TOTAL' -
E]Ya, .tgNo BOILER-LUMP(OVER 100.000 BTU)
1 had J¢Force rated hasaMaa mnerids ra,modnentx ander Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Food.Healm&Safety Castle,Seniors 25505,25533 amt 255M1 L uMemo d that if the NEW RESIDENTIAL MUCH. SQ.FT.
•• building does car ammody Iowa tenant that it is my raxprmsibilitym ratify the cetsim
ofmc reyuimmen0 tabs mud be pct priono' eof.Crntfirstc Oeapsney
. .
a
ITvncraauthori Ern I>te TOTAL ISSUED BY.
n. OFFICE