28858 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
-191,011
ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No 28858'8 8 5 8''
B II,DINGDIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L]V{ lXJ VX
BUILDING PROJECT IDENTIFICATION
UILDINGADDRESS: SANITARYNO. ::JAPPLCAT[ONSUBMEEPALDATI
WNER'S NAME: O Q -PHONE: CU ACIOR'S NAME: LIC NO
"G S NOT COMROLN
. A RJ CHIFICI/ENGINEER: LIC NO: AUI FSS: ❑ '
O
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Feet Paid by Applicant(INtlal) R ELECT MUMB MECH .
❑ El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I leRhm m
y amlal I out bccrosantleriem
l antler provm of Chapter 9(commencing NJOB DESCRIPTION
, 00 wish SaOon]000)af Divitim3NUe Busirtaxatd Pmfanidn Code.vd myliccnsc is RFSIDENTTAL-
�� full Tome aal nlfst. PERMIT ISSUANCE
%WE�Uj UceereCW I.ic.N' ❑SFOw'I. [ KITCHEN RFh10D11,
Dme Gmvale APPLIANCES-RESIDENTIAL 'DADDTTION ❑PLUMBING RE-PIPF:
ARCHITECTS U[CIARATION
F.7w PANELS ❑MULTI-UNIT ❑STRUCNRAL
Z O Z 1 undmxlmd my pWns shall he uW as public rtcddn - MODIFICATION,
OZ-Q UPTO21)OAMPS ❑INTERIOR - IMNEY REPAIR
raot: 1 I.icerucd Profcuiunul Ztll-IIM10gMP5 - IMPROVEMENT
C Y�-1 OWNER-BUILDER DECLARATION
I herchy Nm orthat 1 an,exempt from the Commatorn Licanne Law for me OVER I"AMPS ❑BATH REMOOEUREPAIR []DEMOLITION
X itX a t M UF.. following..(Senior]031.5.B aim,and Pmfdiom Cock:Any cry mrnunry SIGNS ELECTRICAL [I OTHER
W 3 LL ya whim myoira a permit to conrlrut'I,alter.implova,damml sh,or re(nir any strvcturt
E'�OJ INiorto m,iauaanac.alw«quim the vpplitmi for such pemtit to file a signal uetemcot SPECIALCIRCUIT/MI,SC.
Thai ha is Itccn.ad pursuant to tM pnrvitior—fdc Cdnracur'n Licenu law Cower
W xOO (ealnlrcrcing with Seeban711W)mfmai,aw3d rIba Husinavn and Profeuiom Code)or TEMP.METER ORPOLF-INST COMMERCIAL:
tithat eaereom a
he is nnp thfrnd the hair fort allegal cluaraon,Any violation of- [I NEW BLDG/ADDITION DEMOLITION
a
Sban T031.5 by any appBcantfo a permit wbjeds the applicenl n•civil pcnilly of POWER DEVICES
u+�In .❑TENANT ❑FOODSERVICE
nn more than five horded clury,or a y con'.
pLnmaxraf the themOtY,omycmpbyaswithfi afar the"v sale e0m1.Bu.tion, SWIMMING POOL ELECTRIC OTHER�O
,ill dothe wnh,ade,ThaC reirnot imawlal or of close, nale(Star lym,an Bmirec. ❑GTIRER
end Puy who b Code The Coca ilmo 's 1-icertnc Law to does tw.,slym,lf owns M OIITLEIS-SWRCHPS-FIXTURES
an'3_ propertywho build.,faitical to therm,ualwha Jiaouchwnrkhi,l or meattlfh
hu If. employm,provided tlur such improvements art a.on inteldc ca,tcom,for NEW RESIDENTIAL EZ.F.CI'R SQ ET.
sale If.M1uwevn,IMboildingnrimprnva aold wiihinom Ymorinomps,ft, Itr SQ.FT.FLOORARU 'SrsQ.FT. .
owlts-.11a.f will love the harden of rvovin8 that he dal rid build m impmve fm ptr-
❑s a ower of th POP 7(J4 son exclusively canuacoaaa halm Name cmnramms to TOTAL:
ynswn me psujal(.Sec.]IN4,Buninev nId Ih,fevrione Cocle:l The Conwctm'x Li
er -
ateLawdgsp
oes am ly to an owner of taoseet who buikks o impmvct Jermr.and. QTY. PLUMBING PERMIT FEE
wM cumrana for loch projalr wim o cmow,an')liccnsal pursuvu,,the ConvanNa
Lice.law. PERMIT ISSUANCE
(] I am exetnptnoticenotice, fur r Sen. ,B&P C this rwmn ,
Owner Dane ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herchy afro udkr Pendry orperjory erne of are following dslwatimru:
SZ3Etivr and wBl malouineCmifeak ofCdvernloaclf-imure fur Worker's Colyer- DRAINS-FLOOR,ROOFARU,COND.
mtlou,u pnrvldcd for by Section 3]10 of me Labor Cuda,For the perfonwa nof the STORIES TYPE CONSTRUCTION
hark fo which theamt
pai,it tamest. - FIXTURES-PER TRAP '
❑ 1 have and will mainwin Work,',Comlersm on Insurance an mt,cmd by Sakur
3]00o(the LJNnf CWe,for the,parrs ofthc wwk for whi ti flat pemut is usucd. GAS-U.SYSTEM-I INC.O OUTLETS
OCC.GROUP APN
My Waher't Cumpenavinn Insurance canicrand Policy nor
umber e: '
Gorier: Paltry No.: GAS-EA.SYSTEM-OVER 4(U)
CERTIFICATE OF B%EMITION FROM WORK]RS
•COMPENSATION INSURANCE GREA MNDUSTRL WASTE IN IMCEPTDR.
fgas¢nim real erg he cnmplu¢d irthc pmruil is fmsxm dmldollors( 10) BUILDING DIVISION H3FS
mom) GREASETRAP PLANCHECK FEE
I certify Jul in the pmfmsnarcenflm vvs*fur which it permit in i.auM.IsM SEWER-SANITARY-STORM EA.200 FT
Out employ anv p n in any manner to as to 4cwr,w t Io lite Work.Comm- ENERGY FEE,
'
O.z sman Law of California.Date WATER HEATER W/VFNT/ELrm
z O Applicant GRADING FEE
y NOTICE TO APPLICANT If,eller mak' a chin Ceni Ecmc of Excnlptinn,you should µsq STSTEM/TNEATING -
became whjat to Jsc Woher1 Co tion provisios'ssf the Cadc.You mutt SOILS FLE
fnMwiM comply wim such pnn'ieim In this parmit ehall Irene ,,-,,y gTFR SER
D z CONSTRU
If
1 NDIN A W FNf1A1.PCMB. SQ.FT. PAID
V O Iherel,yrufirinthwthetai cat 11 tor f• s< Came Raccifn0
the work fm whtchlhis pemm,is uuN 3s .0
O
TOTA
IenJera theme _ L:
WIrmkr'x Ac mu, TOTAL
y 1 certify Jou 1 have r J this alglintis d oat Out Je above inf BUILDING FEE
V) corrin.1 ears m comply w all city nod county nrdimncc,and sum laws re OR m CITY. MECHANICAL PERMIT FEE
U z building cotunetion.and ymdsariurepretenwivesofthucitytoe upon the SEISMIC FEE
edrve-mcommum pnrpcny In insptstiun purposes. PERMIT ISSUANCE
(We)agrs to ave.it ramify ad keep hunmdatk C' f Car armo agemu ELECTRIC FEE
liabih,ica,judgmcnu,;-bend sawhicIt lwyina yacmn nRniml hate Cay
ALTER OR AD TO MECH. PLUMBING FEF,
m ed..egaea<nrthe granung of
L -
APPLI A`-T UNDERSTANDS-D A 11 LYW LL OyP01 AIR HANDLING UNIT TO 10,"CFM) MECHANICAL FEE
SOUR E :GUTATIONS. `O
R HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
A g r
Sigam n p,Hean rearm Uatc IiXlIAUST HOOD(W/DUCD HOUSING MITIGATION FEES
RDOUS M HATS DISCLOSURE
W11 thea amtorfumre build acupant xlde or haMlc hareNnustwerid EDITING UNIT(TO IOO,IpU BTU)
a,def nee by the Cupertino Mmiti ai Code.Chapter 9.12.and the Health and Safety OCT 10
Coda Semon 2553244 !BATING UNIT(OVER 110,000 BIT)
E3 Yea [3 No i'ND Tn -
VENTILATION PAN(SINGLE'RLSID) _ �VURf{eiN
WJI Itr epp onta a future a Wilding by the B utc equipment o Nim whim �lfvU
t hvnNout air contaminants on defied by the Bay Area Air Quality Management BOILER (3EIP OR I W,Ig10 BTI)
I�cmi
1>sWTOTAL:
n'
❑No BOILIiR-COMP(OVER If0,IXX)BTU)
❑Vcs
I have read the hunnlwln matelids requirtnlrnu odder Chapter 6s95 of the Cal i- AIR CONDITIONER
..ISSUANCE b7fFE
famie Healm&Safely Cale.Seaiou 21503,]5533 aryl]SSIJ.I tmdnverd that if the NEW RESIDENTIAL MECH. SQ.PT.
huiMling data not currently love a lemon,that it ix my resrynsiMlity In notify are,occupant
bf me,rtsryacnrnb which mut be me prig w kwaec of a Cenifime afOmlHvey.
Owns err mthoricatt wlu Date ,TOTAL: ISSUED BY:
OFFICE