29781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
IV29781.
BUILDING DIVISION APPLICATIOWERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
20(09 Mr-� 12
A� oAn TU6�67� 9
OWNER'S NAME: PHONE CONTRACTOR'S NAME LIC NO'. ^ �^I
Fo26E �6H( 4x8 73$- N/ CONIROL.
ARCHTfECTTNGINFBR: LICNO: ADDRESS: El
CONTACT:' PHONE: BUILDING PERMIT INFO
\� M SI � 1 'a/I�'�__ ❑ Consultant Fcev Paid by Applicant(Initial) BLDG E11Cf PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I fi rehy amrm Ih tt 1 am IiauM ander poomorn of a'o,r 9(eammeremg JOB DESCRIPTION.
M�Z with SaVtion 70W)of Division 3 of Ne Btoircs and Pmfessions C,.k.mM my license i. RESIDENTIAL
f400 PERMIT ISSUANCE 0
full fmoc cord clTxt' ❑SEUWL ❑KITCHEN REMODEL
FFQUj Lkcnx Cle.0 LkR APPLIANCES.RESIDENTIAL ❑ADDITION ❑PLUMBING BE PIPE
snQa D.te Cdutxmr -
ARCHITECT'SDECLARATION ❑MUUH-UNIT ❑STRUCTURAL.
F n Z -1 uMeraend my pin•shill be used us Public rtmrds PANELS MODIFICATION
OZ— UP TO 200 AMPS
F�L"'O License Pmfcui,mal ❑INTERIOR El CHIMNEY REPAIR
CC 201-10WAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IM()AMN ❑BATH REMODEURFPAIR ❑DEMOLITION
OC Q 1 bcmhy uEkct orr 1 an cBust fmm the f.ioncmr'n t:A nuc U.for Ne
xLO�O V following¢man Ikaiao 70313.Busircas end Professions CMB:Any dty on=o 'y SIGNS ELECTRICAL
1+1 OP' which its i' vpermit ocdxumrm.Wier,improve,n'olidb.r tepalr enY.^-tort ❑ 1�I�/� (�.q^K!�
Prior Isis icoss,d also rcyuitm Nc vpplicen,m'men permiuohkesiuoe(Ch,cmcm SPECIAL CIRCUITMISC: fY '
�y NW hculiccmcd Pnsuvnt to mise pavivionsofthcConsecs«nLicrnxlsw(CTepm9 1 COMMERCIAL-
CI 00 (amtncncing with kation 7110Naf Division Sofhse Businmesod P,ofoai.Cole)or TEMP.METER OR POU INST. 4
d Wv h,is exemimtherefrom ere Ne buffs for the WI,M exempi,a.Any ruWion of ❑NEW BLDG/AUDITION ❑DEMOLITION
Secmm 7031.5 by enY.,Ii,.tare Ist,rot.suhjecu dsc epplie.nt to.."I paultynf POWER DEVICES
rn ❑TENANT ❑FOOD SERVICE
yyy, non more thene hdrM fivwdollars(b50). IMPROVEMENT
Q ❑Luawnerof the the
sourcor nryorimendedmo erMfm Nt(St,cc 04n1.Buetion, SWIMMING POOL ELECTRIC BOTHER
road doicwork,ends, he Ccmisneinte nmowcmfatW"y to can Bm'tresv
d eso Pmfc.a1m b Code:Tbc Cdunan«s Liana Low docs not apply se lf owtur W OUTLETS-SWITCHES-Fl%'IURFS
H,onsoy wmr.d .w Improses IMeon,end who Jars such work Memel!of Nron{h
H,own s so,l ,ns betri"M them web m is tmcnw ex mrs int ofic w offered for NEW RESIDENTIAL ELI;CfR SU FT
Wc.If.howevc,F bu,u lding Nielsen
cmcm is sold did n sur)sur im,mp,for Oc SO�FT.FLOOR ARF:. f/SG;FT.
owner-buildtt will M1uve the burJen of proving Nm he JW not built or improve for pu-
pox of Wc). -
❑ 1,es owmcr ofd pvopeny,an exclusively svmmeWg what,I"nvM<ontdemrs n - TOTAL
construct the ptojmt(SK.7(N4,Busieas ere Professions CMB:)The Cnnbamor. -
.Uw does not"Iy to en ownerof ptopeny who builds dlmposxs QTY. - PLUMBING PERMIT FEE
wtm eommnx for ouch pmj¢b with n<omnmoHs)liampl Imomam m the Con
. Lica.law. PERMIT ISSUANCE
I on,cxcmp ander Sue. .H k P C fu Nu tenwn
Owm Du. R- &VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION CK FL ECT.DEVICE
1 hereby alto.under peruhy.f p ujwy arc of tk fdbwittg dslnntions:
❑ I bevcvM will nuinldnaCsmf roof Conxm er sal&inauc for W.hcr's Cmnpn FLOOR.RUDE AREA,CONIC.
session,u provided for by Section 377 cf the IObor CMB,for a the Nrlmon of mise - STORIES TYPE.CONSTRUCTION
wM far which this pcmw is osusd. PINT MEES-PER TRAP
O 1 hese end will maintain W'mlmlx Cmr,mmian Imurnnce.vs required by See ion
37W.INe Mbar Coo,for t)r perfdm .f0te wdk fon which Nis enut is usuM. GAS-IA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Inmmnea currier a"Policy number ere:
Cad¢ PoI No.: GAS-EA.SYSTEM-OVER Y(EA)
s CERTIFICATE OF EXEA1ITION PBom WORKERS'
COMPENSATION INSURANCE GRBASMNDUSfRL WASTE INTERCEPTOR
' (This action Deed no,Is,complUM lftltepemcl is fcxcrc hundred dollers(SIM) BUILDING DIVISION FEES
or lmaJ GREASE TRAP PLANCHECK FEE
I carify Nam in the pMsrnxreeof Ne wart for which this pemm is ioel.INall SEWER-SANITARY-S'FORM Et.2W FT.
rot empbry ren,Ixrion in any munrcr.w mm hcrnc ncubj cr m the Worked Con,sm- ENERGY FEE
zZ stmon Lews of CWifomie.Date WATER HEATER WNENTMI-ECIR
2 Applicant GRADING IEE
to NOTICE TO APPLICANT.if,vfmr me4ing Nix Cemrcwcor Excmptiuq you should WATER SYS MuTR11TING
a bccce subjrcl t.the Workv's Cntmrn,,o v Irovisiona of Ne lahsr CMB,you moa SOTS FEF,
fmhwihcomply wi,h such provision.ser this permit sbill be JeeroN rtvnYpl. WATER SERVICE -
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PMH. SQ.FT. PAID
U 0 1ltecby aR 11hea 11cm is n construction k,dineegene,fon Nc ei-omunce of Dae R2aiptM
L1. r- We wore(.which this pnrnm is .,.n(Sec.3097,Ci,C)
O ULamkr's Nome - .TOTAL
Leode,Address TOTAJ_
1 certify IMI I hive red Nis eppi.mosb.M axe tba the valve inforntasim u BUILDING FEE
tail corrccu.l egrtc m comply wild ell ehy vml otomy mJircnecs send smm laws reaming to QTY. MECHANICAL PERMIT FEE
U Z bulmingemuvuction,ud hertby ewMriu eeprexnutivm of Nis city to corm spm dsc SEISMIC FEE
ahovctnemlorm pmrpeny for instun:m Ni,so cr.
t
to urc;it
(We)epee W.mnily cod keep harmless he City of C.p iru egeim. PERMITISSUANCF. ELECTRIC ITE
rulribliet,jud,mocnn,cost vrd expemuwdeh troy in my way Benue ageitnt Wd City ALTERORADDTOMECH.
in cdwequcoce of the granting of this pmmim. PLUMBING IFR
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CFM) '
SOURCE REGULATIONS. MECHANICALFEE
AIR HANDLINGUNITIOVCR 10.00CFM) CONSTRUCDONTAX
Si6naurc MA,li.mCanwnor De,c EXHAUST HOOD(WNUM) HOUSING MITIGATION FEE
HA]ARDOUS MATERIALS DISCLOSURE
Will the upphemo on future building occupant.uam or hurdle lmnnduus nuredW 11EA'rING UMI'(T(3 IMX0 BTU)
m dellrtM by tk Cupnioo Afumapa CMB.Chep.9.12,end Ne Hcalth sod Surety
Cone,Sectio 25532m)7 HEATING UNIT(OVER 101000 BTU)
❑Yes [:J A.
VENTILATION FAN(SINGLE RFSID) PAID Dum RcccipY
4 Will the applicantser future building,rcupani use c4uip,xn,nr Jevkcs which consomBOLTER-COMP(3HP OR 100.00 BN)
car,hismdaus cin itums v def rcd by tk Bay Arte Air Quality Mamgcmenss
I,onctl TOTAL
❑Yon ❑No BOILER-COMP(OVER 10,00)BTU)
I have rend tic huardw.s taenial,"crenmts undrr au,,695 of mise Cdi
AIRCONDITIONER ISSUANCE DATE
fdwe HmIN&Safety Cdk,Sectio.25505.25533 end 25511.1 undcantl Na if sshe NEW RESIDENTIAL MUCH. SQ.IT
building diuc et nem cn,Iy have u tc mnuha it is my responnlbdity to notify ons,occupantIN
4 disc, q.,irttrrnu cinch tent be nwt poor to issuance ofe Cenif me of Occupurtcy.
Door'.,milmn"J egcm Dem roT V ISSUED Y:
OFFICE