29934 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO
BUILDING-ELECTRICAL PERMIT N029934
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MP.CHAMCAI,
BUILDING PROJECT IDENTIFICATION
f BUILDINGADDRPSS:I SANITARY NO. APPLICATION SUBMITTAL DAT[
r-
f •1 OWNER'S NAME: PHONIi: CONTRACTOR'S NAMIi: LIC NO:
4kwuiviao �l�g� NX] CONTROL#
/ CIIIIECl/E IGNEER: WC NO: ADDRESS: ❑
CONTACT PHONE BUILDING PERMIT INFO
J ���� ❑ ConsDlfaBf Fees Paid by AppH an[(INUel) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
m Z I hs by a1Bmt mat l son Idcroscd nyder IK)A.ion,of UuNrr 9 Hnmran@ng JOB DESCRIPTION
wilt Satin]000)of IY,v tars 3 oftha Basilan and Pmfasiau Codi,,and my Beane is RESIDENTIAL
�O rn PERMIT ISSUANCE
full feta ad c1lttr.
TF- ❑SFDWL ❑KffCHEN REMODELF�.U V Liamc CLus Lic.N
VetZW Dem Corona.- ENTAL
❑ADDITION ❑PLUMBING RE-PIPE
ARCHMECI•S DECLARATION PANELS STRUCTURAL
Z0ot; I uNrntatd my plans bal he used as public rc umds ' ❑MULTI-UNIT ; ❑MODIFICATION
pZ _ UPTO2I10AMP5 ❑INTERIOR El CHIMNEY REPAIR
F•hFW I'cc°.pl Pmfcssional 201-100AMN IMPROVEIsIENT
OWNER-BUILDER DECLARATION OVER 10f0AM15 ❑BATH RBMOD�l�EPAIR ❑ OI.ITION
1 J .
1 hemby affirm that I.m exampt from the Conowlors License Law for IIs '
IX 3 a U following rcawn.(S®lion]031.5,Bn iru.vd Pmfanlons Codi,:Any city m coutuy SIGNS ELECBICAL ❑
OTHER
[ �Y-
LLl u.¢ wbich requires a pmrm to comuss I,uller,impmve,dermlWl,or tair onY Nruclurt
I:LLh.] prim to its isauarc'e.also nquim dye.,,Hearst for such permit to file a signed sutemem SPECIALCIRCUl`GMISC.
P• Ibu he is IiaxmM Punuamto de pruviim,of the Contractor's Liana.La.(Chupts9
1 p0 (mmmennngwim Smllnn]Bllfl)nl Uivi.iun3 of the Hwil¢ss atm Profesciam CNe7 yr 9P,MP METER OR POLE INSf. r
COMMERCIAL
L [hut he b ssemp themtinm nnJ the tmix fa me alleged eaetnynirn,Any vlolminn or - ❑NEW BLDGIADDMON ❑ EM
DOLITION
iq5' T Sttvion]11313hyanyaWlicantfmapamit, b*Bdtcapplrenitoacivilpc iyof POWER DEVICES
I++�rn ❑TENANT ❑FOODSERVICE
nottaort
nthan fi.< td
boral dollars(agoOl.
�?pEJ , , . SWIMMINGPOOLELECIRIC IMPROVEMENT
will dofswork,aM.:To,Comisnesi,Le r ,1,,,mJfor axle(,Sec.]094.Buntrof ❑OTHER
enJ T'ndnukm Crdi,:3M Catacux.r Lianae law mrc.s iw apply m w w�ni,r of OUr'LETS-SWITCHES-PXTU
pmpeny who builds a improve.thertvn,end wlto Jan such wit hinueUa thwgh
hu earn employe. idcd,Ps that such im)vovarni as not iuculal m oRertd for NEW RESIDENTIAL ELECTR Q FT
sele.If.bmvcsc,the building or imomoammt u sot!withinao Ycu of compMion,de SQ.FT.FLOOR]AREA'1� s/SQ.FT.
rcr-builder will have the bide.of proving that he did net build a impmve for pm-
Precot'wla).
❑1,w away of the Popcny,um mclwisay rnnuw'dng with Iianm,d cumramm r o. T MAY 2 2
smss u do projttt(See.]093,Buaina aham
Pf¢.imn Code)The Com.,U- 1996
t.law does ml apply loan owns of property who hued.a lmpmva theta m.vd QTY, PLUMBING PERMIT
who cauncu for such Project with a cmtmn«(n)I ctm,ad Pursuant to the CootamoYs
Llama law. PERMIT ISSUANCE-
ALTER
SSUANCE' �� �I t✓VI L1ij IItV
arnapt un rSm. ,R,F PCfm this
ALTER-DRAIN A VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION[ BACK FLOW PROTEGE DEVICE
I hcrtbyaflirm
WORKER'S
nl perjury oto of the following dcdatvmms: _
❑ I have and will maintain aCeniticatcof Commnl msclf-in.um fa Worka'aCmtpcm DRAINS-FLOOR.RODE AREA,GOND. STORIES TYPE CONSTRUCTION
sad.as PmvidW ati
far by Son 3700 of the labi Cale,for the perfoomi of the
war for which IM.Tcnom 4 issued I FIXTURES-PER TRAP
❑ I have mrd will maintain Workda Compcnsaion Insuruta,as requirM by Section
3700of the Ladtr Coda,for lsr,, omuco fdbc wok fa which thin Permit is i.umad. GAS-EA.SYSTEM-1 INC.4 OUTLETS
OCC.GROUP APN
My Wa'kefa Compemutioo Insurance wartier tad Nl' o number vi,: -
Cur. mi,rmi,Nr.: CAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATE OF FXCMPTION FROM WORKERS
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Thi.amirm rrcN nes be complct W if the ,mit is for mo hundad dollars($100) BUILDINfi DIVISION FELLS
or las.) GREASE TRAP PLANCHECK PEE
I certify that mtheperfoommaoflhewmk fmwhich dtu Penitis issuN,lshall SF.NER-SANITARY-STORM EA. FT.
not c WRy any Pecan in any mvuer an a ie to bomsubject m IM Wmkai Coolpen- . ENERGY FEE
0Z wion tiwsof Califmmia.Date WATER HEATER WNENT/FIECTR -
O Applinant GRADING FEE
NOTICE TO APPLICANT.If,after making this Cenifeuc of Eacmpllon,you should h WATER SYS'11?M/1'REATINC
h•' "' dame su ons,y ,t Workds Coins or tha goviaions of the Labor Coke,you mum SOILS EFF.
fonhwiN<amplyw'uh such pnoviaionaamispemdt Wdlsit dmmN rtvakeJ. WATER SERVICE
0
U0CUNSfRUCDONLENDINGAGLNCY NEW RESIDENTIAL PLMU. SQ.FT. PAID Date Rcaipt#
U icfc b bout, atheleieucom4mniralcmling agency fa the Pcr[ammncc of -
W L••� the west fa which titin permit is iuuW(Ss.JIy17,Clv.CJ '
0 U lander'.N. TOTAL'.
IardvS Addsss TOTAL
1 certify that 1 bavc rind mi.upPlicmtioo and nova that to id'e infomution is BUILDING FEE
f.. rn CIXlei,l.I agtm m comply wim all dly trim sourly ordlwnca acrd mete I.-rtleting to QTY, MECHANICAI,PERMIT FEE
U mildingcunurvekogar.l mmaby..mboHmrepmmmsrive.oftlu city In mteruNmtbe SEISMIC FEE _
ebave-neniarui faopeny fm mr,socdon pupmcs.
(We)agna to ave,iMemNly and kem ep harthe City of Cupertino Maras PERMIT ISSUANCE ELECTRIC PIEE
hurbilities,jul[mamn,con atm e,Penus which may in any way anrve.gnaw.end City
in covryun¢x of the Starting of this permit. ALTER OR ADD TO MECI I. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM[ CONSTRUCTIONTAX
Signature of AWIucmOConuumr Ila¢ EXHAUST HOOD(W/DU(T) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the opplicmtorfutus buildingaapum slat err herxllc huardms materiel [BEATING UNIT(`0100,10 BTU) -
as defnad!by de CuPenino Municipal Code,Chmpa 9.11,and the Ho1N and Smfny
Code,Section 255310.0 HEATING UNIT(OVER 100.000 BTU) -
❑Ya ❑No
VENTILATION FAN(SINGLE RESID) PAID -
WiII the applicant a Chun,building occvpml use equipment a davires whish Dma Rnclpt#
nit lrssaNar a it commn'uunts as clefted by the Bay Anu Air Quallry Management BOILER-COMP(34 OR 100.000 BTID
OTA
I Ouuel9
Yes ❑No BOIIFR-COMP(OVER IDI,IXO BTU) •
❑
I have maci the hammou.materialsAIR CONDITIONP ISSUANCE DATE
nryuirtmrnB order Chapter 695 of do Culi-
fomia Health A Safety Cuda,Sadat 25515.25533:md 25534,1 Ivdcrvntq that if ko
Wang does ml cvrtntly ha.xa umn harm is my ratsasswaym mollify the acrepad NEW RESIDENDAL MECH.' - SQ.Fr'.
a ma rcqui,cmenB aeich mom hanet Primm i...uan. a.C_mirme ofDaYlwn,y.
(Tetra aumanuJ.'m Dula TOTAL: ISSUED BY: ' #
OFFICE