30411 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RI=IUCAI. PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL + 30411
BUILDING PROJECT IDENTIFICATION
BUILDING OGRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/D�1 Z �/euui�t/ do• �} Zcr�1.6
OWNP. "NAME. zs3PHONE � CIORSNAMG c. CN NIC CONTROL# -
- � 3 z
�1RC iCT9FNGINEI3R: r UC NO: ADDRESS: - - ❑
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant Hni la) BLDG , ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alarm mal 1 am licen.r[.1 under Iravisirm.n or Chapter 9 mmtm,ndng JOB DESCRIPTION
��0 with Sectl.700t1lof Division3 offset Business and Pmfessionx Code,and my llcencse is PERMITISSUANCE � RESIDENTIAL
1-� full face and effect.
�FV j Lieense Clain Lie# DSFOWL ❑KITCHEN REMODEL
NQL Due CIA
amamer APPLNCES-REMDENIIAL OADDITION OPLIIMBINGRE-PIPE
ARCIi HmcrSUECLARAt1ON PANELS DMULTI-UNIT ❑STRUCTURAL
11 Z O�2 2 1 undershoot my plans dull he cased ses public records r MODIFICATION
BZtp UP TO NIU AMPS DINTERIOR D CHIMNEY REPAIR
Fr,3 CLW Licctared Pmfcasiunel 201-IRURAAIFS IMPROVEMENT >'
OWNER-BUR-DER fir DECLARATION OVER lUX)AMPS O BATH REMODELIREPAIR D DEMOLITION
L'CCw 6 1 M1emhy erfrm ma 1 em exam%from me CtmtncfCoo License Law for the
gg a follawiog matt ,Sectlon'IUJI.S.Bo iws etd Pmf,,mors CUJe:Any city m coumy SIGNS ELECTRICAL 00THER —3 U `^'1'^r
Y.LL which teem—a permit to o.mD.after,imgnve,dennliN,m m r any al actme
prim to its issuana.elw r,9uims th[aplAicum ax vmh penial to lil[ani6ond nummem
totM1c is liamd t the S%:C W.CIRCUIT/MI.SC.
}•„ punuunr a ryoviswm of Ute ConUrwSLiausc[ax'lClalxv9
(canmencing--Sm`Em'm 1m Deco%br of m[,,e iressaMRo Any
Code)nr T13MP.MCD3B OR POLE INST COMMERCIAL: -
a CC mat he is exemp tMmfmm are[the bads lame alldgW nnrynim.Any violation of 0 NEW BLDG/ADDnION 0 DEMOLDION
'�qsNSccticm' 3"byanyeppliantfinepermifsubjec Urcapplinnllo*6i [ Ocyof POWER DEVICES GTENANT OFWDSERVICh:
not more ton five Emmertd coll.S500),tz� 01,mowmr of the propenYa my empgrym with wegnusUheir sde eampeuaaon, SWIMMING POOL ELECTRIC IMPROVEMENT
wd1 do Ile wort.end to soucfune is nag imendal or offered for sal,(Sec.] ,Business0OTHER
d
wProhtoians Cade:The Conm
tmordoes tw n License law dapply to In owno{er Olfl'LEIS-SWITCHES-FIX1lIRF5 -
a prgcny who builds or innfrm,s thacan,acl wW docs such waft himself or mot .
his own employees,provided that.ouch imprmcmcnu are not'mmnded or offered fon NEW RESIDENTIAL ELECTR SQ FT
We.If.howeve"Ill numhorga impmvement is sold within are year.fcompletioa the, SQ.FT.FLOOR AREA LSQ.ET.
asmer-budder will have the Entries N proving that he did not build or impmve for per-
. post nLrnle)
0 I,as wvncr M Nc pmlcnyt am caclmm
ively cauntcting with Iimmr
rrual a amrs cto I TOTAL
.a,,un me pot(See.9UU,Business and Nafcssimu Codc:)Gbc,C—tra mr s U.
Ganse law docs not opplym can..of pmperywm hails or impmvn lhetocn.surd QTY. PLUMBING PERMIT FEE
whomNncfs fa xuch pmjmrs with a cem.forte)liamed pursuant m m[Comosetatn
Fees.law. PERMIT ISSUANCE
0 1 .9 h P C f,r mise reusm '
I neoLI III Date ALG7R-DRAIN,&VENI'-WATER(IA) VALUATION
RKER'S
WO1PBNSATIONDECLARATION BACK FLOW PROTECT DEVICE
r I hemhyaffmt core, ,maI afpm M',oc of me following dmlarmionv
,]Ihavc vd wiB mniouioe Cenificete of ConseN mscllimwe fa Workcls Conrym- ' DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
scion,m pmvidN fr by Section 37M a1 Th,Lothar rr Code,for e perfumumce of the
work for which oris permit es issued. FIXTURES-PER TRAP
0 I have and rill memWn Waters Cornpenantion Imaraece.m rtyuired by Smion
3T00af a ha code.for the pert L 4 b mA to t, h bit permittie i.ed. GAS-EA.SYSl1JN-I INC.Y OUTLETS (KC GROUP APN
MyW t ono ns �s�yy�m,.��{Trmel Policypypy� QJ
Getout n nu' c'i—Policy No.:FLl/a`a-^'�- -t GAS-EA.SYSfEM-0OVER S(FA) -
cUBE IFICA'rE )F EX13MPf10N MOM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTHL WASTE INTERCEPTOR
(This anion a«d urn he,ma,leied if Ohe pemut i,for—, dnllars(SIOtU BUNTING DIVISION FEES
u 1cvf GREASE TRAP. PLANCHECK IEE
I eternity Nut in Ue perf.offs,work forwhi,h mispermit is issaed,[d I SEWER-SANITARY-STORM EA.]IMI FT
not mnploy any p:—m In any meare,so us m lecome mhjeo m,W W"e,'Comp[n- ENERGY FEE
Z cation laws of Cis iformth,Date WATER HE11ER WIVFNTyELECTR r
Q Applicant GRADING FEF.
fn NOTICE TO APPLICANT:It;after making This Cenif to M Exemption,you mould WATER S1:SIFAVIR LYSING
a ; become sahjmY to The Worker's Cump[muion proOsiam.M Be labor code,you must _ SOILS FEE
forthwith comply with sooh prnvisians or oris permit shall be,Joni vle—kwl. WATER SERVICE
UU0 CONSTRUCTIONL[NDINGAGPNCY NEW R[S[OIiNIIALPLMB. SQ,17. ., PAID
O l,far.yaR nThar Thcrt iismod((See
.C.,agemy fr Ne peHonouncc of Date Rccdlr# .
dew NomNich this permit is issued(Sec.309].Civ.C.)
I O F" Lroaers Names TOTAL
I^ U Lenders Address TOTAL
111111 a 1 crnify Net 1 have read this opplicatlon and num that the,above infmmtins is BUILDING IEE
(A correct.l agree to comply van all city sol commy r.Jinraa mel sae laws relating to QTY, MECHANICAL PERMIT FEE
U becksngcwutratioa and thereby vu Arman eepmenaUsu otitis city meNvulsnte SEISMIC FEE
above-men mesad prepeny for inspection purryncs. PERMIT ISSUANCE
(We)agree In vve,ialemnify and keep Evmkss Nc City of Cu,m..&.tELECTRIC
Iinbilitn,j W gmrnts,cvu aN nprnn[e whim may in vny.Iy accrue egainu said City
in nseyarnce of IEC granting of thin permit. A1.113R OR ADD TO MECf1. PLUMBING FEE
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL Nr N-P/�/I�/NT AIR HANDLING UNR(TO Io.000 CFM) MECHANICAL FTE
SOU RF,G TIONp ��/ /p
I �(/ AIR HANDLING UNIT(OVER 10.000 CFh) CONSTRUCTION TAX
Sigmilmmel'A,plicamWormuclor Data EXHAUSTHOOD(WIDUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant staC or haMle himmmoms material HEATINGUNIT(TO 10,000BTU) -
a defer by the Cupertino Municipal Calc.Coopter 9.11,said the Health sad Safety
Cade.S im2553$01 BATING UNIT(OVER 110,000 BTU)
❑Yes ONo VENTILATION FAN(SINGLE RES ID) PAID
Date ReceiMar
Will Ue applicant a furore Wilding by the B use res Air m a JMica wM1ich
kmll hvnrdim air conumitums us okfrcJ by the Bey Arca Aa Quality Murogemrnt BOILER-COMP(TIPOR 100.000BTU)
TOTAL:
UstrhetP �
DYn Otho BOILER-COMP(OVER II0,IX0BN)
t I have roil the,hvaNas mareriala reyua,mrna uNcr Chapter 6.95 oA Uhe Cam- AIR CONDITIONER
ISSUANCE DATE
to.HcoN ou Safcry Coda, ars 255(15,25533 end rmhil [urdmmM that If the NEW RESIDENTIAL MECH. SQ.FT.
W idiom.'- -m mrrently amhave.tcmnp mat n u my nnpornCemiY to leo fy Ncpoo,,. .
of menequvements which mora h[nan paormissuomc ate Ceni!the afskculercy. ,
Owwr ce authorieed,eam Date TOTAL. ISSUED BY:
OFFICE