30419 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F,LEr.TRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 30419
BUILDING PROJF=IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
tai% ' 774r l �o
OWN 'S
NAME THOSE: CIOR'SNAM1IE:' UC NO:
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LIC NO: ;DRS
❑
CONTACT PHONEBUILDING PERMIT INFO
❑ CongBltent Feu Paid by Appllcgnt UBBIBI) BLDG BLeCI' PLUMB/ M[Cx
/Qor\ Q� U� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1.m licensod anis provision Of ChWer 9(comrncncidtg JOB DESCRIPTION
���yycZ with Stttim]fg10)of DivixkmJoftM Bmirtctn anJ Profa.rimt Codc:and mylicmuc ix RESI-_ DE_N_T'IAL:
E-w� PERMIT ISSUANCE
W infullfortxondaffed. ❑Smwf, El KITCHEN REMODEL
N<� cme Clots Caavanor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R PIPE
rn=y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCNRAL
Z I uulaouad my plwnshall be aced nt Public record, MODIFICATION
OZ-0 UPTO2WAMPS ❑INFERIOR El CHIMNEY REPAIR
W Ixrnacd PrOfnrioml 101-1000AMPS I PROVF.MENT
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OWNER-RUDDER DECLARATION OVER I"AMPS TH REMODEUREPAIR El DEMOLITION
lY a I nutao offum thea 1 1. exempt fmm dhc l orkams Code:
:Any
city
o for We
X�1V fdlOwing rmnn.lSeaim]OJLS.Bvaiocu eM Rofnxkas Code:Any dlyacoumYSIGNSELE IGT. []OTHER
3 W wha ich rcquira permit to crosvun,aher,iminOve,demolish.or mpair any rourume
pdordo it,,iuuanoc,el.ro rcquirc.lhcxpplicam formch Peoni a,0kstxigmlumcmrnd SPE IAL RCUIT'NESC.
} that hen lira a p.1a.Nepmtisimn of die Cmvstnda Licemc La.(Chager9
oaf (comnta,in{wiNScum N00)OfUitdsiooldthe Buxidxv.nd Pmfeaieau Code)« TEM MUTER OR POLE INST. COMMERCIAL
d y o C that he is exemq thrrdmin an the bask for the elkgN cxao,foau Any vidmi�m of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1o 4• Section 7031.5 by.ny applicant for a petmit.wLietts the epplkum to a civil pewhy of W.R ES EITENANIT ❑FOOD SERVICE
Z y txx tete than live hundred do1Dri 11500). IMPROVEMENT
t�Q ❑ I,mowner of Nc polenY.m mY cmpbyeet with xugnm Nrirsdc[atmp[madim, SWIMMING IC
�� will d�the work,nmlthcxwnweis nix in¢ndcd oro@mA Gr.ale(.SecA(H4,Balm's, El OTHER
41 tied Profecsionr Code:Lha Contractor'.Liadue Lew duet not grTy to an ounce of 1• OUf -SWITCH BS
a 3— pro arry why builds or impiovn d to surd xbo docs sueb wort hirmelf m WOugh
bx awn employon,Provided Na.verb improvcmrnkt are not intruded an offered fee NEW AL ELT:CfR SQ IT.
Ole.If,however Ne huddinp nr i mprnvconern .,ub within dmc Year of completing the SQ.VL FLOOR AR EA SISQ.N�
owner-bulkier will have the Medcn of proving parr ha did not buiN or imgove for dna nPur-
ngeeors.k.).
❑L m owncr of Sec.7 ,un exclusively convening will licensed convenmx m n
mWrvnd mjedct(sec:. uu,xaxlm�r tied I'n,rrmi r coJe:)'ll,emtmcer-r u- 1J7v
crnYl�wdunoaapgydo en owncrdpmperry who bulMlsorimpmvn❑Berm,and QTY, PLUMBING PERMR FEEPGG J7
who coouxu fmwch gojttts xSdh.rnnuxtor(s)Igen.1 gwuru do dhc Caurecdars
L'crntc law. PERMIT ISSUANCE.
L an cxcmundo Sec.undSec. .B&P C fordhk main t V
Pier Data ALTER-DRAIN&VENT-NATER(EA) VALUATION
WORKER'SCOM DECLARATON BACK FLOW IROTCf.DEVICE
I hcrtby.lumkr pnrvdy of Kr,a,rerc
of Jo following declemdau:
•(]Ihnve.rW xiB maidvaina CcniEnle ofCmtem mself-Imam fm Wmkn's Compcn- DRAINS-FLOOR,ROOT,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Lector Code„for Hee pufartwa Of do
wore for which lhix permit ix luuedl. FIXTURES-1'I7R TRAP
I Tuve Berl will maintain Workefx Compcmvion Irratu.rce.ec o,ai ed by Scrim
3700ofdhe labor Gods.for the perfOrnueceofdhe weak for which this permit u i.oad. GAS-Ek.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Wor4cr'xC - r wW Policynu
/ Cstuicr. n in amcrad No.:i / ]�/� GAS-1?A.SYSTEM-QV1?R 41BA)
C'RT FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEPNDU,STRL WASTE INTERCEPTOR BUILDING DIVISION I=
(Thim ion reed nor be cumplefed ifdlm 1R 1 for are,hunucd doll ($100) GREASETRAP
or le.u.) PLANCHECK PTE
Iccnify Hot in the prrfandunucfdhc work for which Nis Permit avaned,IdiaB SEWER-SANITARY-STORM EA.100 FT.
not employ any pawn in any Donner or¢t m horror,wbjcct to de Workeri Crvnpmm- ENERGY FTE.
Z ,Z, anion Lawn d Calfrrio.Data, WATER HEATER WNENT/ELECI'R
O Applicmd GRADING FEE
y NOTICE TO APPLICANT.If,afux making Nu Cmifxem of Bxemptioo,you should WATER SYSfEMIIREATING
a ; 4«0,subject to the Wsleds Comprn.,aim provisionx of the lobe Cattle,you mat SOILS ECe
F. .011
forthwith comply with ueh govixiorcv or daN runit dudeemed revoked.be derevoked. WAIERSERVICB
1
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIM B. SQ.FT. PAID
;m)C) Nix IhertbY.lr Had dbede last eumwmcdion kMing agency fw the perrfarrnwu'e d Data
W But work for which permit is ixuud(See 197,Ci v.C)
0 V LendeR Name TOTAL
fx1 Lcddcrt Arced
1 anify ihm I have read Nis applic.u.and ume'bar Ne aMwe ior_.inn u BUILDINGFEE
T�/1 anctt 1 agmc m cmdply with all tidy and roomy ordidsnas atm sum laws mlatlng m QTY. MECHANICAL PERMIT FEE
V Z buildingcrostnrctian.and hereby studicrue mprmenndivm of Nit tidy to enter upon the SEISMIC FEE
.hove-mcduindxd pokey for impmiao purpmn. PERMIT ISSUANCE
(We)agree w save,iNenmify and keep harmlax the Ciry of Cupertino agumi BLLCTRIC FF,P.
IwMlidimjudgmenu,ttun and expemn which may in any way accrue.grina veld City ALTER OR ADD TO MECH.
in consegrce
t, Of the grentJoi,of Nu Parrot.in TEP,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB000 CFM) MECHANICAL Iti
S URCEREOULATIO�NS.
AIR HANDLING UNIT(OVER 10.000 CFMI CONSFRUCION TAX
Sign aliV(unoenar -��eEXIIAUSf1100DOVIDUCn HOUSING MITIGAT1oN Tfl:
HAirARDOUS MATERIALS DISCLOSURE
Win He applicant or fwurc Wilding uceuprid um or haMiehvurdan mvcrial HEATING UNIT(TO I Ni”BTU)
m def nal by dbt Cupertino Municipal Code.ChWaur 9.12 adl dhc Hea1N.rd Safay
Code,Section 2 532001 HEATING ON IT LOVER 100.000 BTU)
E:1 Vi No VENTILATION FAN,(SINGLE RFSID) PAID Dem Rcciq#
1 Will Ne app urianmfisc building bycaputuseea Air uordManacc which BOILER-COMP(3HP OR 1W,00U BTU)
mit hmardnm Bir camandinwu a.dcerwl by the Bay Arca Nr Quality Munstgcnem TOTAL
LH�ffi&.Sf�y
BOILER-COMP(OVER 100,000 HTU)
❑No
AIR CONDITIONER reaH He h:vallout mueriatx gNulmdmds under Clmptn fi95 of 1hC Ceti- ISSUANCE DATSafety Cmk Scums 25585:25533 and 135M.1 undcmmnd Jur if de N W F lSIDENTAL MECH. SQ.ut cureavly hte.lcn.m,Nu id It my retpo^sibilitY m no ifyrnds which ddbe nn Priv to i wnrcc of o CrniBcadcofOmpvry.
orized ag<nd Dare kkV ISSUED BY:
OFFICE