30623 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL _PERMIT No, w
BUILDING DIVISION APPLICATION ERMIT PLUMBING-MECHANICAL 30623
'LJ"3
BNLDING PROTECT TDF\TIFIGTION
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t ,DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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;>NERS E: VHUNIR iij CONRACTOR;S NAKV
LIC NO:
NIC OL g
\ \RCHITECT/ENG R: LIC NO: RP : +
CONTACT. _ PHONE: BUILDING PERMIT INFO
m-24170 E-1Consultant FM Paid by Applicant(Initial) El. PL ECH
LICENSED CONTRACOR:S DECLA RATION QTY ELECTRIC PERMIT FEE
X 1 thereby ufflnn Nm l mn l ce.sed covert,Pruvuie i of Chapmr 9(uomnrcaing - B DES IPTION
IW 5 tom]OW I of Divisim J oflM Buslne..eeJ Pmfcs.iaas CNe,end mY licenu i.
OO w PERh1IT ISSUANCE
ieW.0 and cRm. I, KITCHEN REMODI➢.
�FUU Li¢nsc Clash Lie,at
W<[II Dere Cwlrectnr APPLIANCES-RISIDG" IAL []ADD ON C3 PLUMBING RE-PIPE
F 01y ARCHITECTS DECLARATLON PANFls ❑MULTIUNIT El STRUCTURAL
OI-=E-Za1
MODIFICATION
X UPTO2MAM'S INTERIOR El CHIMNEY REPAIR
Licmxd Pmfvl 01-WOAMPS IMPROVEMENT
OWNER BUILDER our the
uION OVER IIMp1AMPS BATH RF.MODH ❑DEMOLITION
oKC q 1 ma,c affirm that 11J eBemni fmm the remionclnr's License y o for the
O a U folbwing rtuw. erim,in]Ill.. . lies and Ftofcssiwu Cade:Any city a cwnry SIGNS CLIiCTRIGL
�+LL which,it,imcs o e,lu ro wnutun,she,itstptavc,de nnii h,a ir,ei,any utuctmc
that
he, sfictterun,rm rtyui ms theokims,of foe,suchpennitmfcirs,Ln ism¢trcnt SPECIAL CIRCUI'I'IMLSC.
;vu!���y thwkis ll,enud Smetu Ito the of Division 3 the the
esrand Pro,law(CTeptn9
�ap0 (conuttauing wiN Sauon]OWIof DivisionJof the Business ud Prafnvimn Coate)or TEMP.METER OR POLE INST OM�AA�
d e m Ihel he in cvmlpt 0mrdmm mid me Forms for the alleged evemPlxn.Any violation of ❑NEW BLDG/ADDITION ❑DI:MOI.MON
�y Section 0031 S by my awliewt for o Rlmil.objecls the applicant to a civil Penally of POWER DEVICES 0TENAN' ❑FOOD SERVICE
Gnot.than five hundrtd doll.($500). IMPROVEMENT
❑I.uowne of the proprny,amy ctnptoyde with wages uthnr sdc compemwion, SWIMMING POOL ELECTRIC
will do the work,and the stmamm u net Intrnld nr oVed forint(Ste.](Ff4,BLNmi ❑OTHER
d
and Pr,fi m Cod,:The Conbaclur's Nernst law dae M aPpIY to an owter d OUTLETS-SWITCHES-FIXTURES
papertY who builds or imarmi thertw,and wlto dove loch wmk himself«through
his own ero,byov, vrovid rl Beet suchimp cvmrucnu me rot mucitr d Lr offcrtd for NEW RESIDENTIAL ELM SQ FT.
vdc.If.Movev,r,the buildingor impuv,tni is soldwiNintm,yeuofemo,it,000,But, SQ.FT FLOOR AREA VSQ.FT.
awrc-buiWer will bevc the burden of paving that he did not build or intlrove for For,
pm,of isle.). �)
❑ 1,u owner of the pmpedy,am culuvively cnmractlnp with Iiceawal r+mtm b—m TOTAL: -
e.the p,q*,(S .]OCL Buiness t d Nofevsiau Cd,:)'Ibe Conuut&s Li- t
crnsc Law docs tot apply to an Omits,a popcny wro builds or impavn therme,and QTY, PLUMBING PERM] sis FEE -
whocommccvfmmchr mjwP with"orbretmts)Iicc,od putsuunuo rte Ctmtmctac'e
Beene La.. PERMIT ISSUANCE
1 sc.acme p IndSec. .H A,P C far this rtx S
sum 27loor
Owtxn Date ALTER-GRAIN&VIt-WATER(PLA) VALUATION"!
LA -
ORKEN'5 COMPENSATION DECLARATION
I hwarty crtby sM.ords of perjury ma,are fdlowlep declarations: HACK FLOW PROTECT.DEVICE aJYCft
i f )LG�
I huveand willnniGam.ComrcemolCor,ml,,.11-i nvortbtr Wcd, .Contpen- DRAINS-FLOOR.ROOK.AREA.GOND,
moron,u pmvie ed foo by Senior 37W a the labor Cads,fm ftp,rt.t,of Iba STORIES TYPE CONSTRUCTION
wnh for which this perms is is,atd, FIXTURES-PER TRAP
E)I have and will maintain Worker's Coso,ii,mairion Imurmwe,as teyuimd by S¢nkm as
3700 ofthe lobar Cade;f«tM1e peirfomwtta ofrc wook for which rtu punct is oured gaaas AS-E\.SYSTEM I INC.4 OUTLETS OCC.GROUP APN
My Wahe(s tiw lsurueccarrivOF ettd PoI wmbn
Cerner. C 1 Aa PION No
G W S V EA1 -
CI?HTIFlC TH PENS TION I N FltAM WORKERS' FL Nff
OMATON INSURANCE GRFASF/INDUSTNLWATMINTERCEPfOR
BUILDING DIVISION
is sttlien recd M IN,eumpleldd
KI 'moil is for.Iwrdrddo las(SIM)(ThEItPC
holes.) GREASL'TRAP PLANCHECK TEE
ramify,auntie mymmurcc is,
hukfor which this pmmitisusrcd,Islrr. SEWER-SANITARY-STORM EA.200 FT.
M employ,any person in any nwtm w n to become whject to th,Worketx'Cwnpem ENERGY FEE
O X Batton laws of California.Dote WATER I(EATER WNFNIAH ECIR
Z Q A']1., GRADING F.
rjl NOTICE TO APPLICANT.If,eller musliinp Wv Cenlftcare of Esentptiw,Y.should WATER SYSTEMTRE\TING
a ; N cmrs,wbjecl to the Wei Coar,,m uiw mvisions of Ne Labor Civic,you mum SOIt-S FEEW 1 .
fntlhwlth comply with vwh pnrvieknv nr Nis P.nnit shall hcdctrcdren{d. WATER SERVICE
a
PZ CONSmisa c ONLENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT PAI
UQ IMrtbyeffort his its isacomlt .t 7,ding agency for perfvmerccof aipik
Lergi for which this'omit iAi.csud lSn.JW],Civ.C.1
ULade',N. V TOTAL:
latvklmifye TOTAL:
I
� ttni(y Nat 1 M1uw trd thisepplinron od ua¢Nm tk uMw,inlommtiw ie BUILDING FEE
axrcct"IagrtctocomplywithallcityvndcoumyordiouuxsadnmelewsmWingto QTy MECHANICAL PERMIT FEE
U z building matructian.ad lcrtby and ire rtpnenehve ofdrscity tomit upm the SEISMIC FET, .
shove-memiorcd prupeny for lnepection IF.,—e. -
(Wet n
)ri ave,ilxknudfy and kap humleca the City of Cupniou apuut PERMIT ISCUANCF. ELECTRIC FEE
IiaMlilie.jdgtlrnu,ecus and cxpcmcs which may in any way ccruc agwim said City ALTER OR ADD TO MEM. PLUMBING FEB
onscyuct¢e of the grunting of this p it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON,POINT AIR HANDLING UNIT(TO 10.000 CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IO,M)CFM) CONSTRUCTION TAX '
Sip of o f �� Doc EXHAUST DOUG(W(DUC r
H1 RDOUS MATERIALS DISCLOSURE HOUSING MITGATION FEE
WII the epplimol trz forumbuilAingoreupom slotmhulkhvudwsnmleriul IIBATING UNIT(TO Or BTU)
u def nd by tk Colston.Municipal Cei Chuptn 9.12,and the Health and Safety
Cde,Senior 25532b)' HEATING UNIT(OVER 100.000 BTU)
❑Yes . [:1 No VENTILATION PAN(SINGLE RESID) PAN
�
Will the applicant or(wort Willing ocwpent ave ryuiprcm m Device which Date R,ceip Y
tdt hnaudaus air tuntamitenta as deBnd by the Bey Arta Air ljuality Menupemcnl BOILER-COMP(JIiP OR 100,000 BTU)
DlwocR
❑Ye ON. BOILER-COMP(OVER IWd)00 BTU)
I ham,reed the hvrandtun machine t,,,cur ttrnts t dr Cheper 6.95 of the GNI" AIR CONDITIONER ISSUANCE
fano Halt,&Ser,ty Code,Sectiw 25303,25533 and 255.)4.T utvkosraod rut if an, NEW RESIDENTIAL MECH. SQ.FT.
building don M eminently has"a I t.rel It Is my nelueiMliry to MifY the scoupnt
Of Ills IDRYIrtItenGl,Whieh rNsl I pnu to iAMNKc of a CRtift,ntc aCce.,v rgy.
or �. -moi
Owtteror agent Due TuFAL: ISSUED
OFFICE