30246 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILD NO-ELECr1HCAL PERMIT N. 30246
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDFNTMICATION
BUILDING ADD R ESS. SANITARY NO. APPLICATION SUBMITTAL DATE
/�. / A�
OWNER'SNAME PHONE: CON�1' ACTOR'SNAME: - LIC NONIC CONTROL 0
: �j 7
-2 -3 ❑ `UIG�
ARCHIT1iCT/GdGINEER: LIC NO. ADDRESS:
F�� J:!�Cnoccuclmr
r PxONE BUILDING PERMIT INFO
�� ❑ Consvllant Fem Paid by Applicant(Initial) B ERCT PLUMB MECH
AN 1L� J%o l-IJC LASED CONPRACTORIS DIiCLARATION QTY - ELECTRIC PERMIT FEE
y wf Nam I em Mesadunder Pmvuirxu of Chapter 9leemmenceing 'JOB DESCRIPTION
Q=Z000)ofDivision]ofile Buainmsund ProfmioosCode,eml myiiccnsaisRFRIDENTIAL00 CRm PERMIT ISSUANCE<F.U- ecr 4 IJc� S �-7 ❑SFDWL ❑KITCHEN REh10DEL
J:!� Cnoccclm APPLIANCES-RPSIDEMiAI, ❑ADDITION [I PLUMBING RE PIPE
ARCIII'IECTS DECLAR A-tWN ❑MULTLUNIT ❑sTRUC1URAL
I'ANEIS
Z O Nana z I urldmtmd tri i3OI b:u¢d e.puhlie orroals MODIFICATION
OZp UPTOMOAMPS El INTERIOR C1 CHIMNEY REPAIR
rr4t:M Licensed PmfessimW ' 101-1000AMPs IMPROVEMENT
f OWNER-BUILDER DECLARATION
% C Q 1 hereby affirm Unt 1 am esetmpt from tM Comrclor's License Law for the OVER IOUOAMPS ❑BATH REMODEfARFPAIR U DEMOLITION
K 31 U following rcvm.(Section]11315,Busi.eM Pmfi. ims Code:Any city er my SIGNS F1F.CTRICAL 0�R
F-�O which oeem'en rt Irani,to cam rocl,alter,improve,&.1M,m'e"'roy siwcmic
Primmits i.esci ales rtquim the applicant for such Permit to File a siBncd Nwenem SPECIAL CIRCUITNISC.
A /�El
py�tvyly thn rte ulkrnrcl pursuant lntk ptovislru of the Conwalers Linselaw(CTapter9 COMMERCIAL
ul p0 (wmlmcrcing with Seniea]OW)ol Divuim]o[dm Bm'vess vrd Rvf.siom Cedc)m TFLdP.&113 9 OR POLE INST.
a e y ther he u exempt Jem rcfroerld Ne Nuu for Ne�kged exemption.Any Gol mess of ❑NEW BI,IXi/ADDRION ❑DEMOLITION
LL• SNtioo703 I S by env applic-amR.a pcmtit wbjecu be apPlimru to a civil lerWty of POWER DEVICES
�y ❑IENAMO FOOD SERVICE
nm more then five the
h pi,Te y,,it cmpl.
F-� ❑ Lmowner of thepmpmY�mmy cmPloyax wllh wngc as their nuk nmtpenwrim, SWIMMING IYIOL ELECTRIC IMPROVIiMEf�k
willmtk wuh,.td deswcmma is nm iole_.-..oroffrtcd for rule LSN.1ULi,Busincu ❑
L and Nokwwu Cade:The Com nicones Lic.Lw row nm apply m w ower of OUTLETS-SWITCHPS-IBXTURES
Property who hailed'«uninevek mhcrcam trod who don wch wM himself in tnrvugh
his own employe.,provided this eech im rovemew are ns,imnd 1 or oRerM fec NEW RESIDENTIAL ELECTt SQ PT.
We.If,twsvevn,Ne boldingur improvement is add within onry<mofnniscmien,the _a SQ.IT.FLOOR AREA LSQ.FT.
owrcr-Willer will have the horde.of proving mel he did rot huild or improve fm par- 1
ptceef.ele) -
Fl I,m owrrr of the property,On exclusively conmucTU with Iiceri convector,to TOTAL: P N
w 1
termini the project(Sec.]OW.Business and Profesiam Code:)The Caurenors Li- .
nae law don not"I"..uwmer of property who hours a improv.th000n,and QTY. PLUMBING PERMIT FEE DEC
wba..s hrouch poejectn
mwith..c rmxvor(0liamucd purwent wthc Cwmxrda r /L 1986
Liue law' - PED`pRMIT ISSUANCE -
I tin exempt un der see .B&1'C fe,'hi.s 1.n
Oawcr Date ALTER-DRAIN&VENT-WATER(EA) tj V�
UI',,, Vxm mixo N
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE V'6f-"3'/
I hereby aR urdn pemalty of perjury one of the following deelanum :
•�I neve and will maiwin•CNtifcate MCavent to self-insum RrWAcrs Canpen- DRAINS-FLOOR.ROOP,AREA COND. D
STORIES TYPECONSIRUCON
s mini,m proviced for by Sectimn 3700 of Pic,InMrr Crete,for the PcrGmrmnce of the
work for which this Permit kIssued. FIXTURES-PERTRAP
F1 1 have em will mummin Worker,Cempcewimm Inwrsnce,m reduirtd by Sectxm
3100 of lie labor Code,fa be peH.of Ns work farwhieh Nispemul i,iawed. GAS-EA.SYSTEM-1 INC.i OVG.ETS OCC.GROUP APN
My Werkq's CC f.csuionlnsu—cvrticr err Polity �yJc,, +
C�nin: A_Ctn�'1 policy No:
"(i GAS-PA.SY.SIEMOVER a(EA) V
CERTIFICATE OF VNEMPTION MGM WOR KERS'
COMPENSATION INSURANCE GR]D SFANDUSTRL WASTE INTERCEPTOR
LDP' (VISION FEES
This section tried rat he axnpleted if the permtit sfor.mnemmtlnllme(SIb (
m less) GREASIiTRAP PMNCHE �
I cenfly that In the pM..of rse wmk or which this,permit If imted.l shill
not employ any pefsen in tiny reanuter w re to hece w
ombject to the Womkai Compco- SEH'ER-SANITARY-STORh1 EA.200 FT.
O Z aetioe law of C.Efumi..DiEM
Die WATER DRAPER WN 'AHJ;CIR ^ `
O Applicant - GRAD _ L
fA NOTICE TO APPLICANT:If,Idler making Nin Cenifcute of E.sentpien,you should WATER SYSTU4,7REATING
!Yi Itccorsubject to Ilse Wurkesis Crmtpematmn previsirru of the Lahr Cole,you must SOILS F,
rc
forthwith comply with such povisimu or this permit shall be deemed svtkcd. WATER SERVICE
0
7z CONSTRUCTION 1PIdDINGAGENCY NEW RESIDENTIAL PCMB, SQ.Flt [ELECTRIC
D
U O IhNeb hick thi Natthere mitfiati ecl(S,ctian len ding agency for the Perfmmence of Date Receiptl
Q !-I Inc wmk fur wnicn Nia permit i.i.aium(sec.1091.Cr,,C.)
Ur IsNcr'n Nnntc - - 'IOTAh:
Irnmd.'aAMltcan TOTAL: -
1 certify,Nat I have real Nu application um;We That be shove imfomutlon k LDING FEE �.
Zl' comma.I iti ec tocommy with all city test natmy ordinances.m nem mwl refining m QTY. MECHANICAL PERMIT FEE
U'ZZ buildingmrnlrtutiw,atW hereby euNmve rtpr.entatly.of Wncimy wemeropnt the SMIC FEE
ebove.cannoned Prtgaty for inspection puryoses.
PERMITISSUANCE
(We)agnc to ei ,'mile..ity unit keep hamdcrs the City ad Cupertino against PER
hich me,m any vey occrue.guinv uid City ALTER OR ADD TO MUCH.
in mnucqucrce of the granting a this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
r SOURCEREGULATIONS.
AIR HANDLING UNTT(OVBR 10.000CFM) CONSTRUCTION TAX
Slgneme of ApplicunVContmchrr - Date EXHNUS9'HOLD(WDUCP) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the appUceirit m future Willing occupant More u hvWle meterA HEATING UNIT TO 100.000 BTU)
m mooed by tM Cupertino Muni W Cade,Chirpier 9.12 end the HnIN em Safety
Code,Section 2553300' DENYING UNIT(OVER 100.000 BTU)
Dyes ❑Ne VPMIIA9'ION PAN(SINGLE RESID) PAID
Duro R.gta
Will Inc opplicent or fmme Wilding ecetipenl um cyripmen,or Device,which
init h srdmu yr mmuenunenu n defined by the Bey Arta Air Oo,6ky Mmugement BOILER-COMP(3HP OR Hp.off,BTU) TOTAL:
DisNcC BODPA-COMP(OVER IM.""ITU)
❑Yrs ❑No
1 have mem the hiectioloc,,reends me,luiresi.x unkr CTefner 6,95 of Ibe Ceti- AIR CONDITIONER ISSUANCE DATE
Rmu HedlN&Sway Code,Sexyiena L5505,25533 em 255bM.I undeirl.nil that if the NEW RESIDENTIAL MECH SQ.FT.
building dm not eunewly huve•errai that it is my mnpom 1wity to notify tire eccupeN
er de .1 hmosst be nem proof miswaNC Ne Cntifrne of Occupuny.
tTv mired egrnt
Dun, TOTAL ISSUED BY:
OFFICE