30908 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, 30908
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MRCIIANICAL
BUILDING PROjBCf IDRN'TIFlCATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMHTALDATF
DNI: L 98
41CHACT,
N' N _ PHONE: C NfRACT RSNAME: C
O'TL NIC CONTROLS
CTINEER: IJCNO: RNSSQ )ft m PHONE: 1 �J� BUILDING PERMIT INFO
-• III/�� �ry�y/ ❑ ConsWfenl Fees Paid by Applicant(Inifia) BO I?LECT/" PLUMB Ni
LICENSED CONTRACTOR'S DECLARATION G qTY ELECTRIC PERMIT FEE LTJ/
1 bmaby afrnn wt I.m licemd amr ho dsi.of Chaos 9(c.nciog JOB DESCRIPTION
�O�yDZ with Section]BBB/of Division J ufthc Ba.i.stowl Pefmaiata Cade.ud my licenx i. AL
F- O infull Bnaudc ' b. PIiRMITISSUANCF. 5�
�UW ❑ADDITI SFDWL ❑KH"CHEPLUMBINREMODEI.
j Lian.c Clus Ix.N—e
�i<a Detc�—!g C®torn« APPLIANCES-RESIDENTIAL ADDITION ❑PLI1h1BING RE-PIPE
,„ VoARCHIIE(.TS DECLARATION PANELS ❑MULTIUNIT El STRUCTURAL
ZO'n,Z, lundvst°od my pWu darl he usd a Public ocaw MODIFICATION
OZ-0 UPTO20OAMP5 [I INTERIOR El CHIMNEY REPAIR
r4 F'ul Liaacd Pmfacsivtul 2(II.I000AMPS IMPROVEMENT
OWNER-BUILDER DECGRATON REAODEVREPAIR ❑DEMOLI77ON
K W Q P bertby.IDnn blot I em exempt from rhe Connector'x lion,.Taw f«thOVER I"AMPS ATH the IQ�{g
�qq�S5 O C V following vita n.ISatinn B.,.,7031.5,Bwis and Pmfcuinns Coda.Any city«county SIGNS ELECTRICAL y�OT LR
u+3
lid, which III a pcnnit to cunvrocb,ohcr,improve,dnrollsh.or rtpatr any dructum - D
WO¢
tiJ briartoiuishotoi atwrogo da,theepplic.ntf«such Concraatnit nfileia,Law groal but fent SPECIAL CIRCUITMISC. ��'�I�
f y�Y thukuliccdscd purattam tottr povisim ofbon Cowecbala Liaaclaw(CT.per9 COMMERCIAL
(mm1C k"gwdh5ttnoon rand In Uvisxnl bt,-i B excr MPn,Any
iCadc)a
TINP.A1P,f1iR OR POLE INSf.
Lyi5 m¢ Rha he i.v eump thcrttinm ami t W Mute G.tW dlegeJ cxcmpinn.Any viulvtim of ❑NEW BLIXHAUUITION ❑DEMOLITION
W^h Swoon 70713 by tiny appliatnbfor a pumii mbjmu the applicant m e ci vi l penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZ} n«m«c than five huodrod ddlam(S501H IMPIROVEMFM
C ❑I.uawmmdbhe pmpmy.amy cmploym with w.guuthc'v role romprnotion. SWIMMING POOL ELECTRIC
will do the work.td thea aoci.rot intcrMed yrulfcrd Proof,ho,c.7100,Budneu ❑OTHER
ad Prufor'.Cdu,The Contmctnr's Ucense I.aw aKs nut apply to an awoc'r of OUTLETS-SWITCHES-FIXTURES
pmpany who Wilds«improves therwn.ad who Doer vuh wale himaclf m bhraugh ,
his awe eittl Provdd tont much ivbpovcmcnu.m wt intcrrdm«oRval f« NEW RESIDENTIAL ELECfR SQ FT.
s.k.If.however.tW Wilding a impovencm is Wdwithin nrte Year of cor�Plnion.the SQ.FE FLOOR ARG 5/SQ.FT
wrcr-W ildcr will have the W r in o(proving t W b he did mux Wild or intpnwe for Pur
Pane of role.).
❑ 1.u owner of bhc propmod.rn eschoifv y cunvac ing with liceaued coeuattora to TOTAL
arutrtct the ptojcn(Sm.70M,Bairrem.nd Phafauom Code:)The Cwmn«.U-
rue La.d«snd.,y to en owneruf ProPeny wW buikfs orimPm.a ttd'rcon,td QTY. PLUMBING PERMIT FEE
won contracts forsuch p,j swish aconuadmr(e)lictnwd Puowant to tW Crnbuctar'x
Ljconie mow' PERMIT ISSUANCE.
❑I.m umop umicrSm. ,B&PCfor this reason
L] Uwc ALTER-DRAIN&VENT-WATER IEA) CY VALUATION
WORKERS COMPENSATION DECLOA'fPON BACK FLOW PROTECT.DEVICE 1 hveby drum odor perolty of perjury one of Ilse fallowing Jac Wuima:
�Ihhave.d wit[noinuln.Cmtificue of Cao. ,to x11`-iraufe for Wari Cornpen. DRAINS-F1.00R.R00P.ARG.CON'D.
provided for by Semon 77W of bon Lada Crocco f«tlr pe foornaae of bon STORIES TYPE CONSTRUCTION
fa which thin Permit i.iewud. TunTERFS-E'ER TRAP
I have and will maintain Worker's Compen.mdon lauruuc,a«quiml by Smbion
7 ofbhe labor C«k,for the Pe*fo^^^na of Newts for which this pcntub is iortul. GAS-EA,SYSTEM-1 INC.d OUTLETS DEC.GROUP AM
My W'orkN�sVIE
C�omm^�ppcnrt'tt�7yf�V.latu.rce cerriu urd Pdiry nu -
Canicn_lSSC1�.pL PnW Ro.: GAS-EA.SYSfI:M-0VER4(PA)( I'IFIC OMPll E SATIO INSURANCE
WURKBRS'
COMPENSATION INSURANCE GRPASFIINDUSTRL WASTE INTERCEPTOR
(TTia section neon rot d crmPkted ifthe Permit mor.dnrdrnl doBan(SI00b BUILDING DIVISION FEES
a Inx) GREASE TRAP PLANCHECK FEF,
I certify that inwork forwhich hi,p:nnit ivi.oud,IJbWI SEWIiR-SANITARY-STORM G.200 FT.
not crop[oy any pawn u any nano r m u to dame subjmt to the W'orberr'Corvpen- ENERGY FEE
ZPpZZ satio�of Calif«nu Date WATER HEATER W7VFNf/ELECIR GRADING FEE
h NOTICE TO APPLICANT.If,after nothing this Cmtificate of Exemption,you should WATER SYST SMEATING
1^ 5 Name subject to the Worker's Conn a onion Provisions of Ute Tabor C«M:,you mud SOILS ME
forthwith comply with mch proviiinns a this Permit shall he deemM rovutd. WATER SERVICE -
7Z CONSTRUCTION LENDING AGENCY NEW RFSIDPNTIALPLM B. SQ,FT. PAID
UIhem_byeffmitlw them isvc«uwcJun lending egvrcy f«Ura pufmrona of Dam Raeiq
LL ho,work for which this Permit ie i.uud(Sm.3(N7,Civ.C.)
O ULctdm's Namc -
W Icndc/.Addras TOTAL
I ttniy tont I hove red this r,licmion ad son dul the a»VC mf rroeJon iv BUILDING FEE
l�q comet.l agrm to comply with all city and county oMnmcws and Wan luww minting to QTY. MECHANICAL PERMIT FEE
V Z building cowracbion.ad Ell auJnriu rcpcxntativa of this city to atkr upon bW SEISMIC FEE
`+ ebave neotlood laI fa lmpectinn pbvfrrea. PERMIT ISSUANCE AA
(Wed .a
agme bove,indemnify ad kmp onnnlea the City of Cupwino agvnV 11 FCTRIC PEE p36
Iiehilitia,judgmrnts,coals.d eepenxs which may in any way acerueagarot mid City ALTER OR ADD T)MECH.
in nx9ucme ofbongrout ofthis permit. PLU FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT TU IB.000 CFM) MEALHEQ /
SOURCE REGUTATONS.
AIR HANDLING UNIT(OVER 10,000 CITE) �OW.TTR�I CI'IENTAX
Signetumuf ApplicenUCanhacb« Date EXHAUST GOOD(WIDULT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MTIGATION F1'E's�
Will the Wfictut orforore Wilding mcupant More a ondk onrudurs materiel HEATING UNIT(TO I W,000 BTU)
as def 1 by t!x Cupertino Municipal Curie,Clo ptu 9.12,ad the Hedth ori Safny
CocaSi 25532(u)Y HEWING UNIT(OVER 10IM BBTU)
❑Yes El No VENTILATION FAN(SWGLE RESIDE PAID
Dam Rmcip x
Will bon applieenb«future building eccuponb ux cquiPrnent or deviceo which
thexunbus mr nmwmioanbsus&rimdbythe Bay Arca Air Quality Management BOILER-COMI'UIIP ON IINI,INNI HTV) ^Q
TOTS C Y) t
❑Ye -1 No HEALER-COA1P(OVER 100,000 BTU)
- I lave red bhc tuzuMu hat'".rsquirtmeusudm Cnaperfi95 of the Cali- AIRCONDITIONER ISSUANCE DATE
famiv Ilalth&Safety Code.Soctiorn 25915,25577 ad 25534,1 do kotad Our if the NEW RESIDENTIAL MECII. SQ.FT l/
building does nd camently haveabrnanLthat it i.myrespmsidliry to notifybW 2
oftherto, bni d.Cenifir
im Owner«authtociil ug. }tc TOTAL: ISSUEUHY: ✓—" � `_ —a"
OFFICE