29763 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELF.CI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL 29763
BUILDING PROJECT IDI3NIYPICATION
BUILDING ADDRESS: �-� SANITARY NO. APPLICATION SUBMITTAL DATE
Q OWNER'S NAM2 F F 3 fl:i Nl'IIAOa uIL` CONTRACTOR'S ML LIC NO: Ntt.
/• CONTROL#
J J - _77 L
ViCHITECf/EIiGINEER: LIC NO ADDRESS: J-0 k� ❑
C.
CONTAC, �n r y PHONE: BUILDING PERMIT INFO
A-Y �� �'�9& ❑ Cuiultant Fm Paid by Applicant(Initial) BLDG FI CF PLUMB MFCH
�(Db 0� w: R� ❑ ❑ ❑
LICFNSIiD N'IRACIOR'S DECLARATION QTY ELECTRIC PERMITFEE
I bereby".that I eon Rcen,cd miler porcumns of Cluper 9(mmmeaeing JOB DESCRIPTION
fgZ withti force
geffectTviaium3ofthc tleircsserd Ptufmviuun CuJe,vd myliccucu
00 � PERMIT ISSUANCE RF3IIlFNTIAI
in and effect. `�� ❑SFDWL ❑KITCHEN REMODEL
Lircvc Clvs7—Uc.Y -
♦nQL Dore--l".J�T�((�Conlevnar APPLIANCPS-RESIDENTIAL (]ADDITION El PLUMBING RF-PIPE
ARCHITECTS DECLA 'PION PAN O MIfLT-UNIT ❑STRUCTURAL.
Of-n Z 1 unJenund my phuu.hell be uscc os'Mic record, � MODIFICATION
Z-Q UPTO2 AMPS A ❑INTERIOR CHIMNEY REPAIR
�'_+f-W IicrnrN l4ufanitmonl 2014000AMPS IMPROVEMENT
�Y�3 OWNER-BUILDER DECLARATION
y C W Q 1 hereby nfBmt Nat 1 am exempt from thb Coco-.ode Licenm law It the OVGCINRNAMPS' ❑BATH REMODE EPAI ❑DEMOLI'ION
�(OOV fM ocge .(Smion 7031.5.Bunot dP.anmaieu Cu Any any or county SIGNSEItC1RICAL ❑OTHER �^^�
41'3 w wM1icn ro{uires a p:mJt eu NnvwcL alter.impevq tkmolleh,or repnv any atruchue11
H prior to lin tssuarce,ilw mWite the,aMicnnt for mchpmtut to File a dgttai umenent SPF.CIALCIRCDIT/M 'C.
2,. thin be is l icensed pursuenuo.he 11-1 lionsof the Cumnemr'.Lit .I—(Chaper9
W9. 0 (COO1O ung withSmirn]LUO)nf Division Jof the Buuteae tail Pmfcatiam Ctde)m TFAIP.METER OR POLE INSL COMMERCIAL
a Nat he is mcmp Nertfrom aril the burls fur rho ell,M uaemp&ro.Any vptU.ion of ❑NEW BLDGIADDITION ❑DEMOLITION
qx'R� Semiam]0315 by ony appli.fice.pmut wbjccs the a pphont to a civil perWty of POWER DLNICFS
4)�rn ❑TENANT ❑FOOD SERVICE
of none Nun Evc htr m duller S500).
p 0 o1.uawncoft propmny myemployeeswiNwgaax irwkmmle SWIMMING POLL ELECTRIC
will do Ne work,urtd the so 1.I.now Intendedwinced for sale(.Sec.]06d',Ho,not, COTTER
Wam Profineimc Code:The,C.w 'U.law Ma nm apply.o en owner of OIIRETS-SWITCHES-Il
It a^ pnpcoy who builds ur impntvm dercnn,and wtm docuuch work him.clf or though tn
hi.own employ., rnvidbd Jul wch imprmemrnts e.e twt inteMed or uRvul far NEW RISIDENTIAL IJ.E SQ Fn.
uJe.lf,however,dtc luildingaimpwvcmcnt is wd within one year of completion,de SQ.FT FLOOR AREA SJSQ.FT.
anbui will hart the linden of proving that be did.wtbuildorintpmvefor Put-
pnc nLvlcJ.
L u oamer tithe prop:ny,em mdu.ivdy ctvtrec.ing with IicTbeeJ«e. hoc,t to
conetnxn the,pni(Sec.]IIW,Rtwu. ,end P.ofmaian�Codc)Tin CanuactaYe V- P i' T
cenx laws rrot;r,ly to.nawncrof prole,,who huild,co imprnven thmmn.onnd 0-y.. PLUMBIN PERM F B"
who.coma.farsuch Project,with.cumtr or(.E IiccmN pmvunt to the Connatal.
Leenxe Law. PERMIT ISSUANCE
gg
I]Iune.empmder Sec. ,B&PCf«ohm. PR 2319
n.
ALTER-DRAIN&VEYI'-WA (FAH vrJl VALUATION
owner Dna Up L,rry_
WORKER'S COMPENSATION DECLARATION BACK FLAW PR[1TEC1' :VTC 1 ..1 S6It Ob
IMebY off uodexpmlty of perjury one of rte following decluuites: 'J
,]IM1uveenJ will mnintuin.Cenihnun(Con¢nnn.rdf-Heart G+Workers Contpcn- DRAINS-FLOORR R C STORIES TYPECONSRUCION
a.tioo,u pwidcd fa M S¢tioo J]f)D of ole Mbar Conk,for the perfnmuree of ole
wuwkaw which thiepcmtiti.e i.crlor FIX'R1R R'IRA I ' I I I
14-ed will tmimfo,Warkels .occ ofeuimt In.urtt whi h nk c by Section V /v
3]ql nftM laMv Gila,fav the pcHnmurce of Je work tin wM1'tcn this porno ix isueJ. GAS-EA.SYSTCJd-11d FTS OCC.GROUP APN
My M'orkel ltµyt.ot�copier aril Policy.
cnr,k,: ' Pnhcy Na: a Y'!! 7,)-9S" GAS-IA.SYSTEMn Ra(FAI �3
CERTIFICATE EXEMPTION EMPTION FROM WORKUS'
if COMPENSATION INSURANCE GRI?ASHIINDUSIRL W STB INTERCEPTOR
(This s.ian ri not he ctnnphhod iftle permitk!crone hutelml collmsISIN) - BUILDING DIVISION PEES
or Ica) GRIASE TRAP PLANCHECK FEE
I certify duo in the oty no en,of ate work Fin which thio permit in n'Cr.I Dull
.employ any perean in any mvmerw ny.o becc.rc whjcct mole Wtxtrn'Compco- SEWER-SANITARY-STORM EA.MU FT ENERGY FP.E
0zwim lawoNCilifami..Duc WATER HEATERW/VENTIELECI'It
Z 2 Applkmu GRADING FEE
y NOTCH TO APPLICANT:If,enter making Nis C,rtificae of Excmpiim,yw Jwuld WATER 9YSl1JN/IALATING
become wh*I.a the,Wu4e,Cummpi.io
pcaJon ove of the la ..bor Code,you u SOILS FEE '
forthwith comply with wch oo,mitns or thio permit Port he ticcneJ mvu�4W. WATER SERVICE
a �
5Z CONSTRUCTION LENDING AGENCY NIiW RESIUIiM'1ALPLAHB. SQ,FT. PAID
LL P Thor which thwdee uectd(SectionkrtJing.gcrcyfor.hc perf«mauc of Date Reaiptl
OU the wtrrk for which this pcmtit is israad tSm.L5],Ci,C,)
CF.1 L<nder'x N. TOTAL:
IeMcr'I Address TOTAL:
y I cerfify duo I hese ith i i ciapFlicetinn.ntl stone that and
,huc l inftx�ting ix BUILDING FEE
Z? bunch.,l eget et comply with ell city end covey iodlwrca uml riq laws Bluing he QTY. MECHANICAL PERMIT FEE
U Z buiWingconunrl'to ted lertbyecti.o represcotetivm of.his ci.y.o rnto upon the SLISMIC FEF,
eMve-neonate property for insPee"oriltiun!km ha. PERMIT ISSUANCE
(we).p«to ave,iodn.mily and keep hemdma ole City of Cupuoimt.guns. F.IF,CfRIC FEC
linbilitie,oc,nom,or,oe and exlemc which nay in any wuy accrue og.i,l wid Cay ALTER OR ADD TO MEC
HA oeoce of de grainmni
ing M this pt. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IT ,000 Fh11
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT( 10, ) CONSTRUCTION TAX
Sigecture of AM1kvnUCowactcr I). FXHAUSI'HQQU HOUSING MITIGATION MEHA lARDOUS MATERIALS DISCLOSURE
Wllthcepplictrnt or Intuit lvAdin,«cupaot uac or hn.dle boaunrdon,nuroiil HEATING UNIT ETOL "B )
u defined by the Culenino Municipal Cee,Chnper 9.12,mW ole Health and Sofny
Cudc.S Han 2551200? HLATNG UNIT(OV 100.000 BTID
❑Yc. ko VENTILATION FAN(SINGILE RESIDE PAID
.Dec Rmcip 0
Will the appliont or Tawe buildidefinng by ffic Bu se equir or JMnotswhich BOILER-COMP(3HP OR 100.000 BTU)
Mt haraNaa.0 conu.nunaru.u Jcfml by the Bey Arm Air Quvliry hlnugcmen.
T '
Y >mcIT BOILER-COMP(OVER 100,000 BTU)
❑Yin UNo
Ilene o,,rd ole boneudiw n.verii equircmeme wtdv Chelan 695 of de Celi- AIR CONDITIONER
ISSUANICH DATE
Gimia HohM1 A Safety Cudc.Secrimu 21105.25533 trod 255Jd.1 otnk tail thin it de NEW RESIDENTIAL MECH. SQ.FT,
bWWly does nor awtenJy have a tvtay.duo it Is my mni nuibiluY to rnufy ate umpad
of the rryuitemrnte which muu he rtet priori auvtce ofaCmiliote Mux
Owner or uu ue TOTAL: ISSUED BY.
OFFICE