30110 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30110 O 1 1 O
BUILDING DIVISION APPLICATIONIPERMIT' PLUMBING-MECHANICAI, <J
BUILDING.PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APP6A=ONLDA
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MEHONEC RAIOR'SNAMO
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CONTACT: PHONE:3 / BUILDING PERMIT INFO
OL Consultant Fces Paid by Applicant(Initial) a CT PL IMB M 'H.32
LICENSED CONTRACTOR'S DECLARATION �iQTy ELECTRIC PERMIT FEE
I neseby of irm anal t.rot licensed under Po,skials of Clrnper 9(comisnorina I JOB DESCRIPTION
with Smion 7007 fDiviawn J rNbe B.Inas and suits Cade, Wro,lics sex
,IOp ` � RESIDENTIAL
�LLF in full fume and ellen IG%-- PERMIT ISSUANCE -
Qk-VZ V En CADDIL ❑KITCHEN
PLUMBING
REMODEL
tn6LL Dem Cnmrnnur APPLIARCF_S-RESIDENTIAL ❑ADDITION ❑PLUMBIBG RE-PIPE
~O=3 AR IECGS DECLARATION PPANELS ❑MULTI-UNIT CSTRUC'IVRAL
Z
n1 unds mend my plans shull ba umd m Ielhlic mu,md MODIFICATION
OZ-M UPTO"AMPS
-,�I"' U ❑EJTERIOR ❑CIIIMNEY REPAIR
1 UccnsW Profesnlonul 101-i"AMPS IMPROVEMFNT
Qy, W Oot Ion exempt R DECLARATION OVER ILU)AMPS C BATH REMODEfBEPA1R C DEMOLITION
Q 1 M1cmM1y nTm�Thom 1 um Hump from the DECLARATION
Lianm law for Ne
O W U folWwill�rea��n.(Smivn 7031.5.Buaucxs vld Pmfeuiona Codes;Any city or Hammy SIGNS ELECTRICAL. OTHER
YI'3 LL N¢ which rtyuiru o perinil m comlmcl,alley,improve,demolish,or repair any.turt
prior to its ivsuarce..lso requires(bc ap,licam fior ch permit Bk a timed N IPe SPECIAL CIR LSC.
Tom hcislicewiffiSr.tied tolhepmviAsin 3 oOWHusimur'.s D-oHiaw(CM1nper9
0 (<mnmercing villi Section 7000)dUivisionJollle Businessud lTofeuianaCoJc)a TEhSP.Miil ORF). T.
6 a
that he is escmF WcmGom and Je mLq fm be allcgnf exemption,Any violemdn of 'FW BLD ADDITIO ❑DEMOLITION
�h Section 7031 by any eppIm-1for.Permit auhjccu IM.,dicunmo•civil pcnelty of POWIiR DG CL ❑TENANT ❑FOODSERVICE
~ZQnot mom tMn five hundml dollu.(SSW).
❑ 1.mownerof be Pmpeny,or my employees with w.ges m their sole comllensmion, SWIMMING POOLE IC IMPROVEMENT
€� will dote work.and ane auucuuc is not inmtdcd w o0emd for sak(Sa.7641,BuJvess ❑OTHER
W vii end Pmfesdons Cade:The Cmaenors License law docs not apply o en,weer of OIITI,FTS-SWITCIiI' RCS f•; P
d3- hi,owywhohces,primped Ili Wemue,udwhodmm wartccd or ofJuwgh
his own however,
to Provided IM111 such impravemenla vee rod imerdM or offend for NEW RESIDENTIAL I:LLCTR SQ PT.
m,mer awever.Ihebui 0s,hin impnvcmin,our liwhdnoa ycraf cmopinwe,tM1e SQ.IL,�REASJITa-0ui ywill M1nv<mhe M1urdrn of proving lMl M1c did wN hulJwimpruve fnr �nwn pati of sale).❑ I,awwrur uflM pmpeny,.m cxdusivdy n%Illaclink wile liLnnxdrnnlrvcblmop onalvucl the prucm(9a.]D4i,Blniva.and Pmfeuidu CLdc:)TIe Convxm�s Li- U ��QTY. PLUMBING PERMIT `
winces sfasl hProjectsviNacam Ws)lkensn1Pr Bothe C(mia rs
IJwrcr Date.1 mlaw. PERMIT ISSUANCE
eaclslpt under Sec. ,B&PCfwmnitoc.
\ ALTER DRAIN � VALU
r 1
WORKER'S COMPENSATION
COry DECLARATION
lHACK FLOW PROTECT.DEVICE
I hmby under pulty arcijuy one of lAfollowng n
31
L] IMve and!will nmdnlyn.Ccnifcale ofConerv nmlf-irmoma for Worktm:Cormrn- DRAINS-FLOOR.ROOF,AREA,
GOND. STORIES TVI'li ONS UCfION
mmian,as Provided fa by Section 37(X)of the Lahor Cafe,lou the pcK,.e of ate
work for which(his permit u mum KTURES-PER TRAP to
I b.ve and will nmimain Workers Compenseiiun lm,co e,v m4uiml by Secrim
3]W Mlhc later Code.roe lM1e pcR«Morse ofthc woh fa which❑hie pemdt uiuud. GAS-EA.SYSTEI-IINC.d OUTLETS
OC .GROUP APN
Came,.
Cwnlznmtion Imumrcecathud Pdiry,other ore:
�Cnuier: Policy Na.: ' GAS-EA.SYSTEM-OVER d(FA) �
CIiRTIFICCOMPE SATIONIINN FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This mdiourcedmom heeonsplmed ifthcprnni(is for one huMnel dammers(SI W) BUILDING qVISION IFFS
or leu) GRPASETRAP PLANCIIECK IEE
FOR,
rda:w.r4 GrwhicM1 dlLv pcnnil ix irvaU.l ihnli' SEWER-SANITARY-STORM FA.1(p W, k
Z W, Ph 1 Is' i Como- F,NERGV FEE I
z O A A,S- - WATER NEATER WNENTfCLECHt O -11
7T�T�T GNADING FE9
NOT[ tm8 Nu eC nlTle'CtLTI FaellyNnn,Jw should WATER SYSTEMrTRFATING
I-- '-' b¢mesubject to Wa Ww4sra ComMitation Possnott of the lahar Code,eau mux SOILS PEE
Lu foMwil r comply with_mcM1 pmvinilxLv or Nis permit shell Wd enoecl m,oE d. WATER SERVICE
a �
.`T. Z CONHim1 is.com Li lend AGENCY NEW RFSIDEI.TIAL PLM H. SQ,Ff. PAID
V 1c for loiffirson ch
sronti isocatlarNendioe agency ear lhepMmnurce of Oele kari
OL) Lc work for wh'Ich Nin,pcmlit is issunl(Sr,,..309].civ.C.) .
V LcMee,,Nane
} 1<IderI AJJmu _ \
F 0. I anify IM1et 1 M1nve mW Chia applicvti,n end nmm Ihv the aMve inf,nlueun n BUILDING FEE
to alrrcc7.l vgmc 1,compty v'ilh.11 city erd mlmy Wlnnasand arvc laws mlasinym QTY, MECHANICAL PERMIT FEE
building camlructim and hereby roti ric,snes,roamwx of this city to erier upon lbs SEISMIC IEE '
.bavc-mcvJarml Property,For im scaon purposes, T'ERMITISSUANCE
(Wc).gme n sove,indemndy end kc hormI "IM1e cry ofc.,do o against ELEMIC FEE
IivNtitic.s.jadg arw eapemcsv ' mayin wyaccfueeg.iwmid City
_ ALTER OR ADD TO MECH. .� ^`
r he I 8-f is Pr PLUMBING FIRE (fJ
APPIaA DER.'AN AN LLC LYWITH ALL NON-POINT ALR HANDLING UNIT TO IO.gp CFM)
SO UI 5. MECHANICAL FEE
AIR HANDLING UNIT(OVER IO,(IgI CFM) CONSTRUCDONTAK
Si,protore of A,ican✓C... v Dome E%HAUSTHGODOMMUCn
HAZARDOUS MATERIALS DISCLOSURE HOUSING MrOGAT10N IFP
Will the appiicva orfdum nodding uccupem Uwe or handle berardous material HEATING UNIT TO 10P.(U)BTU)
m JcfnN by Ine Cupcnimn Municipal Cede,Chasten 4,11,and do,lieallh ud Safe,
Cale,Smbn$532(.)'1 HEATING UNIT(OVER 1 W.(X)0 BTU)
❑Ycs [INo VENTILATION PAN(SINGLE RPSID) PAID
Dau Reccip Y
Will the it coram in future building by th,Bl u.e equipment 1h devices which BOILER-COMP IJHP OR I(Ml,gl(1 BTU)
rm hvudaus it<Im(amitunts ea dcfml by Nc PaY Arm Air(juolity MvwLcrrcnl
` Dismcl:' TOTAh
❑Yes E)No BOILER-COMP(OVER IW,(M BTU)
I have mad the bnvrdus im m.ls AIR CONDITIONER
m,u 533 m.wafer❑mina 645of Int:coli- ISSUANCE DATE
fomes,duct& Orr Cade.Smits2]303.2553]W255}1.1 ulld[rVeal Jutifthe NEW RESIDF:NTAI,MFLH. SQ FT.
aSi inQd:am "whidy have be
moth11hr,it isnrylvpalsC rfflrmaxil Yale ADW,.
N the requumenLa vfiich Itw be mel prim b iasuvex af.CeniCrae 0.r Oaigancy.
Owoeraauwnmd.gent Dete A ISSUED BY:
OFFICE