29088 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIRMIT NO. O
I BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUIL
pINGIADD�S�Ir�Do V ' SANITARY NO. APPLICATIONSUBMITTAL DAJE
OWN D' IN,I FNI 1�3- CO AM y I.N —I
V NIC CONTROL
ARCH .CT/FNGINEER: WC NO ADDRESS: ❑
CO PHONE:
139 1 BUILDING PERMIT INFO
❑ Consultant Fers Paid by Applicant(Initial) BLDG PLUMB EC
❑ ❑
LICENSED CONTRACTOR'S DECLARATION I QTY ELECTRIC PERMIT FEE
L Ie1fL,affion that 1 do Ikcnwd aadar Provuh,nt of Cnaper 9lrnmmcmaing JO DESCRIPTION
:X00 "uh 5fn;oo 2ddB) Sof de Ba,ileaem Pmfeui Code,ao mylicfnrfit RESIDENTIAL
00 in ho"faccard of,ry�p/� °� PERMITLSSOANCE
:RubRub v c'l/ `J ❑ WI, ❑KRCHQJREMODF.L
FQF.
licsex Class Lic.M
VI Qa Dice Cnmmda AI'PLIANCtS-RESIDENTIAL DDRION ❑PLUMBING RE-PIPE
RCHULCf•S DEC V.
Fah I PANELS MULTI-UNIT El STRUCTURAL
z p'n z I undenhuW my Plw shall he coed u Public costals MODIFICATION
Oz-0 t UPTO200AMP5
(- w Llcutwad Prcfcai"nal ❑INTERIOR ❑CHIMNEY REPAIR
CLARATION 2111-1000AMPS IMPROVEMENT
1 bepaIf
by ran and IJEuo a elmp Iioml condors Lisho.Liw fm the OVER IWAMPS ❑BATH REMODEURFPAIR ❑DEMOLITION
K 3 c.F�U. following ri(Senlnn 9031.5.Bulinus i,od Purfts ilmv Costs:Any city or county SIGNS ELECTRICAL El OTH2R
ttl -(; which nulr6 a Porotic to cWfOYCt C11fr.ImPTre,dfm1h ,on rc*r tiny a,UCNR
^Cg Prim toil,iotor,.nls"¢yuires de u,Pliewhossuch psmitto fka signed stamment SPECIAL CIRCUUTvHSC.
�} dal he io licem d psnuem to dr povisuru of the Cuncaclors licrnse law(CKW-9
aC�O (connncncing wid Sccli"n20(XhofD1',m,n 3oflne Enoinceo turd!Pr Codb)or TEMP.METER OR POLE INST. fOMMERCIAL
a a e C du he it c,uun i drrdmn eel do lash for IM 01n,1—so,xi"a Any vml.iian of ❑NEW BLDG/ADDITION ❑DEMOLRION
H
Section 7031.5 by try applicant for aTenni,suhjccls de applicant to a ciyd pndly of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Z} nu moue than five hCM«d&)I—(5500).
C Q ❑� O SWIMMING POOL ELECTRIC IAIPROVEMENf
ill Po de wank,cold the hs,Con a na imcd or Law
do Inn wilt 1Sfc.)1H4,Hetincof ❑OTI1EIt
i �_ erW Nofeuiont Calc The Contracnu's andlu'e lsw loco not apply torn owner of OUTLETS-SWRCHLS-PDCR)RES
pmpny who Wilds M stcad u t ntalh and wW thous stwh tourkmic hinuclf or&cough
his own employ.',povidW That such Improvemcme ere nth inlen4.1 a Mored for NEW RESIDENTIAL ELECfR SQ FT.
sok lLWda, illfbulld, out iffproin iswW within muildorcnmplftiort,the SQ.FT.FLOOR AREA y$Q.FT.
awnlf-W l,.), 0 have chs laden of paving lou Na did lwl build a ugnuvc for or-
Rh
Hl
❑0 1 o ourn). Apo -
1,u owner u de I+open,,.B sal rivfly s„nlrxung wid Iicenrul cnnacdor a to TOTAL:
conelrun IHC Pn'lert 1St.-loth.Buv.f o, h,whoiona l cur 'Re Coohanar'a Li- ]7
w Icourt frwuchPlyloen nwna of lmq+cnywhcw coo in,tows Conty,ar,d QTY, PLUMBING ER FEE L//y ` 11,96
W 110 CMI Wets for NC11 prn)ef4 win 9 CONMCIa(t)KfR1tt1 pY1HWlll10 de Cpdr%y"rl
ticrnm Law, Vr
❑Iamsacmplur Sm. ,B&PCfmdiaruum PERM1tIT ISSUANCE
Owlxr Dxc ALTER-DRAIN&VG'f-WATER IEA) VALQDON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 33 J
I hereby aRmm under pchmaky of Isrjury Me of d<fdbwing declnretianc
❑I have and will cminlnina Cenifcum ofCaomm e,.11-hnure fa Workers Compem DRAINS-FLOOR.ROOF,AN
ewr
iona M, povidRa by Sfcocis 37M of the Labor Cock,fon the pfrfarrrerce of chs STORIES TYPE CONSTRUCTION
wick for which this P.irthl is i..d FIXTURES-PER TRAP
❑ I lust ill n' tern wort«s Comlematim Intmnllce,u rcquirsd M'Scuon
3200 of de n IhcPMumurc<ofthe wok til io is OAS-EA.SYSTEM-I INCYOIITIPfS OCC.GROUP APN
,oh - u ccarticfolicy N,y 1
Cartier. Pdiry No.: KKK/// GAS-EA.SYSIEh1-OVER4RA)
CERTIFICATE( t EXEMP ION FROM WORKERS'
COM NSATION P'SURANCE GREASF/INDUSTRL WASTE LYILRCEPIOR
(Ihinta't ion d nM Inc loondclnl ifdc permit is fMone hunded&,It,(511X) BUILDING DIVISION FEES
M keo.) GREASETRAP PIANCHECK FEE
Iseniny Juin the perfamwmenDdba ,A,to
w1hpahto III, iltci.u'at Corroon SEWER-SANITARY-STORM EA.200 Fr.
IIW employ any 1'ua"n in any rtunner n ea 1"bfcomc suhjm m III,Worlm'CMnPem ENERGY Fl:I:
2 .moan lawn of Culifomie.Darn
� WATER HGTER WNFM/ELF.CTR
O NOTICE
tat GRADING FIiE
- NOIJGB TO Alto' A Artistes
es Corr nlnking du Cfnifiu4 of FLabor ion. .y doalJ HATER STSfEMTtEATING
�E" hrthwi usna,Iothe Work«s Canna ort i, puvi,"of Ids nrirCods,ya matt salts IEE
� fonhwld comply withtuch Pmvisiouadis prmil stall ne defcced revekM WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ FT. PAID
1..) O Inacby effirm thsl lherc ixeunswnion lemling agercY fa thou peRircnwl¢c n[ Date Rfcdpt#
O dm wok fm which d'u Lcnni,is istual(S .309'/,Civ.G)
Lcndu'a Nacos TOTAL
Liam Add«' TOTAL:
CL. I Cenlfy dol l havC ns1 dIt o,dratim Cal mete in.,de above tnfoWwino u BUILDING FIRE
U Z nuildin le tocomplywiddldtyeadcaon,y Mdivmnud> lawsreiatingro QTY MECHANICAL PERMIT FEE
g nmtwnion,and hcleby audMiu repcuenrulvn ofdis ciry,o ever upon d1e SEISMIC FEE
`+ eWve.mrndord p,,,i for inssctiun purposes. m
(Wc)agme 1".alae.llekmmry unl keep banWuo de City a Cupenlw agaimt PEANUT ISSUANCE •JV 1FCTRIC FEE d
IiebBitin,j nu,coslseM th'ms as which troy in any way.,.ngtinst.said City
ALTER OR ADD TO MECH.
mcvnt� f grmdng of lou pefmlt. PLUMBING FEE aa1C V
APPLIC IF. STANDS D WILL COMPLY WITH AL NO -POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE FA V CHANICAL FEE
AIR HANDLING UNIT lOVER[a."CFM) CONs;PBUcTONTAX
Sigmw«of ApplkwlUContru'rtn a EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSUR17
Will chs alTlicenl or nature Wildlog nccupanlstob,mtlmJle heaanknus run ial / HEATING UNIT(TO 100.000 BTU) Z.Z�
u dcfrd b,Oct Cupertiro Municipal Cods.CTupar 9.12,and!Iht Hsallh and Safc,y
Cock.Sedum 2 532(a)P HEATING UNIT(OVER IM."BTU)
❑Yes [I No PAIL)
VENTILATION FAN(SINGLE RFSID) Duh, RvaroplY
Will de eir c nImam building(scby III,B ,.m ,.Air Q l a Devices which HOLLER-COMP QHP OR 100.000 BTU)
I hurvdws air couaminenca u dsf ofd M IW Bay Area Air Quallly Managemrnt ..
�Diiricl! 1 BOILER-COMP(OVER 1011.000 BTU) TGT •' V
0.0.
❑Yn FIN.
l have rd do lnm wmah,nek pu h.95 of de Calm AIR CONURIONER ISSUANCE DATE
mquirtmuas udder Che
fo nia Health&,Wyly Codc.5 Lops 24505,25533 ank dots,
1 cMcrduinJ dux if that, RESIDENTIAL MECH. SQ.Ff.
Wilding dorcwrendy have a rarxn6 dal it is my r,s,,u WIt,d III the ocvm
pu
,fthe or,ulrcrai which.1 to net pnocto uwwnce d•Csnifcue of(kc,.y.
Owner M eudout agent Due TOTAL: uJ I.SSUEDB .
OFFICE