28617 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'rINO RUILDING-F LLCI'RICAI, i'ENMITNU. ,w
BUILDING DIVISION APPLICATIONIPERNUT PLINIOING-ME CHAN[CAI" 'LJ l8 {V�
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SAN]I'ARY NO. APPLICAI'I(1N SIlNMIIT .DATE
6 2 �' 6�n
O NER'S NAME: PHONE: CONIRA ftl 'S NAME: LIC 0
•��`�/' NIC CONTROL
ItCH7
ITECT❑iNGINI!lik; LIC NO: AUD iSY: ❑ •
CONTACT: PHONE: BUILDING PERMIT INFO
_ /
El Consultant FCU'PBIJ by Applicant(Initial) BLDG ELECT PLU MECH
C W) e C3 ElElLICENSED COM'k ACTON'S DECLARATIONQTYELECTRIC PERMIT FEE
1 facially aHinth Wnt I.,it b«moa under prnri.ions of chapter 9 a,nnmendnr JOB DESCRIPTION
WZ WSmiw]INxllof Division Ld Weliminc»ad Pmfessinm Cdc.mW myliceumin R SIF DENTIAI:
OO wr PERMIT ISSUANCE ❑SITWI. . ❑KITCHEN REMODEL
W full forte unJ0
N<}1 Limnac Clu». (,—Lie.x —Tr/ APPLIANCES-RESIDENl'IAL ❑ADDITION ❑PLUMBINGRGPIPE
to Z a Daln Cumrwmr
FOy ARCHO ECUS DECLARATION YANELS ❑MULTI-UNIT ❑STRUCTURAL
Z02K IankruanJ my pWO,loll beoudaa public rcanrds HPTO 21O AMY5 MODIFICATION
O2-.q ❑INTERIOR ❑CHIMNEY REPAIR
F�t " [.learned Pmfessi..nal 201.100NIAMFS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IIXM1nMl'S ❑BAI'II REMODEIIREPAIR ❑DEMOLITION
yy lY 1 henchy affirm That I ant a.cnhpt hunt the Gan.,.."a Liccnw law IW the
)d�1W fullosing«a.m.I Spniun 7031 S.Du.ineaanl Plotdainn,Cada:Anyalyor foully SIGNS CLECI'RICAL (-]OTHER
YELL BO}�' h h y P u I n o - p de TI repair Y infinite
.aJ pr.l n y IM,applicantl inch tl fl g J rt ret SPECIAL CINCIII'I'/MISC ��,
t.lhu be 11 ' u t 1 III C t' . I 1 ICIquer9
p ->, loom mg wish 1. TXxll Iti r) IB II JI I ( opo I I:Mr M III FR uR 1411.1!INS'1'. CO M RCIAL:
{1. Wu he.s eaahge Ihcml nr n and rhe sn s for tee al.,.d....upson.Any violid rel ❑NEW BLUG/ADDITION ❑UHMOLII'ION
Xm�
Section 7031.5 by any aPPlicun.for L•nnila -ecu lLe oppliomJyu eiv'd"Oollynf POWER DEVIC1'S ❑TIiNANT ❑FOODSERVICE
Y1 inn num loon live hundred Julian(5 Xmll.fncr IMPROVEMENT
.F�.CO []I,c,ownerof the oopi.y.of fly to wages. esnnhpenaotion, SWIMMING Ill ELLCfRIC
wJI Jn Ne wn,A.mol iLe,nncmre anal in IunJlumJfur k eJ1114,Valine,. ❑Ol'IIER
W•�$ sod Dofc»inns Cole: -Be C.... , m V J a u ly to inn owner of UBTIf;IS-SWIICHI'.S-FI%TURES
R' pmpeny won M1uilJa ur imp.. c. J who W,d 'h work himself pr lhmogh
hishis own owevere �-11 it /I, rir not intended or pled...for NEW kISIDEN'I'IAI.IiLECfR SQ FT.
bowvtm.lhe Ida hmpror a ..withinonentendecompkered toe SQ.FL FLOOR AREA ESQ.IT.
wnenbuilJcr wi h: buNcn 01 Wr g IV,e did mK buil)or in,pnnx for Per-
pus.of sale.).
Nor❑1.mow. the pm n culmivcly elffl.61a,with lacread controewnah TO'T'AL:
orrsaam dic pnrjam(Seo.7(A4.Business and Pndassio Coda:)The Commcon',Li-
nselawdoes not apply to an Owner ofpropcny who builds or inhproves there'll.and QT'Y. PLUMBING PERMIT FEE
wbunrmncs Lm,u.h Vmjsa,with a aommemrbl IicpnscJ punuum ro the Cnumnu/a
I.Icenac law. PERMIT ISSUANCE
❑Ian nen iol ankr "n ,H&PC ti,r III,..,an
/ - ALTER-DRAIN&VENT-WATER(VA) VALUATIOt;L
Owner
Date
V((!YER'S COMPHNSAI ION DECLARATION HACK FLOW PROTECT.DEVICEDO Q
r Ihe.byathnm under Penalty of perjury One of the following deflaraliom:
I have and will riuimuin o Cenllicue of Consent.scB-iron.for Workees Compen- DRAINS-FldIOR.ROOF.AREA,COND. STORIES ET
Minn,as provided fu by Senium 3700 of the talar Cole,for the serf amwme of the
..I fpr which this permit is issued. FIXTURES-PER TRAP
❑1 have unit will nwlnlain Worker'.Cumpenaullon Insurance,as recluired by Section
3]1X1 of We Lad Oude.for Wepedmaraffe refill pA for whmilflas permit..issued, GAS-EA.SYSTEM-I INCA OUTLGIS OCC.GROUP
M1ourse, a Iron su licy oar ae:
Carrier: No GAS-EA.GAS-IiA.SYSI'EMOVER 41UA)
CERTIF ATE;OFE%EMPGONFkOM WORKERS' �'G-/ GREASE/INDUSTRL WASTE INFERCEPIOR
C(OMPENSAI ION INSURANCE .}BUIIDINO DIVISION FEES , vadt•,
1'I his mni..nned nu.1.eumpkmd it W,ponnot is fo ane hundred dollar,IS 11X11 GREASE'I'RAI' LANCH-
u,
law)
YLANCIIF.CK PEE
1«nily lout ionic perfull-oeutlheworkba whichlhia permit.,issued.I sho11 SEWER-SANI'I'AHY-STORM EA.21O FT.
nm vnnpL9 unY lasso..man,manner u,m et Leanne subject.0 life W...ken'Compen. ENERGY fEl!
rZ shlimn Iowa of Calilonla.D:nc WAI'Hit IIHAI'1!H WYVI!M'll!I.ECIR
ZO Applw,ad GRADING FEE
NOUCE'IO APPIJCAN'1':II,alter maAing thin Cenilk.l.of Laemplion.You thrift; WAII7R SYST EiM/TRI;APING
[-^ prone 0hjmt u,IM W,ekar'a Com,va,aOnn pruvisiuns of the labor Code.Pu root SOUS FEE
{aJJ
forthwith....reply wallsf,b pookientorlus,onail.hdl hc,kennd tattooed. WATER SERVICE
Q
p' CONSTRUCTION LENDING AGENCY NEW NESIUEN'HAL PLMB. - SQ.PT. IAID Date Rmciptg
I U Q l hereby anion that them is aConstruction lending agency for the perfomtance'l1
D. E" We work for whist,tbia permit i,issued(See.3197.Civ.CI �' JI
OU Leder'IName K ) AL
{IJ Lender's Adlms. TOTAL:
0. 1 certify that I have mad this applieatipn and slate Thal the above information is BUILDING FEE
i.. 0 comms.l aDcem fnstply,with al)lily ulW mum,indentures..fit laws relaingm QTY MECHANICAL PERMIT - FEE r SEISMIC FEE
1 U� building foo Lmoti,m,mWbe,ab,ual....4ampmannaive,0fthi,eily,,crier upon the lip 1,
above-men iuneJ property Int rmpeaion tuallaa,. FERMI T ISSUANCE ELECTRIC FEE
IWe)agree to leve,indemnily unit lot humloa the City of Cupertino against
inhilhia.luJgmenb.coau and ar,lales whiotunny in nay way ucfmo uguimlan!d City ALTER OR ADD'I'0 MECH. PLUMBING MY -
in onoegneme of One graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING upfrao l0.(O cm) MECHANICAL FEE
SOURCE REGI . 'hONS.
.� 7 � � AIR HANDLING UNITIOVER RAN CFMI CONSTRUCTION TAX
Signora ofA cealcoamoemr Du¢ EXHAUST GOOD(WIIIUCI) HOUSING MI'I'IGATIDN FET!
I IALARI%)US MAI EKIALS DISCLOSURE
Will theapplie.ato,lumm budiir,00,upoa,m.ur boot[hn.oloonil HEATING UNIT UO IUhLXO BTU)
in Joined byline Cppenlnu Municipal Code,Chopmr 9.12,and the Health and Safety
Code,Section 23532(ol'r HEATING UNIT(OVER IDLOlO B'10)
❑Vola 0N VEN'I'HAI'IONFAN(SINGLE RESIDE PAID
Dale Reeeipl g
Will lh<applicant of(alumluiLbng'lccurym.....iryneintor devicaa which BOILER-COMPDIIPGN IW,IXO RTU)
h ] uuManu u,defined by the Buy Arca Air Quul ly Mmagemenl
Disaii BOILER-COMP(OVER 100,000131-U)
❑Ye. ON.
I hove mOa,lbs mood,u,matenal,fcrsunder Chapter 695nf the Cali AIR CON DI"I'iONER ISSUANCE.DATE
yn.mdn
fxnia IInIW&Sufny 6W:..ka+inns 255113.:3533 od 23334.1 urukmm�l that if We NEW RESIDLNTInE.MECH. SQ.FT.
builJing Jrca not eau<n0y Love a.aunt.Nm I.is my mai,.nnililiiy ret notily the rOcnpam
of We,ey n fwnwrh uu G Incl Inl{a/y'n of a Candles.,id cu Y. -
I Wil'—` / r— TOTAL: ISSUED B .
Owner a Wo o eJ agrnl if