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CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUURUNG-MECHANICAL
k1/11 11SG PROJECT IDENTIFICATION
PF. Il' NO
J 2128
BUILDING ADDRESS:
r
SANITARY NO.
APPLICATION SUBMII.1'AL DATE
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❑
CONTROLM
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IT=GINEER:
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CONTACT: y�: `
BUILDING PERMIT INFO
wBGyla:
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❑ Consultant Fees Paid by Applicant (Initial)
LDG MECH
R ❑ ❑
LWENSED CONTRACTOR'S DECLARATION
I hereby affirm that I an, Bdem,m miller pro.i%ions of Chapter 9 thommentleg
calm section 7alU)nl Division3of me Busincssu ill, fie ions Calc nndmylicemeis
a in full force and effect. �-
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
bFUWL KITCHEN REMODEL
I] ❑
PHRMIT ISSUANC[
APPLIANCES -RESIDENTIAL
LicensC Lic.p
D:ne canwcmr
❑AUDITION [I PLUMBING BE PIPE
C] MULTI -UNIT ❑STRUCTURAL.
MOUIPICATION
El INTERIOR [D CHIMNEY REPAIR
IMPROVEMENT SWIMh11NG PCOIS
i kC111TECT'S OEChARA'I'ION
• 1 undersiond lily Plans shall ba used es public records
1 Liceoeed Professional
PANIJ.S
UP 10200 AMPS
201-IdflOAMPS
OWNER -BUILDER DECLARATION
1 hereby offirin mat 1 .m exempt firm me Comeanor's License Law for the
bulletin, reuo n. (Sectioo 703 L5. Business and Proa,inns Code: Any oily or county
A'THRV1E EIJ :AIR DEMOLITION
❑ OTHIik
OVER I000AMPl
SIGNS ELECTRICAL
j which requires a permit to canswa. alar, improve, demolish. of repair any amnure
SPECIAL CIRCUIT/MISC.
prior to its issuance, also requires the applicant for permit o file a signed statement
1 that he is lidensedporsmnun[he loolloons of me Cnml.cho s License law(Chapmr 9
(conmmnding wish Seen l70W)ofUSM......3my thslWoorse and Professions Cadu)nr
he is coral[ therd}n land the basis fir meallugul caempfin 0. Any vinle innof
..3M 1'. M ET ER OR POLI. I NS' I'.That
DG/ADDITION ❑DEMOLI'T'ION
Section]031.5 by any applicant for o Forme subjects the applicant m a civil penalty of
n mareman five hmmdmd dollars (8500} I, as Owner or the norm Ines with waes as their sole cote tion,
and me amendedm
❑ prvpe ci yemp Y g ,crss willPr
Businessand
POWER DEVICES
❑FOODSERVICE
SWIMMING POOL ELECTRICEMENT
he Coloisnot
liework.
aw dos not a(Sec. Loan
Professions Culc: The Contractors, law dins no[ apply Rs un owner of
OUTLITS-SWITCHILS-ITXTURES
kE3
NI3W RIiSNF.NTIAl. I3LL'CrB SQ PI'.
ad a
ho, own wM1. builAs or impedes ,such i and whodun such work dial o forthroghhisown owe,sr. On provided mot tech impnw,menu ire not intended or clition. far
ealc.ILhowever. the hnilding Orimmnrvammna ixsld within one yeundconaplctinn. me
Tf. FLOOR ARCA
SISQ, FI'.
ownorbuilder will hive the huNen of Frnving [hit( he did not build or improve for par -
pow of sale.).
❑ 1, to owner of the property. am exclusively contracting with licensed contractors to
tO
TOTAL:
msmact the prefers (See. 7011, Business and Professions Cale:) The Contractors Li-
selawdoesnmapplymaniscaner ofpmpely who hiolds a, improve, moment it
QTY. PLUMBING PERMIT F•
who contracts for such projems with a convenors) licensed pars...... me Comracmr s
License Law,
PERMIT ISSUANCE
71 1 am exemm amid, Sec. . B & PC lin this reason
ALI'13R-BRAIN & VENT'- WATER (EA)
VALUATION
Owner nae
WORKERCOMPP,NSAI'ION DECLARATION
under of me following
y it mai under pemalD of decWorkers
BACK FLOW PROTECT. DEVICE
' crJ O
DRAINS - FLOOR, RWP,AREA, GOND.
STORIES
TYPE CONSTRUCfIOD
orlon enc
have and o r WmkeRCd
❑on,a%andwill maintaineCertificate ofConsmnr
Covidensur the of
,clink, as provided (or Section 3]IX) of the Labor Code, for the perfnmtmce of the
ark for which this Feted[ is issued.
,,
PLX'I'URF,S -PEk TRAP
w Insurance, h his red by Section
Workerpedis Come (,film
haveandwill node, for
3 0nftho Labor Cada, lirt the perfommnsx of abe work for which this pennh as Issued.
OCC GROUP
AYN
GAS - EA$ OUTLETS
My Wnrke,'' nnpcau': Insnrtnec a ''�nA Polley n:
Currier: f,MPTI ldy No,RO
S-13Ag $'I?M-0 - (13A)
GRL'IIINDUS'1'HI. S" INTERCEFTOR
Clil IFICAT$OP 'XEMITION IBOM WORKIiHs'
AF O
C MPFNSATIONINtiI1RANCE
BUILDING DIVISION FF.FS_
(This section need not lb, completed if the permit is for one haahcd dollars _�
or loss.)
REAS R '
1'LANCHECK FEE
pWHR-SANITARY -, iIIIA. 200 FE
Ienify that in the performance ofine work for which this Fennh is ia,.ed, I
not employ any penin in any manner so as m become subject m the Worker: Co a
ENERGY FEE
WATER THEATER WNRN'f/p, R
' aa(inn Lows of Culifaniu. Dae
/applicant
GRADING FEE
NOTICE TO AYI'LICAN'1': If, after making this Cleffeac of Exenp[ion, you ld mIg
became subject to the Workers Compensation pmv s of the Labor Code. you pu
G
SOLI S RLE v
WADER SERVICE
fnnhwiNidand, with such pnecomnso, his penall,mll d: deemed revoked
i
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the prommmnce of
[he asork for which this permit is issued (See. 3197, Civ. C.)
Lenders Name
PAID
D Rceeiptp
NEW RESIDENTIAL PI.MB. SQ, FT.
TOTAL:
I A -' JD
Lender's Addles,
BUILDING FEE
1 certify that I have read this application and amt, that the a ild information is
9 correct. l.greem comply with all lily and countyoMnances and smmlawsreletingto
building constriction, and hereby authorize mprescomice afthis city to enter upon the
HANICAL PERMIT FEE
QTY.MFIANIDIANGUN
SEISMIC FEE
NCE.
ELECTRIC FEE
above .,blamed pmpeny for inspection p i"sm.
(We) agree to save, indemnify and keep harmless the City of Cuperino against
ALTER TOMECH.
PIAMRING
Iieddities,judgmcros.cook and caprmcs which may in any wayaccmcagains[said City
in consequence of the grouting of this peraid,
UNI'I'('H) I,ddd CFM]
MIiC11ANICAL FEE
APPLICANT' UN PERS'I'AN US AND WILT, COMPLY WTI 'II AI.I. NON POINT
SOURCE REGULATIONS.G
UNI'I'(OVER IOAIy CFM)
CONSTRUCTION TAX
Signature id Applirma Convecto, Dae
D IW/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100.000 BIL)
Will the applicant or hature building necupant stare or handle hmtNau,material
us defined by the Cotten ince Municipal Ude, Chapter 9.12, and the health and Safety
Code, Section 2553200?
PpA'PING UNIT (OVER 119.0X0 BTU)
VI3N'I'ILAT'IONIANISINOI.HRESID)
El Yes [I No
PAID Date Receipt#
Will he aFplodia nr future building ucrumid use equipment nr devices which
emit hevalloas air comminutes as defined by the Bay Area Air Quality Management
BORER -COMP (3111' OR Ilq,lpll BTU)
TOT
Dis[ri<C
❑Yes ❑Nn
BOILER-COMP(OVER I00,0a)RTU)
�
AIR CONDITIONER
Ihrvercad the hsrmdous materials nNiiremenu under- Chapter- 6,95 of the Cali-
fnmi. Heath & Safely Gale, Sections 255115, 25533 and 115311 mnderann l that if the
/j ISSUAN EDATE
Q /- �� g
NEW RESIDENTIAL MI3CH, SQ. lel'.
building does nor cnrmmly hada a tenant, that i1 is any responsibility to nol lfy Lha oceup.m
at [tic requiremnn, which must he me[ prior to ishuunce of a Cerllfcate u1'Occ quallY.
ISSUED BY:
TOTAL:
Owner m iumbomed agent Date
OFFICE