S 1822 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL -L. \V PEBA1IT N0. 1822^y8^ �a
2 '2
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS w SANITARY NO. AI.1'LICAI'IUN SUHMI'ITAI.DATE
OWNER' NAM 111ION,: CON TRACTOR'S NAME: - LIC NO: N/C CONTROL
1 t 47� 6 - o l u
ARCH]ITCf/EbIGINEER: L NO: A)DRES,: ❑
CONTE PHONE. - BUILDING PERMIT INFO
�/ tl�YO a 4r3'V71 ❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMtl wl�n
❑ ElICJ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm Nat I am licenm massonIs of Chapter 9(commencing
QWZ OWC iif PfiC ded m )i n is
RESIDENTIAL'
F in full ome and OPERMII ISSUANCE ❑SPDWL
[I KITCHEN REMODEL
CLicasaCLia.U
APPLIANCES—RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
F7W Date Contractor
y a ❑MULTI-UbHT [I STRUCTURAL
=anARCHITECTS DECLARA'ION
z O`�z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ4O UPT0200AMPS [I INTERIOR [I CHIMNEY REPAIR
r4 z9 Licensed Prol'es6ouel 201.1000AMPS IMPROVEMENT 0SWIMMING POOLS
CqC� OWNER-HUILDER DECLARATION OVER Iqp AMPS ❑BATH RI!MODEUREPAIR EI DEMOLITION
a 1 hereby of oor that I am exempt from the Contract,,,',License Law far the
O LLF fallowing reason.(Semina 7031.5,Baxincas and Professions Cade:Any city m county SIGNS ELECTRICAL ❑OfHiiR
O,� which require.a Permit to c,,n,l alsr,improve,Or lisp,nr to air any eweture
�� priannin issrnce,also requires the applicant fnr reh pc fie III Oinedsmmmcm SPECIAL CIRCUIT/MISC. e
Mp. that he is licensed pursuant to the provisions of the nnmxt I'sL nsel.aw(Clmptm9
apo (commencing with Section 9(0X001 Divisions oftri s WPn hasainns Cnit)or '1'EMP.MFSERORPOLEINST COMMERCIAL
that he is exempt Ihemtrmn and the hxsix Inr the�mpnian.Any violation Or ❑NEW BLUGIAODIDON ❑DEMOLITION
Wim Scminn 703 1.5 any applicant fora\,s hjec cup sora mvcivil penahy of PUWER DEVICCS ❑TENANT ❑FOOD SERVICE.
n more than live hurdred drift.(E IMPROVEMENT
❑Lm,,wnerafthep rpxfXu,m, esw wagnnifficu,mae..mpen,aian, SWIMMINGPOOLELECIRIC
w.11 Jct the work,and estmmuremna ITercJ lbr.ule(Sec.7W4,Nusine,.v ❑OTHER
Wand Professions CI f The Con( mease Law does nut apply m an owner of OU'Il.l?TS—SWITCHF'_S—I'IXTURES �-
propcny who build:n Improves td who dies such work himself or through I r_
his own employee. provided m s impmvcments are not intended or offered Inr NEW REST DIRG IAL ELECTR SQ FL t
sale,IL however. mildin rimprov mm is sold within one ynmal'crnnplctloo,the IFI FLOOR AREA E/5
�,waer-hailder will a amen or proving that he did not build or improve for put- 'I� MAY p 5 99
w,c of sola.).
❑ ta
1,as owner of the props y,am eseluskal,cantracdarlwith licensed m:mracmrs to T( SII
mmamct the project(Sec. Business and Professions Code.)Use Cnnaanar's Li- IJ
cense law does not apply to owner of property who builds or improves(hereon,and QTY PLUMBING PERMIT FEE
who contracts lin such pmjectx with a contractors)licensed pumuanua the Contractor's y
Liccnac Law. PERMIT ISSUANCE Il.—ll--'-
❑ I am exempt under Sce. ,R&P C far this reman
ASTER—DRAIN&VIiNT—WATER(EA) VALUATION
• Owner Dare
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I hereby alfmt under penalty of perjury nm:of the logrolling Jcda,miuns J Ve
ElIhave andwillmainminaCertifrm of ConxentlwclT-insurelor Wndcr'xCompen- / DRAINS—FLOOR,ROOP,AR STORIES TYPE CONSTRUCI'[ON
radon,os provided for by Section 3900 of the Labor Coda,tar Thu performance of the
k for which this permit is issued. FUTURES—PER TRAP
I have and will mammin Worker's Compensation Insurance,as reyuirtd by Section
aide Lahn,Cadc,lot he pcdnmmnce of the.,it far wamh,hi,permit is issued. OAS—EA.SYSTEM-1 INC.40UTLETS OCC GROUP APN
My WorIt sCa amarm,am lnsumnyc dl'alicynti her re GAS—FA.SYSTEM-OVER 4(EA)
Carnar: .(./¢ !! fcy No.:
C17 IF!CA E OF EXE TION FROM WOR E S GREASI'ANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FRES
DTisscnion need not be complcmd iOm permit is future hundred dollors($Ilk) GREASE THAI'
ca,Icss) PLANCHLCK FCC
I cenily lM1m intoe pednnnance of.hawnrk for wM1ichthispcmtil is issueQlnhall SEWER—SANITARY—STORM EA.2110 FT.
not emyploany p iram to any manna so as to became subject to Ire Workers'G:mpem ENERGY FEE
z, smion Laws of California.Data WATER HFATI3R W/VENTIFLECTR
z Q GRADING P[E
Applicant
ti
y NOTICE TO APPLICANT.If,after marking Ibis CmOicme Of Exemption,you should WATER SYSTPM/TREATING SOILS FEE
Er become subject to the Wmker's COOtpensmlon provisions of the Labor Cade,you must
fnnhwith comply witnnmh pnwlsiorx or this rimmitshall M deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NF.W RESIDENTIAL PLMH. SQ.FC PATO Dye ReceilnN
U O I for which
hh this a r n lk issued(See.;30 leading agency tar the peHnmtree ar
� the work for which This penult is IxmeJ(Sec.1R)].Civ.C.) 'fOTAI.:
0 U I.a.ndcr's Near,
} Lcnder,Addmss TOTAL'
1 eyenifIhm 1 have real Inls application and,tam m:u the ohove mrom alion is BUILDING I '
Fr lay cancer l agree to comply with all city and county ordinmces and state laws alining to QTY. MECHANICAL PERMIT FEE SEISMICFF '
U 7, building connnuaian,and heathy uudir ivc m,mvematives Of this city m enmrupan the
` rhove-mcmioned Pmpcny for inspection purposes. PERMIT ISSUANCE F.LECTR I E
(We)agree m cavo,indemnify and keep hvnnlexs the City of Cupatinn against
Iiahi'dies,judgments,costs and experes which may in any way accrue against said City ALTER OR ADD TO MECII. PLUMBINGTW
in mwyuance of the granting of this panni..
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO H),M)CFM) MECHANIC ,ITE O
SOURCE.REGULATIONS.
' AIR HANDLING UNIT(OVEN IRrXm CIM) CONSTRUCT[( FAX
SinamreofApPlicvnVC,,nnram 'Dam— EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARD US MATERIALS DISCLOSURE
Will he applicant or fumm buildingoocupam smrenr handle haaanlr,material HEWING UNIT LTO 10B.0(ID HTILO f
os defined by the Cupertino Municipal Calc,Crispier 9.12,and the I Ie,Ith said Safety
Coal,CoSection 25533(u)1 HEATING UNIT(OVER 100.(X)BTU) -
0Yca ❑NO VENTILATION FAN(SINGLE RESIDE PAID
Data ReeeiptY
•
Will the applicant or future building occupant us equipment or devices which BOILER—COMP DHL'OR I00OX)BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management YfAL L/
District? BOILER—COMP(OVER 100Jc0 BTU)
L]Ya, t_J tact
1 rime medium hemnlous mamdys requimnmms under Chapter fi n5 of the Cali- I AIR CONDI'DONER ISSUANCE DATE n
frmin Health&Safety Calc,Sections 3 m
505,3511 and 11114,1 unde:xnd thin if E Ire NEW RESIDENTIAL MF.CU SQ.FP. T 9
building Jces not currently have a term,that a k my respunsibiliry to unify the occupant
,II requncomm,wMch must Fm mel pnu,mi.atimatife Ce 'fte m Ixcup,mcy. �J//'�
Ow rasilemor ri agent ill m TOTA C SSUED BY: T
OFFICE
ADDITIONAL PERMIT FEES&S
BUILDING PROJECT IDENTIFICATION yVALUATION
DD�DREu�2�
OWNE"
NAME FEE SUMMARY
PNOxE
DOMI.^C*DR S BUILDING
NAME
LIC.xo. PLAN CHECK
CONTRACTORS FEE
ADDRE
Pxoxi SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL V, D
SIGNS D
TOTAL
SIGNS TRANS.
SPECIAL CIRCUIT
vERmlr VALIDATIONEMP.METER OR POLE INS.
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Zz
F o TOTAL
WH ISSUANCE DATE
> OTY. PLUMBING PERMIT FEE BLDG. ELECT. PEG. MECH.
tl
Z) Z ALTERDRAIN&VENT-WA TER(EA.) El 11 1-1 1:1
00 BACK FLOW PROTECT.DEVICE
LL O W DRAWS-FLOOR.ROOF,AREA,COND.
a FIXTURES-PER TRAP
HZ GAS-EA.SYSTEM-1 INC.4OUTLETS
V GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPR INKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAI
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT 1TO I0=CF.M)
AIR HANDLING UNIT(OVER 10=CF.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COMP 13 H.P.or 100,000 B.T.U.)
801 LERCOMP(0-,1.LAID aTU)SEE FEE SCH.
TOTAL