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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
RESIDENTIAL
CSEDWL
RUILDING- E].ECTRICAL
BUILDING DIVISION
APPLICATIONMERMIT
PLUMBING - NIECDANICAL
in full face and! cRea. C l
DRAINS- MAJOR, ROOF. AREA. COND.
PRO//J-EECT/I
BUITIDIN /,
/may
IDDENTIFIC\TIODN
BUBUILLDD%ING
�rtCHITECDENGINHER: r LIUNO AI `RV.
COMEACE PHONE:
❑ Consultant Fern Paid by Applicant (Initial'
z -d 'T t - 38q-0133
RESIDENTIAL
CSEDWL
LICENSEI CONTRACTOR'S DECLARATION
I haraby afftm Cha 1 am Beat urdec proriaias of CTmplm 9 Isminrnrine
QTY
ORLUNIBINGRE-PIPE
with Galion ]IXpI of Division J of IM+Bupinev vd ProRssiom C�xk and my licrnw is
in full face and! cRea. C l
DRAINS- MAJOR, ROOF. AREA. COND.
MODIFICATION
Liccnw Clu Lich
ULc Cauncla
IMPROVEMFNT
E] SWIMMING POOLS
ARCHFfELTS DECIAR 01
1 aakmad nr rlm. atoll m avxl �, loblr rccada
GRFASEBNDUSTRL WASTE. IMfERCEPTOR
Liami Prafecaiorml
GREASE TRAP
OWNER -BUILDER DECLARATION
COMMERCIAL:
1 hereby Wf don I um cxcmpt roan But Concha u's Licene Law for the
ONEWBIDGIADDHION
following maws. LShnim 7031.5. Busimv and I4ofndom Coda: Any city or cI-my
which rryuiry a Permit to cone al, ulter, i Wane, dcmulish, or mpter any omcm un,
[I FOOD SERVICE
priorm itsi.., also quires the applicalt for such pmnin to file sieved Mat.,
that M is livch ad pmruant m the provisien, of Inc C.m.1or, s Li,. Ino Campari)
❑ OTHER
fcmmmain8 with Smiam ]IXI01 of fhvision J dthe Ruairreu ed Itofrnias Cldc) a
dont Im is exempt Ihacfrom sal the Not lar the alk8al cremption. Any violmimn of
TOTAL:
Salim 7031.5 by any applicw for a permit wbjecra the appkWn to a civil penalty M
BUILDING EF.E
mx mxv than Five nualred dollars ($500).
SEISMIC JAHE
I.uawrmrdthc ley ny.amy<mpl%ee with x�gs ver their rok nmpen.vn»n,
tCfRIC 1'EJI 'i
willdothewrxt, and ma strucmmisnoti trcaw
A%TRR OR ADD TO MECO
lofts newaffiec.. im ownaraf
and Pmfessiau Cade: The Comnm� a lurnc Law aaea na eppl, b an rnner of
Lic
pouchy eanrf builds nr impnwo Hereon and wto a himsdf a tlmegr
IIANICAL ICJ?
nuwml
this two pmvidad tan puma impros mil eOcrd fa
s art na Namf
NSIRU.TIONTAXy IJJ
rouchIlisl
ipsold withinore Ynrofannplctfor the
.ole.if. hmwc old
awaeanrfhvumsa�the
Ii HAUST HOOD OVIDUCT)
w ill haatb,Inaentof mmcnt
ocnhuilJcr will ha.e de harden of loving that he did not buil a ingxove for par.
HEATING UNIT (TO 101,000 BTU)
Aac of sale.).
I[BATING UNIT (OVER MOX) B'I'U)
1, us owner of Ile popsahs . am excluively contracting with haucl amnnmlaae It,
comiruct Ora pmjecl (Sec. ]DW, Business and Professimis Ctdit Tlr Comalrc'. U.
Lawdtos tutapply tours oval FInopcny whohuildaurimpmvcs Ihacon. and
QTY,
wva
hoLars fa wch pmjccts with • mnlraOor(.) licenvd pmuvn to the Cmhactnr'p
Llan,- .m Lew.
1 un eaemp adv Sec. . B A P C for Nis mam
her Dat
WORKER'S COMPENSATION DECIARATION
1 hcrtby oRrm order saponify d parjury ate of the fdlmwine deeWntiorn'.
1n.. po WlunWinby a don,37lC nr tm¢nlm Cada. Wer Ina
wnlRre sof tha
u puvidhi fa i Sabo J]UO d the Mbar Cde, for Om prfanmce of Nc
II fa which this ansa is Wal.
1IWvBed will
oda. f mht Phf aidiaan Iruuruemuhi. pacdby Sectio
0, dm Inbar Gde. fur the rrrformnirc of Nc xrul for which Nis pnnit is issued.
CIdKI'IPICATE OR HXEMFFION FROM WORKERS
COMPENSATION INSURANCE
Clhis ration and not he canpldN if the peril is for err hutdml dollars (5100)
ak .)
Ianify pi in Ian pAmw
trcofDoph
wnes fa whichchi. ooisimad.lshall
not cmxd%any peron in any menrer w u to heceve wbjacl to th Watrri Cami
.".a laws of CWifaniu Dam
ZAp bcan \
NOTICE M APPLICANT: 11: uher melon{ this Cent fcam of F enn ion, You should
F lice..wbjeo to Ire Walv'I Comleluaian provisions of the Lebo Coda. You most
foMmith comply with such prnvinims or this pmol shall to deemal mvntcd.
aQ
VU. O CONSTRUCTION LENDING
AGENCY
Il dom Nndrre, Ocuh3m adingvgcaY
far de ptomof
Ne weI,.1hich his prnnt is swwd(See 097,
Cis. C.)
Ladd. Nano
Isdcfreu
Add
I anify NuI I Use mad Chir Spplicaim old sate Out Or edwc infmtWdm it
fa/1 cumtts.l agree to comply with all city and asuraY adinarra ard..,.c lvwx relninem QTY.
Z idmg amstatiun. vert hcrchy vulM peon wnm ism ArlM1is dry wrnmruxw lnc
aMvc.msuiuml pmprty for imNecdm purishi .
(We) agree hr wvc, iMnnaify and keep harmless the City (A Cuts, aypimM
Iubihtin.jdpphi amps ed cxpuca which maymany•ay amarum afpu pwd City
im onquer Af the Branting of this pcmdl.
APPLItt VSiDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HA%ARI)OUS MAMIALS DISCLOSURE
W R Int a Cul,int rr Tatum Fui ! Co ut Chant stere a hvdle hazrvdous moa f ty
damned by the Cuprniro MunkipW Cak, Cnaptn 9. 12, and the HaIN cont Safety
de, Ga lm 25332(aTt
❑ Yea No
Will the ePpfchm a future hi inF attvrymt mat
�uipmrnt m davices which
aamNuux air cmtamiwd. err final by 0o Bay Arta Nr UsWity Ntmmgcmrnt
kt?
C Yc. No
bustmadthe h:vudlmx 'uI quimn¢ I orderChupier6x95ofdmCali-
famia HnIN A , v Cak. Sec 2531H. 25511 lid 35531. 1 udnuad that if de
"mmmBdrean ¢m LNolilislnyrcynn.ihillylnmxifylMaxvpanl
of Oe ttA aper to iwu¢x d a CemifiAcor'IicjeIw v.
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 300 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TlIAIR METER OR MIA; INST.
POWER DEVICES
SWIMMING POOL id FCfRIC
OUO.ETS - SWITCHES - FIX7
NEW RESIDENTIAL EIEC R SQ
L■
BUILDING PERMIT INFO
LDC, ELECT PLUMB MECH
❑ ❑ ck�' ❑
JOB DESCRIPIION
RESIDENTIAL
CSEDWL
❑KfTCHENREMODEI.
❑ADDITION
ORLUNIBINGRE-PIPE
CMULTI-UNIT
CSTRUCTURAL
DRAINS- MAJOR, ROOF. AREA. COND.
MODIFICATION
C INTERIOR
CCHIMNEYREPAIR
IMPROVEMFNT
E] SWIMMING POOLS
C BATH REMODEL/REPAIR CDEMOLIHION
O OTHER
GRFASEBNDUSTRL WASTE. IMfERCEPTOR
BUILDING DIVISION ITIS
GREASE TRAP
PIANCHECK FEE
COMMERCIAL:
ENERGY IEE
ONEWBIDGIADDHION
❑DEMOLITION
CTENANT
[I FOOD SERVICE
IMPROVEMENT
PAID
❑ OTHER
Dae Receipt N
SQ. FT. FLOOR AREA
PLUMBING PERMIT FEE
PERMIT ISSUANCE. S
ALTER - DRAIN Sa VENT - WATER (EA)
VALUATION
HACK II.OW PROTECT. DEVICE
DRAINS- MAJOR, ROOF. AREA. COND.
STORIES
TYPEC(
IIX'IURES - PER TRAP
GAS-FA.SYSI M-IINCAO11'ILEIS
OCC, GROUP
2-( P
GAS - EA. SYSTEM-OVI'R A (FA)
GRFASEBNDUSTRL WASTE. IMfERCEPTOR
BUILDING DIVISION ITIS
GREASE TRAP
PIANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT
ENERGY IEE
WATER HEATER W)VENTIE:LEC-FR '
GRADING IYt
WATER SYRUE IREATING
SOUS FEE
WATER SERVICE
PAID
N EW RESIDENTIAL%,MB. SQ, IT
Dae Receipt N
TOTAL:
TOTAL
BUILDING EF.E
MECHANICAL PERMIT FEE
SEISMIC JAHE
PERMIT ISSUANCE
tCfRIC 1'EJI 'i
A%TRR OR ADD TO MECO
ICING WE
AIR HANDLING AND 10 10.000 Mli
IIANICAL ICJ?
AIR HANDLING UNIT(OVER 10.000CF&D
NSIRU.TIONTAXy IJJ
I
V
Ii HAUST HOOD OVIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 101,000 BTU)
By
I[BATING UNIT (OVER MOX) B'I'U)
VPNI'I IATI ON IAN RI NGLII RESI1)
BORAR-COMP (311P OR IIXDXX) IIT -B
IIOIL17R -COMP (OVER 11X1.010 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MF.CH. SQ. IT
OFFICE
TOTAL
PAID
DataR aipt N
TOTAL:
ISSUANCE DATE
ISSUEIX BY:
s/SQ, FT