29443 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUIIAING-ELECTRICAL. PERMITNO.
BUILDINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29 �I �I
J 4 4
BUILDINGADDRESS: SHW - SANITARY NO. APPLICATION SUHMIITAI.DATE
I Lt-
OW AMI tea— IHOp CON RACIDR'S NAME: LIC NO:
�• ss NIC CONTROL
•NRCHIT ECDENGINEER: LIC NO: ADDRCSS: ❑ .
COMPACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG " ELECT PLUMB ML -
❑ ❑ ❑
LICENSEDCONTRACTOR'S under S oom to f LION QTY ELECTRIC PERMIT FEE EJ
1 ion:ny nmrm Na I am Brtaaw under pmvi,hm..ofchapx.r 9(commencing JOB DESCRIPTION
O0Z with Scctinn]IMgp ol'Uivicinn3 ofthc l3uaine,x and PndnsinnsCwe,and mylimnxc is
WOO PERMIT ISSUANCE RESIDF,NTIAL'
ce in forceand effect.
aUU License Class Lich ❑SFDWL E-)KITCHEN REMODEL
yZW Dae Contractor APPLIANCLS-RESIDENTIAL []ADDITION -[I PLUMBING RE-PIPE
ARCHITECPS DECLARATION [I MULL-UNIT [I STRUCTURAL
iZpyZ 1unJemmnd my plans anal)be usW mpuhlic raoNPANELS s MODIFlCAI'ION
OZ—Q UPT02W AMPS [I INTERIOR ❑CHIMNEY REPAIR
F'P F•W Licensed l'Infeaaionaf 201-1000AMPS IMPROVEMENT
y W OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
OL Q 1 hemby a0irm nM1at 1 am c+cmpl Boothe Comrvctnr'a Liccnx Law for nM1c
X 3 a U following re—m.(Section]0315,Business and Prefcssions Code:Any city or county SIGNS 17LEC'IBICAL C1 OTHER ���qr�_
R] p.vFai which mi a{gout sur construct.alter,improve demolish,or repair any murmurs - i j,J�[.{�r,Xj�Vy�•
as prior to its svoonuc.soon mpuims the applicant for such p,,rinitit)file a signed statement SPECIAL.CIRCULI'/MISQ
��- Nal he is Eta,xd ponaam u,the proviotmot me Coul,ulnr.U.n.e Lawfchapmr9 COMMERCIAL
� C, (comnmrmingwith Scaion]0(XJof Division3otnhe Bnorev unit Ponfissionu Cndc)or TIiMI'.MlPllpt Oli POLE INST.
a m ey that he is exanpt therefrom and the basis for[tic alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOL1'TION,
km4 Section A13L5 by tiny applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
ul�tn El TENANT ❑FOODSERVICE.
TSGnot mon:than Ove hundred dollars(SSW IMPROVEMENT). IMPROVEMENT
❑ Lo the work,the pestruc,unnyemployecs with wagcaaaheinale 0m1,Business SWIMMING POOL IiLIiCTRIC ,
F will Jo Nc work.Code
The structure is intended draw dofor sout apply to
Business BOTHER
L3 m and eny who bs Gdc:The Contractor's theta's Liccnx Law does out apply m an owner of OUTLETS-SWI'fCf{Eti-FI%IlIRfS
.. his own who build,or improver t such i and who Jar m n work deed or or Nmugh
his own employees,building
uilds g that such mentis old within art not immndcd or oltcxd for NEW RESIDENTIAL ELECfR SQ FT.
sale.ILhower concave thn burden rovcmcng that hdone ycanfmmpldiomthe $Q:PT.FLOOR AREA S/SQ.FT.
ow net.1 antlJer will have IM1c burden of purring that he did not build or imProm for par-
pox of rolene
❑1, owner of the Smpcny,am sines and contracting with:)Th, ro.oe'n t TOTAL
constructeLotheproject(Sm.7044.Business andP wholns Caleb Ilan Contractor',Li-
e Lawdtesnmtappyloanowner ofprapenywhebudd.orintpmspecomic.... QI'Y. PLUMBING PERMIT FEE
AR 0
whn�onI...lot suuM1 projects with v ennuuaogn7licen.cJ pursu:mno the Conoactora
Liccnac cie" P12RMII'ISSUANCH
�❑lrmn exert tmiter$ce. ,Havre,builds rtaxnm
VWner ' Ilan AhI'I?R-DRAIN,Yt VHN'1'-WA'I'Eu(EA) lJl' VALUATION
WORK .'COSIPENS 'I ON DECIARAI[ON BACK FLAW PRO'fl?CI'.DEVICE
I by of0rmu rpenaltyof pc,.,oncof the following ilxdxrations:
Ihis and will maintain a Cenifcae of Comenuo self-insure lint Worker s Compcn- DRAINS-FLUOR.ROOF,AREA.COND. STORIES I'YPECONSTRUCTION
cation,as pmvided for by Section 3700 of the Labor Code,for the performance of the
work for which this Permit i,issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Imam e,as requires]by Section
3700afthe l.MeCode.far the performance aflhe work for which this permit is ixaaw. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AIN
My Worker's Compenxtion Insurance caries and Policy number am:
Carrier: Policy Na: GAS-EA.SYSTEb1-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUTTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES(This section need not be completed iflhe permit is for one hundred dollar IS I W)
or less.) - _ GREAsIi TRAP' PIANCHECK FEE
I ccnify that in thepserhmmoccuf Nc work for which this nnit is issued.l shell SEWER-SANITARY-STORM EA.200 FT.
.,it cmplmya.ylevan in any manneraoash,bmiune,mhjectunhc Worker,'Cnmpem- ENERGY FEE -
Z alion LawanfCabl'orno.Dote
ZAppific.int WATER HEAL PLR WNEMPELECTR GRADINGFEE
NOTIC17 TO APPLICANT.IL alter making this Ccnifaac of Exemption,you should WN117R SYS'I'1?MG REAL ING
a > become suNmI to the Wurke,'s Com tion folie Labor Code;you mart SOILS FEE
pcnm pmvi,ions n
�
forthwith comply with such proviaonx or this permit shall the deemed revoked. WATER SERVICE
o
= Z CONSONLENDING AGENCY NEW RESIDENTIAL PLMB. $Q.FT. PAID
U Q Ihcrtby affirm that
cre is isaronswction lending agency fnnhc performance of Deo Receipt is
CL. F' Ne work far which this permit is issued(Sea 301 Civ.C.)
lander.Name TOTAL:
V Lamm.Address TOTAL:
F1 I certify that 1 have read This applicadan and stain that the ahrva information is BUILDING FEE
to correct.I agree m comply with all city and county ordinances and atom Iowa misting m QTY. MECHANICAL PERMIT Flip.
V Z building construction,and hereby authoriae representatives of this city in crimrupon the SEISMIC FEE
aMrve-memlomw property for inspection purycAe, I�
(We)agree to save,indemnify and keep harmless the City of Cupeniro against PERMIT ISSUANCE ELECTRIC FEE
bithilitiex.j.d,otern.costsand expense,which may irony vayaccrunagaiml said City ALTER OR ADD'TO MECIi. PLUMBING FEE
in nxcyucnce of the granting of this pennon.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(1010,000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNI'T(OVER 10.000 CPM) CONSTRUCTIONTA%
Sigfraturt of Applicant/Contractor flan EXHAUST HOOD ONMUCI") HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle haurdous material HEATING UNIT(TO 100.000 BTU)
as Jxhned by the Cupertino Municipal Cade.Chapter 9,12,and the Health and Safety
Code.Section 255321x)? HEATING UNI"r(OVER 1 WAW BN)
❑Ye, ❑No VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building Date Receipt pp d by the m sax ea Air m lily Management
nt BOILER-COMP OHP OR 100.000 BTU)
emit i avNom air cmmaminanm as d<Rnw by the HuY Area Air Quality Mawgcmenn TOTAL:
Diann] BOILER COMP(OVER 100,000 BT
[:)Yet ❑No - U) , `^
I havemial NehuzaJous marenalsr tx under Cha 695 dFa Cali- AIR CONDI'I IONFR ' _
cyuimmm� Incr ISSUANCEEDATE
fomiu Health n t a rx,Calc,e a Sections 23505,2—ty rand 25534.1 undeeey In that if N° NF,W Rlitil Ul?N'I'IAI.MECII, SQ.Ff.
of Cheng dues not carni h bust a fuelp that it Is my rcxrymvCsifiy m nrnlly 1M occupant
orate myai erns which moa le recon ndano i2aenee m'a ernbmrneoffa"nnuner.
as
Ownennamhon rd amid Dae OFFICE T"-: ISSUED By
i