31120APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT No. A
BUILDING DIVISION APP ICATION/PERMIT PLUMBING - MECHANICAL
31120
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS'.
SANITARY NO.
APPLICATION SUBMITTAL DATE
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OWNER'SNAN PHONE
Cb'6.141• CIY1R'S NAME: LIC NO:
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CONT PHONE'.
BUILDING PERMIT LNFO
❑ Consultant Fees Paid by AppBean[ (Initlap
B ELECT PLUMB` MEcx
Ole
`C
Lad mad I O CO ALTO IECIARATION
1 tertbr arrmt th➢I 1 dem Eranml , nvismns of Chapter 9 (mmmenemg
with SeNm )Illp)of DlvisimJo[meBmi and mofeeions Code,aadm licence ie
y
Lfull forcead! cRc�,y�
`s7 Lic.M 'y�O
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RFSJDFNTIAL.
❑SFUWL [I KITCHEN
PERMIT ISSUANCE
APPWANCFS- RESIDENTIAL
Dile-CWas _
6te �_�Canlrecl« -
❑ADDITION [I PLUMBING kF.-PIPE
RETIRE
❑MULTI -UNIT El STRUCTURAL
CINTERIOR El CHIMNEY REPAIR
IMPROVEMENT
C1 BATH REMODEI/REPAIR [:1 DEMOLITION
❑ OTHER
l ARCHHLCTS DEUL4RATT6N
1 ntdenelead my p1a", fall o, use dei public records
PANELS
PANELS
UP TO 200 AMPS
Licensed PmCc.avinnil
OWNER -BUILDER DECLARATION
1 hereby of irro Net I am excmlx from the Caattucmre L keno law for the
tnllowing sawn. (Scat« )BJ LS, Husircss and Professions Codc'. Any city «county
whleb requites u formal to conelmn, alter, improve, demolish, or repeir my svucmre
prim to its Issuance, elmrcgolrts the applicant for.wch permit to file asignedvatemenl
mot he it licensed pmsudenl mine pmddon. of ile Cameami's Llcens, Law (Chapter 9
251-10IDAMPS
OVERI"AMPg
SIGNS ELECTRICAL
SPECIAL CIRCUITNISC.
TEMP SIETER OR POLE INS7COMMERCIAL'
1cummetcing with Section 7AXd.fDivision Sof the Busircommd Pmfeuinne Cada)«
Jim he is exempt therefrom mad the breis for the alleged exemption. Any violation of
Sedion7031.5 by any applicant for a permit subjects the applicant to a civil pewlty of
a« oeae men Five Maadrtd mums(S500) ,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
(]TENANT ❑FUOD SERVICE
POWERDEVICI'S
SWIMMING POOL ELECIRI
I,�Lasow'ner o(theprnperty,«mYempinyenwim wasemmcirmlemmpenmtim,
,will do the work, vol meawcmrt u oat ineadM or oRorN G. salt (Sec.96/4, Business
IMPROVEMENT
❑ OTHER
dead Proreyoores Cote: The patricmt, Le. Law dies not apply Io an .. of
OU1LErES - SWTICHM - F[XrURES
ptopnly who halms or intfrcems thereon, and who docs .such work himself or thr... h
his own employ«,, ptuvi led That such imm
pnrvcents me no, inlath`d or off ti for
NEW RESIDENTIAL SQ ET
toile. If, however, the building orimpresimenl is sold within one yomicoarphain,me—
SQ, 7.. FLOOR AREA
1SQ. 17.
wrcr-builder will he M
ave Ins, of prour «
oving that he did build improve for Pur-
pose ofsnIt ), -
❑ 1, ns owrcr ur tot prier am exclusively connecting with lammed,mdd,d oho
w'
O L:
mat ewd the projai (S¢.91N4. Business ad Pmforiaa Coln:) The Contradar's G-
cmc
- A D
Law dote net apply to sur owner of property who boils« improves Berom, aced
who wnlrvcts for,oli poo eat with a arearactemO licemal foment In tot Colowim's
QTy, PLUMBING PE FEE
qe.AD (�O
PERMIT ISSUANCE
License law.
n I an cxcmq under Sec. . B & P C f« this realm
,9n1\ 2
nK
ALTER - DRAIN&VENT-WA (
BACK FLOW PROTECT DEVICE
Owner Uam
V uA .T10N
/y
- n I ANO
' WORKER'S COMPENSATION DECLARATION
1 M1ama
eby mritm de, pcalty of perjury ora of the following declamations:
DRAINS- FLOOR, ROOF. AREA, COND.
I Mve and will minlaine Ccnifcmc of Cunwnuu vdf-iruurt f«W«ktr'e Cnmpem
mdm, u p,a, ideal for it, Section 3)110 of the laMn Cads, for tot peAxmance, of tad
STORIES
TYPE. CONSTRUCTION
FIXTURES - PER TRAP
work fax which Nis .it, is issued. I
❑ 1 have aril will mainain Worker'• on Insurance, ns rtquitM by Satins
3)Oflnf Per loots nlc.1«Ihe arc rfthew«kf«which teas pennil'a iuucd.
MyW C penmi rand l'nlieyn tt�ej°�j
GA.S-FA. SYSTEM -1 INC, COUTLETS
OCC.GROUP
APN
GAS -G.SYSTEM-0VERO(BA)
Can Pcb' Nn.: /L1jJOI���
C 1 CATF, 'EXE_ 'TION FROM WOkKERS'
"
GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSAT)ON INSURANCE
BUILDING DIVISION FEES
Mal Section need m be cmnplea t ifOm pmmitis for obe haadrei dellan (SI W)
or loss.)GREASE
I certify Wain the perfomarcc o(Ile work f«w'hich this psoras it i,uM.I NeII
W I employ cony pawn in any «morn« w as m heconrte subject Io dm Wmkas' Compen-
Alimn law' of Califnmiv. Date
TEAR
PLANCHECK FE1i
SEWER-SANITARY-STORMEA,200FT.
ENERGY FEE
WATER HEATER WNENI/ELEC R
GRADING FEE
NOTCH
NOTICE'IO APPLICANT. If, affair noticing this Cister,of of Lelyor Cccyou sham,
become whject the Wohefs Comp masa« provisions of the ImMx Code, you moat
WATER SYS'TEM"FREATINO
SOILS FEF,
fonhwim dxnply with such pmvi,iov «teas Pcmtit JallMdaemcd invoked.
y
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I Mrnby allimt Wllhert isecroswctim leading agency f«The fert«mana of
PAID
NEW RESIDENTIAL PLMB. SQ. FI.
One, Res'eipt
the work for which mi, permit i, issued (Sec. J090. Ci, C.)
TOTAL:
Lader', Nemo
Leader's Addabs,
TOTAL:
BUILDING FEE
1 certify the( 1 have read thisapplicelion and late that the above iofordraon is
QTY. MECHANICAL PERMIT FEE
mead 1 agree to comply with all city and county orditanms ad state lows relating to
building cormraaims
. dead hereby aulhorixe rcµcnatives M mil city to enter upon Ih[
SEISMIC
ohove-mentimr4 parpeny for'mspeeme ",,s.
(We) agree to save, iadcmnify and keep hmmlev the City of Cupthou against
ha dities.judgmrnn,toe's and exposes which may in any way mane against said City
in ancgmame of the gmarem, of this pemtit.
PERMIT ISSUANCE
ALTER OR ADD TO SUCH.
BI FEE
AIR HANDLING UNIT (DO 10.000 CFM)
APPLICANT UND STANDS AND WILL COMPLY WITH ALL NON -POINT
SOU ILA SNS.
MECHANICALFEE
,
AIR HANDLING UNIT (OVER IO,fpfICFM)
J
CONSTRULTONTA
Sign.m5,1fA,dh tenon« Detc
HATAR W IS MATERIALS DISCLOSURE
EX HAUST HOOD(WMUCq
HOUSING MITIGATION FEE
HEATING UNIT (TO LOO," BTU)
Will the applicwt«future handing«cufant nom or bashe M1areadoca ma¢riN
es definM by the Cupenimr Municipal Code, Chapter 9.12, and IM Health and Safety
Code, Satire 25532(.)'
HEATING UNIT (OVER I W,000 BTU)
PAID
❑Yes ❑No
VENTILATION PAN (SINGLE RESID)
Will the applicant «future WIIdIng occupam uw equipment or deviuu which
Dam Receipt M
JI ha vtlous sir contamindenu v Jcfnd by tot Bay Arte Air Quality Management
BOILER -COMP (3HP OR I(p.OW BTU)
JL.?
TOTAL:
BOILER- COMP (OVER 100.000 BTU)
❑Yea E] No
AIR CONDITIONER
I have rad me bararkw.s narmelx ".irtmena Imdur Chapter 6.95 of W Cali-
Tante Healm &Surety Cede. Bottom 25Nt5. i55JJ mrd 25511. 1 undauand Wt if the
hd Mune doer m curmNy Mve a tenant, that it is my m puresibility m mgify pe mutant
of 0e rtquitcnena whkh must be mot an mtomml of. Ccnlf IC of OAmaod
ISSUAN
ISSUED H Is
NEW RESIDENTIAL MI CH. - SQ. FT
Ownet our aumonmd agar Dam
TOTAL:
OFFICE _ \f l